Study: Life stressors significantly impact long-term outcomes and post-acute symptoms 12-months after COVID-19 hospitalization. Image Credit: / Shutterstock

Long COVID symptoms made worse by stressful events

A recent study published in the Journal of Neurological Sciences reported that life stressors impact post-acute symptoms and long-term outcomes following hospitalization for coronavirus disease 2019 (COVID-19).

Post-acute sequelae of COVID-19 (PASC) have been observed in 25% to 69% of non-hospitalized patients and 33% to 90% of hospitalized patients. The variable prevalence could stem from differences in study design, symptoms, and timing of assessment. Despite numerous studies reporting the prevalence of post-COVID-19 sequelae, there are few data on predictors of long-term quality of life and cognitive and functional outcomes.

Study: Life stressors significantly impact long-term outcomes and post-acute symptoms 12 months after hospitalization for COVID-19. Image Credit: / Shutterstock

About the study

In the current study, researchers prospectively examined the impact of demographics, hospital clinical variables, pre-COVID-19 comorbid conditions, and life stressors on outcome parameters at six months and a year after hospitalization for COVID-19. This observational study was conducted on patients hospitalized with COVID-19 from March 10 to May 20, 2022.

Follow-up interviews were conducted six months and one year after the initial diagnosis of COVID-19. Subjects were eligible if they were 18 years of age or older and hospitalized with a positive SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) test, with consent for the follow-up interview. People were excluded if they were assessed in the emergency room or on an outpatient basis.

Data on demographics, medical/neurological history, new neurological or other complications in hospital, and medications used during acute COVID-19 were recorded. Severity of illness was graded based on ventilation requirements and Sequential Organ Failure Assessment (SOFA) score. The Modified Rankin Scale (mRS) was used to assess subjects’ baseline functional status before COVID-19.

Longitudinal evaluations were carried out by telephone interviews. Contact was attempted six and 12 months after the initial diagnosis of COVID-19. Functional and disability status was assessed using the mRS; cognitive outcomes were examined with the Montreal Cognitive Assessment (t-MoCA) by telephone.

The Barthel Index was used to assess activities of daily living (ADL), and self-reported health parameters of depression, fatigue, sleep, and anxiety were collected through short questionnaires on quality of life in neurological disorders (NeuroQoL). PASC results were defined as new/persistent symptoms occurring four weeks after COVID-19.


Follow-up maintenance attempts were made on 790 and 590 patients at six and 12 months, respectively. Of these, only 382 (48%) and 242 (41%) patients completed the interviews at six and 12 months, respectively. Participants who only completed the six-month interview were older (median age: 69) than those who completed the 12-month interview (65).

No differences were found in gender, education level, race, pre-COVID-19 mRS scores, history of dementia/psychiatric illness, severity of COVID-19, and rates of neurological complications during hospitalization between patients who completed the interviews at six months and 12 months. Headache, anxiety, cognitive abnormalities, depression, fatigue and sleep disturbances were common neurological symptoms at 12 months.

Approximately 90% of patients at six months and 87% at 12 months had abnormalities on at least one assessed measure, with abnormalities on mRS and t-MoCA being the most common. A weak but significant correlation was observed between post-acute symptoms of COVID-19 and NeuroQoL anxiety scores ≥ 60. with NeuroQoL depression scores at one year.

Female gender was associated with high anxiety scores at one year and poor Barthel’s Index at six and 12 months. Neurological complications such as hypoxic-ischemic brain injury and toxic metabolic encephalopathy strongly predicted poor Barthel’s index and mRS at six and 12 months and worse fatigue and depression scores at one year. Poor SOFA scores and mechanical ventilation predicted poor Barthel score at six months.

The researchers found no consistent effect of COVID-19 drugs on outcome measures. However, more than 50% of participants reported experiencing at least one life stressor in the month prior to the 12-month follow-up. A new personal illness, social isolation, financial insecurity, and illness/death of a close acquaintance were the most common life stressors.

The presence of stressors was strongly linked to post-acute COVID-19 symptoms and poor NeuroQoL scores. There was a significant association between food and financial insecurity, new close contact disability/death, social isolation, and personal illness with worse NeuroQoL measures. On the other hand, new disabilities and personal illnesses were associated with the Barthel index and the mRS.


In summary, the authors found independent associations of conventional predictors of poor outcomes, such as older age, poor pre-COVID-19 functional status, and disease severity, with worse t-MoCA scores, Barthel Index and mRS and post-acute symptoms of COVID-19. Additionally, they found that life stressors negatively impacted post-acute COVID-19 symptoms, depression, fatigue, sleep, and measures of disability. Taking life stressors into account, interventions aimed at alleviating life stress are associated with better cognitive, neuropsychiatric, and functional outcomes 12 months after hospitalization with COVID-19.

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