Cognitive problems are common after acute SARS-CoV-2 infection and can be disabling and frightening Symptoms tend to improve, but this may take up to a year. Those with chronically persistent symptoms lasting more than 12 months have a lower chance of improving Symptoms usually fluctuate Assessment should be directed to documenting the nature and trajectory of the impairment and excluding alternative diagnoses Self-management techniques may help patients manage their condition As of March 2023, when the Office for National Statistics stopped collecting data on this condition, 1.879 million individuals had self-assessed as having long covid—symptoms lasting more than 12 weeks following acute covid-19 infection. Of these, the proportion of individuals with symptoms lasting two years or more is around 42%, suggesting a decline in new cases of long covid but a persistence of those with ongoing symptoms.1 Some systematic reviews and meta-analyses have reported that up to a third of such individuals have persistent symptoms of cognitive impairment,23 but estimates vary widely and are complicated by methodological heterogeneity—eg, study size, assessment approach, follow-up duration, and different sampling frames (from self-reported surveys4 to large retrospective matched cohort studies of health records5), as discussed in a recent meta-analysis.6 The pathological underpinnings and potential therapeutic possibilities for cognitive impairment in long covid are also uncertain. The bulk of evidence to date is mechanistic (using basic science, animal models, or human tissue), observational (using longitudinal cohort studies), or hypothetical (reasoning from basic principles); this literature has been well summarised by the RECOVER Consortium.7 Because of the methodological heterogeneity, even when individual studies have been rigorously conducted, it is difficult to know to what extent their findings can be extrapolated and generalised across those with long covid. A few randomised controlled trials of potential treatments (pharmacological and non-pharmacological) have been completed, and others are under way.7 Cognitive performance is typically conceptualised in terms of functional domains depending upon the task at hand. Domains are hierarchical and inter-related, ranging from more basic sensory and perceptual processes to executive functioning and cognitive control.8 Both psychometric studies and qualitative studies of the patient experience identify problems across one or more of these domains. The most frequent symptoms seem to affect memory, attention, and concentration9 but discrete impairments are also seen in attentional and executive processing,1011 different types of memory,1012 visuospatial processing,13 and language.12 Many patients show deficits in multiple domains,1214 which may or may not correlate with self-reported symptoms.15 Moreover, linked systemic symptoms such as fatigue, insomnia, and a general befuddled state frequently termed “brain fog” are commonly reported. This seems to wax and wane with physical fatigue.16 A higher symptom burden is often associated with concomitant mood disorders or post-traumatic stress disorder, regardless of illness severity.15171819 Longitudinal cohort, case control, and qualitative studies have shown that while many individuals improve gradually over time, cognitive symptoms fluctuate unpredictably, causing uncertainty and (in some) anxiety.9202122 These impairments can have profound impacts on an individual’s life, with significant ramifications for relationships, jobs, and normal daily activities.422 This article explores the impact of these symptoms and offers a practical guide for GPs to help them approach cognitive dysfunction in individuals with long covid as indicated by the evolving and conflicting evidence base. An account from a patient’s perspective is given in box 1. Box 1 Patient experience When I got covid in December 2020 I was worried about what might happen. It was before vaccines, and the news was full of statistics of the hospitalised and those who’d lost their lives. After my 14 day isolation I was relieved to get back to normal life, thinking I had dodged quite a bullet. I was quickly aware that something wasn’t right. At the time of my infection I was a drama teacher in a secondary school. I remember being at work in January 2021 and finding it impossible to concentrate on what I had to do. Trying to focus made my head spin, and working on a computer screen was almost impossible. In the classroom I couldn’t process what was happening around me like I used to be able to, there was a sharpness lost, and that had a significant impact on both my teaching ability and classroom management. After several attempts at returning to work it became clear that I wasn’t able to continue, and I left teaching in January 2022. Alongside my difficulties focusing there are problems with memory. Remembering things from one minute to the next is often diff

University of Colorado study in rats demonstrates that SARS-CoV-2 protein activity drives longer-term vulnerability to another infection, augmenting physiological problems such as neuroinflammation, autonomic dysregulation, and hormonal imbalances