Managing long-COVID and Alzheimer’s-Dementia

Long-Covid is a constellation of presentations and patients infected with Covid-19 within the last 2-3 months may experience physical performance difficulties despite being physically active 
(Pics by Samantha Perera)

• Vaccines as well as anti-viral medications like Paxlovid minimizes the chances or risks of long Covid
• Adequate amount of sleep is six hours because sleep deprivation is now associated with AD

Even though the COVID-19 pandemic has ended and life has returned to normalcy medical experts advise people to keep themselves protected from future infections. In other words people are advised to get vaccinated in order to prevent hospitalizations, ICU admissions and death. While many controversies revolved around the pandemic, research studies for preventive medication for conditions such as long COVID are still underway. On the other hand new tools for diagnosing conditions such as Alzheimer’s-Dementia may allow patients to receive treatments at an early stage. 

Managing long-COVID 

Speaking at a guest lecture organized by the Sri Lanka Medical Association, Prof. Deepthi Jayasekara – Consultant infectious diseases specialist in USA said that even though the pandemic has ended it doesn’t mean that the COVID-19 infection has been completely eradicated. “We need to understand that vaccines and boosters don’t prevent infections per se, but they prevent hospitalisation, ICU admissions and death. So for those who are immunocompromised or have chronic medical problems it is important to be vaccinated and boosted.
“Last week the second bivalent vaccine was approved and this means that we are very serious about giving the Covid-19 vaccine boosters, especially the bivalent boosters every year.

Then came a very controversial subject of, if you have had an infection how much of immunity would be there and how long would it last. But if you’re vaccinated and boosted you can still get an infection. These are 99.99% mild infections in a normal immunocompetent patient. But if you have had an infection, either vaccinated or not, the latest Lancet article proves that you have around 10 months of immunity going forward. That’s a critical point. But these are the points that scientists fail to recognize. This is why it’s controversial. Those who are vaccinated and boosted have immunity but those who have had the real infection, then that immunity would last for 10 months,” Prof. Jayasekara said while explaining that T-cell immunity lasts longer than B-cell immunity.

Most AD patients are sporadic and there are so many things we could do to change the risk factors. We cannot just get ready at 60 to prevent dementia when you’re 80. You need to start a little bit early on according to the research that we are finding
- Dr. Ruwani Gunawardena Neurology specialist in Fulton, USA

While shedding light on Covid conspiracies he also spoke about long-Covid, which is a constellation of presentations. “You may be infected with Covid-19 within the last 2-3 months, but now your brain may not function well; you still cannot smell, taste, you’re very fatigued and your heart rate is very high despite being a good athlete. Therefore it’s a combination of constellation of presentations which we say Post Acute Sequalae of Covid which includes cognitive symptoms, chronic cough but thankfully a lot of them resolve within a matter of 3-6 months. But it is a problem because most of these sub-variants are very contagious. This long Covid can take a big turn on you. Why? Because only in 10% of cases it become a real problem. But at the same time the real number is more than that. Symptoms include brain fog, chronic cough, POTS syndrome or dysautonomia, chronic fatigue, sleep disturbances and therefore it is not only affecting you but your livelihoods as well.

“So how do we solve this problem? We don’t know because we simply don’t know the mechanism behind long-Covid syndrome. But it happens only in about 10% of cases and about 65 million people around the world are suffering currently. It typically last for about 3-6 months but a large study in Scotland showed that more than half recover within 18 months. There’s some good news that vaccines as well as anti-viral medications like Paxlovid minimizes the chances or risks of long Covid. But then again somebody else who don’t believe in vaccines might question that. On the other hand some of these patients have a high risk of dying. Acute coronary events such as arrhythmias or myocardial infarctions, strokes, cardiac arrests, type II diabetes, are linked to long Covid syndrome. So we as physicians need to pay attention to long Covid going forward,” he advised while adding that there are no specific tests to diagnose long Covid but that it is important to know what the symptoms are like. 

Management of Alzheimer’s disease-what’s new?

Alzheimer’s disease is the most common type of dementia. It is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. Even though patients are living longer, a study in the United States predicted that there would be a 50-fold increase of patients with Alzheimer’s-Dementia by 2050.“Prevalence is increasing, so we have to do something about it so that it prevents patients with Mild Cognitive Impairment (MCI), progressing to Alzheimer’s-Dementia (AD),” said Dr. Ruwani Gunawardana, a neurology specialist in Fulton, USA. “The latest article I read suggests that you could do something to prevent patients with MCI developing Alzheimers- Dementia. 80% of patients will move on but for 30% there are so many lifestyle changes that could initiate a shift to the normal stage,” said Dr. Gunawardana.

Key pathology 

AD indicates a build up of amyloid plaque which is a soluble protein and this buildup can start as early as 45 years of age. “We might be asymptomatic, doing all our activities with no problem. The tau proteins in the micro tubules will form neurofibrilliary tangles and these two – the amyloid plaque and the neurofibrilliary tangles can go through so many changes and cause destruction in the nerve cells, neurons eventually leading to neurodegeneration,” said Dr. Gunawardana. 

Risk factors for AD

Speaking about risk factors, Dr. Gunawardana said that it’s not all genetic. “Most AD patients are sporadic and there are so many things we could do to change the risk factors. We cannot just get ready at 60 to prevent dementia when you’re 80. You need to start a little bit early on according to the research that we are finding. In early life we know that there’s a direct link with more patients who had AD there was an association with lower education and developing AD. Mid-life risk factors include hearing loss. If patients have hearing loss I advice them to get a hearing aid because hearing loss can promote patients going on to AD. Traumatic brain injury, excessive alcohol intake and obesity are other risk factors. Obesity could in fact lead to cerebral vascular disease. Many patients with AD not only had amyloid plaques but they also had vascular ischemic changes in the brain,” she added.

We simply don’t know the mechanism behind long-Covid syndrome. But it happens only in about 10% of cases and about 65 million people around the world are suffering currently. It typically last for about 3-6 months but a large study in Scotland showed that more than half recover within 18 months
-  Prof. Deepthi Jayasekara – Consultant infectious diseases specialist in USA

Dr. Gunawardena said that Hypercholesterolemia is another risk factor. “We know that increased cholesterol cause small vessels to develop cerebrovascular disease and there is so much research that starting patients on statins early on for cerebrovascular disease will prevent dementia. We are involved in a trial called IDEAS trial and the purpose of this trial is to recognize patients early on in the MCI state. If the spouse or significant others have noticed subtle memory lapses, but these patients are functionally normal because they are compensating, we do a scan called the amyloid scan and if they have positive amyloid patients would ask what they could do to prevent being diagnosed with AD. Prevention is the most important aspect at this time because amyloid-based medications are still under progress. Starting statins early on in the disease if they have cerebrovascular disease and high cholesterol is recommended because we need plaque stabilization as we are not treating a level at this time. We are treating plaque stabilization and micro vascular disease and this is strongly linked with AD. Obesity is quite common in the US due to lack of exercise, eating the wrong diet and so on. Eating greens, grains, fruits and a Mediterranean diet is important. Especially saturated fats increase with cognitive decline, so a plant-based Mediterranean diet, incorporating fish is recommendedbut you need to leave out saturated fat or processed food. Processed foods would create an imbalance of the micro biome in your gut. Hence there are so many things we could do in mid life to prevent this disastrous journey of AD,” explained Dr. Gunawardena.

“Late life risk factors include smoking and we encourage patients for smoking cessation. Depression is a risk factor mostly seen in the US. So if we add serotonin re-uptake inhibitors to their medication it helps patients. If patients with depression and anxiety are not treated there is good evidence to show that these patients would develop AD. Another risk factor is sleep deprivation. Adequate amount of sleep is six hours because sleep deprivation is now associated with AD. Time we sleep is when we clear the build up of toxic agents that can lead to dementia. But what about too much sleep? That too is bad for you. There is now a sweet spot for sleep. Less than six hours of sleep and more than 10 hours of sleep is not good. Diabetes is pretty much rising because of not having much exercise and it leads to cerebrovascular disease and many patients with AD are now linked to diabetes,” said Dr. Gunawardena. 

Medication 

Speaking about medications she said that there have been no disease modifying therapies from 1996 to 2021. “Most trials failed to show a good outcome especially to improve cognition. In 2021 came Aducanumab and it was quite controversial. There was a rapid approval but there were good benefits from one part of the study. There are two other drugs coming up at the end of the year, Donanemab and Lecanemab – all these mabs are monoclonal antibodies. Lots of monoclonal antibodies are now being used for migraine, AD and many other treatments,” she said in conclusion.