Brain fog assessment in patients recovered from COVID-19 in China: a development and validation study

Post coronavirus disease 2019 (COVID-19) pandemic, the widespread emergence and persistence of brain fog has led to a decline in people's productivity and quality of life. However, the clinical characteristics of COVID-19-associated brain fog are unclear, and standardized assessments are lacking. This study aims to develop a scale for brain fog assessment and support clinical practice and research.

The 17-item Brain Fog Assessment (BFA) scale was developed using a standardized methodology, including literature review, focus group discussions (FGDs), expert evaluation, and psychometric validation. Eighteen potential items were generated following the literature review. These items were subsequently refined during FGDs, which included input from patients, caregivers, and multidisciplinary experts in neurology, cognitive neuroscience, and psychology. After thorough deliberation and expert evaluation, the item pool was finalized into a 17-item scale. We recruited 1,325 patients recovered from COVID-19 from Chinese communities. Psychometric properties were assessed by reliability and validity analysis.

Exploratory factor analysis of the BFA scale revealed a three-factor mode comprising 'cognitive decline' (nine items), 'confusion - disorientation' (five items), and 'fatigue' (three items). The internal consistency of each factor was strong (Cronbach's α: 0.82-0.92). Confirmatory factor analysis showed that the model fit, convergent validity, and discriminant validity of the scale were satisfactory. The test-retest reliability was strong (intraclass correlation coefficient = 0.84). Criterion-related validity analysis showed a strong correlation to the Wood Mental Fatigue Inventory (r = 0.70, p < 0.001). Individuals with a higher BFA score tended to score lower on the Montreal Cognitive Assessment (r = -0.23, p = 0.015).

We established a novel BFA scale to quantify multiple clinical aspects of COVID-19-associated brain fog. Using the BFA scale, fatigue and declining performance in memory, attention, and thought were identified as the main symptoms of COVID-19-associated brain fog. This scale has potential implications for disease monitoring and therapy development for individuals with COVID-19-associated brain fog.