Improved Odor Identification Ability and Increased Regional Gray Matter Volume After Olfactory Training in Patients With Idiopathic Olfactory Loss

Recovery rates and long-term olfactory dysfunction following COVID-19 infection

Objectives

Olfactory dysfunction is one of the most recognized symptoms of COVID-19, significantly impacting quality of life, particularly in cases where recovery is prolonged. This review aims to explore patterns of olfactory recovery post-COVID-19 infection, with particular focus on delayed recovery.

Data Sources

Published literature in the English language, including senior author's own work, online and social media platforms, and patients' anecdotal reports.

Method

A comprehensive review of the literature was undertaken by the authors with guidance from the senior author with expertise in the field of olfaction.

Results

Based on self-report, an estimated 95% of patients recover their olfactory function within 6 months post-COVID-19 infection. However, psychophysical testing detects higher rates of persistent olfactory dysfunction. Recovery has been found to continue for at least 2 years postinfection; negative prognostic indicators include severe olfactory loss in the acute phase, female sex, and older age. Variability in quantitative and qualitative disturbance in prolonged cases likely reflects both peripheral and central pathophysiological mechanisms. Limitations of many of the reviewed studies reflect lack of psychophysical testing and baseline olfactory assessment.

Conclusions

Post-COVID-19 olfactory dysfunction remains a significant health and psychosocial burden. Emerging evidence is improving awareness and knowledge among clinicians to better support patients through their olfactory rehabilitation, with hope of recovery after several months or years. Further research is needed to better understand the underlying pathogenesis of delayed recovery, identify at risk individuals earlier in the disease course, and develop therapeutic targets.

Null cross-modal effects of olfactory training on visual, auditory or olfactory working memory in 6- to 9-year-old children

Systematic exposure to odours (olfactory training, OT) is a method of smell loss treatment. Due to olfactory system projections to prefrontal brain areas, OT has been hypothesized to enhance cognitive functions, but its effects have been studied predominantly in adults. This study tested OT effects on working memory (WM), i.e., the ability to store and manipulate information for a short time, in healthy children aged 6-9 years. We expected OT to improve olfactory WM and establish cross-modal transfer to visual and auditory WM. Participants performed 12 weeks of bi-daily OT with either 4 odours (lemon, eucalyptus, rose, cloves; OT group) or odourless propylene glycol (placebo group). Pre- and post-training, participants' WM was measured utilizing odours (olfactory WM) or pictures (visual WM) and a word-span task (auditory WM). 84 children (40 girls) completed the study. The analyses revealed no changes in the WM performance following OT. The olfactory WM task was the most difficult for children, highlighting the need to include olfactory-related tasks in educational programmes to improve children's odour knowledge and memory, just as they learn about sounds and pictures. Further neuroimaging research is needed to fully understand the impact of OT on cognitive functions in children.

Does Olfactory Training Improve Brain Function and Cognition? A Systematic Review

Olfactory training (OT), or smell training,consists of repeated exposure to odorants over time with the intended neuroplastic effect of improving or remediating olfactory functioning. Declines in olfaction parallel declines in cognition in various pathological conditions and aging. Research suggests a dynamic neural connection exists between olfaction and cognition. Thus, if OT can improve olfaction, could OT also improve cognition and support brain function? To answer this question, we conducted a systematic review of the literature to determine whether there is evidence that OT translates to improved cognition or altered brain morphology and connectivity that supports cognition. Across three databases (MEDLINE, Scopus, & Embase), 18 articles were identified in this systematic review. Overall, the reviewed studies provided emerging evidence that OT is associated with improved global cognition, and in particular, verbal fluency and verbal learning/memory. OT is also associated with increases in the volume/size of olfactory-related brain regions, including the olfactory bulb and hippocampus, and altered functional connectivity. Interestingly, these positive effects were not limited to patients with smell loss (i.e., hyposmia & anosmia) but normosmic (i.e., normal ability to smell) participants benefitted as well. Implications for practice and research are provided.

Olfactory training effects in children after mild traumatic brain injury

OBJECTIVE

Mild traumatic brain injury (mTBI) might impair the sense of smell and cognitive functioning. Repeated, systematic exposure to odors, i.e., olfactory training (OT) has been proposed for treatment of olfactory dysfunctions, including post-traumatic smell loss. Additionally, OT has been shown to mitigate cognitive deterioration in older population and enhance selected cognitive functions in adults. We aimed to investigate olfactory and cognitive effects of OT in the pediatric population after mTBI, likely to exhibit cognitive and olfactory deficits.

METHODS

Our study comprised 159 children after mTBI and healthy controls aged 6-16 years (M = 9.68 ± 2.78 years, 107 males), who performed 6-months-long OT with a set of 4 either high- or low-concentrated odors. Before and after OT we assessed olfactory functions, fluid intelligence, and executive functions.

RESULTS

OT with low-concentrated odors increased olfactory sensitivity in children after mTBI. Regardless of health status, children who underwent OT with low-concentrated odors had higher fluid intelligence scores at post-training measurement, whereas scores of children performing OT with high-concentrated odors did not change.

CONCLUSION

Our study suggests that OT with low-concentrated odors might accelerate rehabilitation of olfactory sensitivity in children after mTBI and support cognitive functions in the area of fluid intelligence regardless of head trauma.

Overnight olfactory enrichment using an odorant diffuser improves memory and modifies the uncinate fasciculus in older adults

OBJECTIVE

Cognitive loss in older adults is a growing issue in our society, and there is a need to develop inexpensive, simple, effective in-home treatments. This study was conducted to explore the use of olfactory enrichment at night to improve cognitive ability in healthy older adults.

METHODS

Male and female older adults (N = 43), age 60-85, were enrolled in the study and randomly assigned to an Olfactory Enriched or Control group. Individuals in the enriched group were exposed to 7 different odorants a week, one per night, for 2 h, using an odorant diffuser. Individuals in the control group had the same experience with de minimis amounts of odorant. Neuropsychological assessments and fMRI scans were administered at the beginning of the study and after 6 months.

RESULTS

A statistically significant 226% improvement was observed in the enriched group compared to the control group on the Rey Auditory Verbal Learning Test and improved functioning was observed in the left uncinate fasciculus, as assessed by mean diffusivity.

CONCLUSION

Minimal olfactory enrichment administered at night produces improvements in both cognitive and neural functioning. Thus, olfactory enrichment may provide an effective and low-effort pathway to improved brain health.

Altered Grey Matter-Brain Healthcare Quotient: Interventions of Olfactory Training and Learning of Neuroplasticity

Recent studies revealed that grey matter (GM) changes due to various training and learning experiences, using magnetic resonance imaging. In this study, we investigate the effect of psychological characteristics and attitudes toward training and learning on GM changes. Ninety participants were recruited and distributed into three groups: an olfactory training group that underwent 40 olfactory training sessions designed for odour classification tasks, a group classified for learning of neuroplasticity and brain healthcare using a TED Talk video and 28 daily brain healthcare messages, and a control group. Further, we assessed psychological characteristics, such as curiosity and personal growth initiatives. In the olfactory training group, we conducted a questionnaire survey on olfactory training regarding their interests and sense of accomplishment. In the olfactory training group, the GM change was significantly correlated with the sense of achievement and interest in training. The learning of neuroplasticity and brain healthcare group showed a significantly smaller 2-month GM decline than did the control group. The Curiosity and Exploration Inventory-II scores were significantly correlated with GM changes in both intervention groups only. In conclusion, our result suggested that training or learning with a sense of accomplishment, interest, and curiosity would lead to greater GM changes.

Olfactory loss is a predisposing factor for depression, while olfactory enrichment is an effective treatment for depression

The loss of olfactory stimulation correlates well with at least 68 widely differing neurological disorders, including depression, and we raise the possibility that this relationship may be causal. That is, it seems possible that olfactory loss makes the brain vulnerable to expressing the symptoms of these neurological disorders, while daily olfactory enrichment may decrease the risk of expressing these symptoms. This situation resembles the cognitive reserve that is thought to protect people with Alzheimer’s neuropathology from expressing the functional deficit in memory through the cumulative effect of intellectual stimulation. These relationships also resemble the functional response of animal models of human neurological disorders to environmental enrichment, wherein the animals continue to have the induced neuropathology, but do not express the symptoms as they do in a standard environment with restricted sensorimotor stimulation.

COVID-19 and olfactory dysfunction: a looming wave of dementia?

Olfactory dysfunction is a hallmark symptom of COVID-19 disease resulting from the SARS-CoV-2 virus. The cause of the sudden and usually temporary anosmia that most people suffer from COVID-19 is likely entirely peripheral-inflammation and other damage caused by the virus in the sensory epithelium inside the upper recesses of the nasal cavity can damage or prevent chemicals from properly activating the olfactory sensory neurons. However, persistent olfactory dysfunction from COVID-19, in the form of hyposmia and parosmia (decreased or altered smell) may affect as many as 15 million people worldwide. This epidemic of olfactory dysfunction is thus a continuing public health concern. Mounting evidence suggests that the SARS-CoV-2 virus itself or inflammation from the immune response in the nasal sensory epithelium may invade the olfactory bulb, likely via non-neuronal transmission. COVID-19-related long-term olfactory dysfunction and early damage to olfactory and limbic brain regions suggest a pattern of degeneration similar to that seen in early stages of Alzheimer's disease, Parkinson's disease, and Lewy body dementia. Thus, long-term olfactory dysfunction coupled with cognitive and emotional disturbance from COVID-19 may be the first signs of delayed onset dementia from neurodegeneration. Few treatments are known to be effective to prevent further degeneration, but the first line of defense against degeneration may be olfactory and environmental enrichment. There is a pressing need for more research on treatments for olfactory dysfunction and longitudinal studies including cognitive and olfactory function from patients who have recovered from even mild COVID-19.NEW & NOTEWORTHY More than 15 million people worldwide experience persistent COVID-19 olfactory dysfunction, possibly caused by olfactory bulb damage. SARS-CoV-2 can cause inflammation and viral invasion of the olfactory bulb, initiating a cascade of degeneration similar to Alzheimer's disease and Lewy body disease. People who have had even mild cases of COVID-19 show signs of degeneration in cortical areas connected with the olfactory system. These data suggest a wave of post-COVID dementia in the coming decades.

SARS-CoV-2 is associated with changes in brain structure in UK Biobank

There is strong evidence for brain-related abnormalities in COVID-19 1-13 . It remains unknown however whether the impact of SARS-CoV-2 infection can be detected in milder cases, and whether this can reveal possible mechanisms contributing to brain pathology. Here, we investigated brain changes in 785 UK Biobank participants (aged 51-81) imaged twice, including 401 cases who tested positive for infection with SARS-CoV-2 between their two scans, with 141 days on average separating their diagnosis and second scan, and 384 controls. The availability of pre-infection imaging data reduces the likelihood of pre-existing risk factors being misinterpreted as disease effects. We identified significant longitudinal effects when comparing the two groups, including: (i) greater reduction in grey matter thickness and tissue-contrast in the orbitofrontal cortex and parahippocampal gyrus, (ii) greater changes in markers of tissue damage in regions functionally-connected to the primary olfactory cortex, and (iii) greater reduction in global brain size. The infected participants also showed on average larger cognitive decline between the two timepoints. Importantly, these imaging and cognitive longitudinal effects were still seen after excluding the 15 cases who had been hospitalised. These mainly limbic brain imaging results may be the in vivo hallmarks of a degenerative spread of the disease via olfactory pathways, of neuroinflammatory events, or of the loss of sensory input due to anosmia. Whether this deleterious impact can be partially reversed, or whether these effects will persist in the long term, remains to be investigated with additional follow up.

Research Progress of Olfactory Nerve Regeneration Mechanism and Olfactory Training

The olfactory nerve (ON) is the only cranial nerve exposed to the external environment. Hence, it is susceptible to damage from head trauma, viral infection, inflammatory stimulation, and chemical toxins, which can lead to olfactory dysfunction. However, compared with all other cranial nerves, the ON is unique due to its inherent ability to regenerate. This characteristic provides a theoretical basis for treatment of olfactory dysfunction. Olfactory training (OT) is one of the main treatments for olfactory dysfunction. It is easy to apply and has few side-effects, and has been shown to be efficacious for patients with olfactory dysfunction of various causes. To further understand the application value of ON regeneration and OT on olfactory dysfunction, we review the research progress on the mechanism of ON regeneration and OT.