Although cognitive health always deserves attention and continuous care, the need to preserve and promote cognitive health on a global and national scale during the coronavirus disease 2019 (COVID- 19) pandemic has evolved from necessary to essential.

COGNITION AND COGNITIVE DECLINE
Cognition is the range of mental processes that allow us to acquire, store, manipulate, and retrieve information, exercise judgment, and behave appropriately. It is essentially who we are. Cognitive decline, in short, is the loss of these abilities at various degrees. In some instances, cognitive deficits may occur suddenly, such as after a traumatic brain injury or stroke. In most people, however, cognitive decline is an insidious and slow process. One may lose capacity in a specific cognitive area, such as memory, or the decline may occur globally across many cognitive domains.

Importantly, not all cognitive decline evolves to dementia. “Brain fog” and mild cognitive impairment occur far more commonly than overt dementia,1 and, unlike dementia, these states may be reversible.2 It is also important to note that preserving cognitive function is easier and has a greater chance of success, ultimately, than repairing or restoring it. Thus, it is crucial to appropriately identify and manage the underlying factors that contribute to cognitive decline as early as possible at any life stage.

When contemplating the factors associated with cognitive decline, it is clear the necessary measures brought on by COVID-19 may exacerbate some of the underlying factors that affect cognitive health (see FIGURE).



Lifestyle factors that lead to cognitive decline include diminished socialization and increased isolation, lack of brain stimulation and physical activity, and an unhealthy diet.3 Excessive alcohol use and smoking also contribute to cognitive decline.3 These lifestyle factors are intimately associated with underlying medical issues. Poor diet and a sedentary lifestyle greatly increase the risk of cardiovascular disease, dyslipidemia, metabolic syndrome, mid-life hypertension, mid-life obesity, and type 2 diabetes. Each of these conditions, in turn, raises the risk of cognitive decline.3 For reasons that are not entirely clear, mid-life hearing loss also increases the risk of cognitive decline.4

Lifestyle and underlying medical issues, in turn, exacerbate mental health problems, such as anxiety and depression. Late-life depression is clearly associated with cognitive decline.5 Importantly, emotional and mental well-being may not need to rise to the levels of diagnosis of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders to negatively affect cognition. Social isolation is an independent risk factor for cognitive decline, for example.3 Emotional and mental disquiet can also be a profound barrier to the modification of risk factors. It is considerably more difficult for a person who is isolated and has a negative mood to begin eating a healthy diet and exercising.6

BY THE NUMBERS
In June 2020, Cognivue, the developer of the Cognivue Thrive cognitive assessment device, conducted a national survey of US adults (n = 693 with CI ± 3.7%) eliciting responses on how COVID-19 has affected factors related to cognitive decline and health. Nearly 40% of respondents reported that their financial and sleep situations were worse or much worse since the emergence of the disease, and 30% reported a negative impact on their diets. COVID-19 appears to have affected the smokers in the survey, with 40% of them reporting smoking more or much more since the pandemic began. Similar proportional increases were found in the greater use of alcohol (26%) and recreational drugs (40%).

Since COVID-19 restrictions were instituted, 27% of respondents reported new symptoms of anxiety, and 21% reported new symptoms of depression. This suggests that the pandemic may be the provocative factor for new mental health disorders. Further, the number of respondents reporting that their blood pressure is now worse or much worse has increased by 42% since COVID-19 began. Likewise, weight control is now worse or much worse in 35% of respondents who are obese or overweight. Indeed, according to Cognivue’s research, 91% of respondents reported that COVID-19 brought on or worsened at least 1 factor that causes cognitive decline.

BREAKING THE CYCLE
Fortunately, there are many ways to intervene in the cycle of cognitive decline. The first step, of course, is to identify individuals who face worsening cognitive stressors or are at an increased risk, especially during this difficult time.7 Pharmacists are highly accessible clinicians who have frequent encounters with patients and could help identify those who are high-risk and promote cognitive health with appropriate counseling and health care provider referrals when necessary.

LEVERAGING THE COMMUNITY PHARMACIST
Knowing that cognitive health can be affected in many patients, medical providers do not need to support patients by themselves. Community pharmacists are in an ideal position to facilitate cognitive education and screening for mutual patients, in addition to those patients who are a part of their community pharmacy footprints.

The National Community Pharmacists Association estimates that there are 14,866 zip codes in the United States with at least 1 pharmacy.8 Additionally, many community pharmacies provide a unique array of services and are in a prime position to serve as anchor points for immediate cognitive screening, potentially reducing the burden of providers through this ancillary support. By layering this service into the community pharmacy setting, patients can be triaged to determine whether additional testing is necessary and if so referred to their primary-care providers.

COVID-19 has challenged many pharmacies to seek alternatives within their workflows to bridge the gap with patients. Through navigation of medication delivery and opportunities with medication synchronization programs, pharmacists can implement additional questions to check in with patients who have been isolated to determine if cognitive screening is needed. There is evidence that depression and loneliness are on the rise, especially for seniors who were experiencing these challenges even before COVID-19. Furthermore, the stigma around the term “mental health” can cause patients to avoid cognitive screenings. However, pharmacists can educate patients to understand the differences between cognitive and mental health. In doing so, community pharmacists will provide additional value to their communities and become providers of knowledge and screenings related to cognitive health.
 
Reina Benabou, MD, PhD, is the senior vice president and chief development officer of BioXcel Therapeutics in New Haven, Connecticut.

Amina Abubakar, PharmD, AAHIVP, is the owner of Rx Clinic Pharmacy in Charlotte, North Carolina, the founder and president of the Avant Institute of Clinicians in Charlotte, and a clinical pharmacist consultant to Cognivue.

Saswat K. Kabisatpathy, PharmD, is the chief operating officer at Rx Clinic Pharmacy and an instructor at the Avant Institute of Clinicians.



REFERENCES
  1. Langa KM, Levine DA. The diagnosis and management of mild cognitive impairment: a clinical review. JAMA. 2014;312(23):2551-2561. doi:10.1001/jama.2014.13806
  2. Ganguli M, Jia Y, Hughes TF, et al. Mild Cognitive Impairment that Does Not Progress to Dementia: a population-based study. J Am Geriatr Soc. 2019;67(2):232-238. doi:10.1111/jgs.15642
  3. Baumgart M, Snyder HM, Carrillo MC, Fazio S, Kim H, Johns H. Summary of the evidence on modifiable risk factors for cognitive decline and dementia: a population-based perspective. Alzheimers Dement. 2015;11(6):718-726. doi:10.1016/j.jalz.2015.05.016
  4. Orgeta V, Mukadam N, Sommerlad A, Livingston G. The Lancet Commission on Dementia Prevention, Intervention, and Care: a call for action. Ir J Psychol Med. 2019;36(2):85-88. doi:10.1017/ipm.2018.4
  5. Wilson RS, Capuano AW, Boyle PA, et al. Clinical-pathologic study of depressive symptoms and cognitive decline in old age. Neurology. 2014;83(8):702-709. doi:10.1212/WNL.0000000000000715
  6. Burgess E, Hassmén P, Pumpa KL. Determinants of adherence to lifestyle intervention in adults with obesity: a systematic review. Clin Obes. 2017;7(3):123-135. doi:10.1111/cob.12183
  7. McGuire LC, Maslow K. Centers for Disease Control and Prevention’s Healthy Brain Initiative: a public health approach to cognitive health. Innov Aging. 2018;2(suppl 1):85-86. doi:10.1093/geroni/igy023.326
  8. Independent pharmacy is the safety net against COVID-19 for millions of Americans, new data shows. News release. National Community Pharmacists Association; April 7, 2020. Accessed July 27, 2020. https://ncpa.org/newsroom/news-releases/2020/04/07/independent-pharmacy-safety-net-against-covid-19-millions