COVID-19, neurocognitive disorders, and civil capacity

The coronavirus disease 2019 (COVID-19) pandemic has caused great concern and posed a real challenge to the Brazilian health system. COVID-19 is a systemic disease with neuropsychiatric manifestations, which include encephalopathy, delirium, mild cognitive impairment, and cerebrovascular disease.¹

SARS-CoV-2 infection is associated with a severe immune response and a sustained increase in systemic cytokine levels. Because systemic inflammation can promote cognitive decline and neurodegenerative disease, COVID-19 survivors may have some degree of neurodegeneration and be at increased risk of developing Alzheimer’s dementia in subsequent years.²

In an observational series of 58 patients with COVID-19, 33% had dysexecutive syndrome, characterized by inattention and disorientation, with findings of frontotemporal hypoperfusion on magnetic resonance imaging of the brain.³ COVID-19 is a neuroinvasive disease, triggering inflammatory and neurodegenerative processes.⁴ The long-term consequences of this neuroinfection remain unknown, but they may be associated with impairment in cognitive, affective, and behavioral domains.⁵ Each of these domains can influence an individual’s quality of life and the exercise of autonomy and citizenship.

Civil capacity is legally defined as an individual’s ability, capability, or fitness to fully perform any civil act. This includes the ability to comprehend the consequences of one’s acts in this spectrum of social life, such as signing a document, making purchases or sales, getting married, and settling an agreement.

Individuals with mental or cognitive disorders should not lose their rights to their own bodies, privacy, education, health, work, consent to treatment, and voting. Trusteeship is an extraordinary measure, and a court ruling must contain the reasons and motivations for its establishment, preserving the interests of the person under trusteeship. It should be noted that even partial trusteeship (e.g., of assets and businesses) is a measure that limits individual rights, as the ability to own and manage assets is an important aspect of individual citizenship.

Studies have demonstrated psychiatric problems such as stress, anxiety, depression, impaired memory, psychosis, PTSD, and sleep disorder in individuals with COVID-19.⁶ Older adults may experience even greater difficulties in dealing with the crisis brought by the pandemic. The issues of neurocognition and civil capacity in the elderly need to be addressed together with other psychiatric disorders throughout the lifespan.

The repercussions of the COVID-19 pandemic go far beyond measures to prevent disease transmission and reduce its direct impact on the world population.⁷ The provision of clinical and psychiatric services for patients with cognitive disorders or early-stage dementia is essential for the preservation and prevention of further deterioration of intellectual function.

We might witness an increase in requests for adult guardianship due to neuropsychiatric complications of COVID-19, such as dementia and other neurocognitive disorders. However, it is important that psychiatrists and other health professionals be aware of the fact that the course, prognosis, and treatment responsiveness of these complications are not well established, and they may even be reversible.

Proper clinical and psychiatric evaluations and neuropsychological and neuroimaging studies are required to correctly measure an individual’s capacity, such as the ability to consent to treatment, to administer assets and legal affairs, and to exercise other civil rights. The psychiatric report will influence the judicial decision in these cases. It is of utmost importance to preserve individuals’ autonomy to exercise their own rights within their universe of competencies.

References

• ¹
  Kotfis K, Roberson SW, Wilson JE, Dabrowski W, Pun BT, Ely EW. COVID-19: ICU delirium management during SARS-CoV-2 pandemic. Crit Care.2020;24:176.
• ²
  Heneka MT, Golenbock D, Latz E, Morgan D, Brown R. Immediate and long-term consequences of COVID-19 infections for the development of neurological disease. Alzheimers Res Ther.2020;12:69.
• ³
  Helms J, Kremer S, Merdji H, Clere-Jehl R, Schenck M, Kummerlen C, et al. Neurologic Features in Severe SARS-CoV-2 Infection. N Engl J Med.2020;382:2268-70.
• ⁴
  Raony I, de Figueiredo CS, Pandolfo P, Giestal-de-Araújo E, Bomfim PO, Savino W. Psycho-neuroendocrine-immune interactions in COVID-19: potential impacts on mental health. Front Immunol.2020;11:1170.
• ⁵
  Hascup ER, Hascup KN. Does SARS-CoV-2 infection cause chronic neurological complications? Geroscience.2020;42:1083-7.
• ⁶
  Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry.2020;7:611-27.
• ⁷
  Telles LE, Valenca AM, Barros AJ, da Silva AG. Domestic violence in the COVID-19 pandemic: a forensic psychiatric perspective. Braz J Psychiatry.2020 Jun 1;S1516-44462020005015211. doi: http://10.1590/1516-4446-2020-1060 Online ahead of print.
  » http://10.1590/1516-4446-2020-1060

Publication Dates

• Publication in this collection
  09 Oct 2020
• Date of issue
  Jul-Aug 2021

History

• Received
  30 July 2020
• Accepted
  12 Aug 2020