Delirium can signal COVID-19 in the elderly

Elderly people admitted to the emergency room (ED) and diagnosed with SARS-CoV-2 infection often presented with delirium and no other COVID-19 symptoms, a multicenter cohort study showed.

About 28% of COVID-19 patients aged 65 years or older presented to ED with delirium, and delirium was a primary symptom in 16% of these patients, reported Maura Kennedy, MD, MPH, del Massachusetts General Hospital in Boston and co-authors.

More than a third (37%) of patients with delirium did not have the typical signs of COVID-19 such as fever or shortness of breath, they wrote in JAMA Network Open.

Delirium was the sixth most common presenting symptom in the elderly. “Other atypical symptoms were also common; 11% of patients reported a fall and 9% reported dizziness or fainting,” Kennedy said.

“Typical symptoms of COVID-19 were absent in many elderly patients in this study. Only 56 percent of patients reported fever and 50 percent cough,” he said. MedPage today.

“Delirium is often a health barometer for the elderly, which means it can be a very sensitive indicator when something goes wrong,” noted co-author Sharon Inouye, MD, MPH, of Harvard Medical School. It serves as an atypical presentation of many diseases, “and unsurprisingly it is also a common presentation for COVID-19 infection in the elderly in the emergency room,” he noted.

“What is surprising is how often the delusion continues to be overlooked,” Inouye said MedPage today. While the CDC lists “new confusion” as an emergency COVID-19 warning sign on its website, the delusion is not on the agency’s reporting form or the top symptom checklist that many sites use to determine who. is being tested, Inouye said. This means that some cases of COVID-19 in older patients may not be detected, he pointed out.

“Some experts have argued that this omission may have contributed to the large number of deaths observed in nursing homes,” he said. “The elderly may have been sent back without testing – since COVID-19 was not suspected when they had ‘only’ delirium – and continued to spread infections in their facilities.”

Delirium has been linked to COVID-19 in other research. A prospective study showed that encephalopathy was the most common new-onset neurologic manifestation seen in hospitalized COVID-19 patients, with a rate of 6.8%. Retrospective reports have shown an even higher prevalence of delirium or encephalopathy, although some have not made fun of the roles that sedation or pre-existing conditions may play.

In this analysis, Kennedy and colleagues studied 817 older adults with COVID-19 who showed up at one of seven ED sites in the United States on March 13, 2020 or later. COVID-19 was diagnosed by polymerase chain reaction (PCR) with positive nasal swab test for SARS-CoV-2 (99% of cases) or chest X-ray or CT showing the classic appearance of COVID-19 and the distribution of frosted glass opacities (1%). Delirium was identified from medical record review, with uncertain cases awarded by at least two clinical experts. Some sites routinely used delirium screening tools.

About half (47%) of the study participants were men. Most (62%) were white, 27% black and 7% Hispanic or Latino. The median age was approximately 78 years.

The most common presenting symptoms in ED were fever (56%), shortness of breath (51%), cough (50%), hypoxia (40%) and weakness (30%), followed by delirium (28%), fatigue (26%), diarrhea (16%) and anorexia (15%). The incidence of delirium was higher than had typically been reported in ED studies prior to COVID-19, which ranged from 7% to 20%, the researchers noted.

Symptoms of delirium included impaired consciousness (54%), disorientation (43%), hypoactive delirium symptoms (20%), and symptoms of agitation or hyperactive delirium (16%).

Factors associated with the risk of delirium included age over 75, previous use of psychoactive drugs, assisted residency or residency in qualified nursing facilities, vision or hearing problems, stroke, and Parkinson’s disease. (Dementia and mental health conditions were removed from this analysis due to multicollinearity.) Delirium at presentation was significantly associated with an increased risk of adverse hospital outcomes, including ICU stay, hospital discharge. rehabilitation and death.

The findings echoed what vendors witnessed in the early days of the pandemic, noted Jennifer Frontera, MD, of NYU Langone Health, who was not involved in the study.

“A lot of older people were waiting to come to the hospital,” Frontera said MedPage today. “They were delayed until they were really in bad shape, or they were confused and that’s when the family brought them here.”

The research had several limitations, Kennedy and co-authors noted. Most EDs do not routinely screen for delirium, and research staff have not been admitted into EDs due to infection control policies, so prevalence may be underestimated. A large percentage of patients came from assisted living facilities or nursing homes (36%) or had previously been diagnosed with dementia (30%) and the results may not apply to other populations. Because the study focused on delirium as a presenting symptom, it lacked data on factors that could prevent it during hospitalization.