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Add delirium to the checklist of COVID-19 symptoms in the elderly




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Delirium According to a multicenter study of elderly people visiting the emergency department, it should be included in the checklist for the signs and symptoms of COVID-19, especially in the elderly.

According to one study, 28% of the 817 elderly people who visited the emergency department and were diagnosed with COVID-19 suffered from delirium. Published online November 19th JAMA network open.. In addition, 16% of these patients suffered from delirium without the typical symptoms and signs of SARS-CoV-2 infection.

Patients with delirium were more likely to be admitted to the intensive care unit than patients without delirium (adjusted relative risk) [aRR], 1.67; 95% CI, 1.30 – 2.15), and high likelihood of death (aRR, 1.24; 95% CI, 1.00 – 1.55).

Dr. Maura Kennedy

“These findings suggest the clinical importance of including delirium in a checklist of signs and symptoms of COVID-19 that guides screening, testing, and evaluation,” said Maura Kennedy, MD, MPH, and A colleague writes.

Kennedy, an emergency department doctor and assistant professor at Massachusetts General Hospital, explained, “I had definitely seen cases of delirium without other symptoms of COVID-19, but there was not much data on its frequency.” .. Majored in Emergency Medicine at Harvard Medical School in Boston.

“And compared to what was seen in the non-COVID study of delirium, the rate was somewhat surprising, but then our research group came from a long-term care facility and previously stroke Hyperactivity disorder and agitation were also seen, but the most common form of delirium was hypoactivity drowsiness and unresponsiveness.

Kennedy believes that adding delirium as a common symptom to the diagnostic checklist will prevent some cases from being missed and enable early detection and management of COVID-19 patients at high risk of poor outcome. I will. “We certainly don’t want to send them back to the care facility without diagnosing them or promote the infection in the hospital,” she said. Medscape Medical News..

That step has already been carried out at several US centers. “Delirium has been our focus since early summer,” said Angelacatic, MD, an geriatric scholar who is an assistant professor at the Huffington Aging Center at Baylor College of Medicine and the Michael E. Devaki VA Medical Center in Houston, Texas. I am.

“If you have delirium, you’re looking for COVID-19,” said Katick, who wasn’t involved in the study.

In Catic’s experience, it is “not unusual” to see a patient whose only symptom of COVID-19 is delirium. Like other infections and illnesses, “the aged brain is very vulnerable,” she said.

William W. Associate Professor of Geriatrics and Palliative Medicine at Mount Sinai School of Medicine, New York City. According to Hung, MD, and MPH, delirium is “generally a common sign of serious problems” in the elderly. “In the case of COVID-19, the hypoxia caused by infection can play a role,” he said. Medscape Medical News.. He agreed that delirium should be included in the differential diagnosis of COVID-19, but he said the frequency with which it was the only symptom at the time of presentation would need to be determined in a fairly large population. It was.

Dr. Christopher R. Carpenter

Joining the company of people observing the symptoms of COVID-19 is Christopher R. Carpenter, a professor of emergency medicine at the University of Washington in St. Louis, St. Louis, Missouri. He was not a participant in the current study.

“I absolutely saw and recorded delirium as the chief complaint of an elderly adult patient who was finally diagnosed with SARS-CoV-2. Since March, I have considered SARS-CoV-2 every time I identify delirium. “We do,” Carpenter said. Medscape Medical News.. “Honestly, I (and most of my colleagues) have recently considered SARS-CoV-2 for a variety of symptoms and complaints because of the strange symptoms we all encountered.”

Details of the study

In this study, Kennedy and colleagues enrolled consecutive adults aged 65 and over who were diagnosed with Active COVID-19 and visited the emergency departments of seven centers in Massachusetts, Maine, Connecticut, Michigan, and North Carolina after March 13. did. 2020. SARS-CoV-2 active infection is based on the results of a nasal swab polymerase chain reaction test (99% of cases) or the appearance and distribution of frosted glassy shadows on chest radiographs or CT (1%). It was decided.

Of the 817 patients enrolled, 386 (47%) were male, 493 (62%) were white, 215 (27%) were black, and 54 (7%) were Hispanic or Latin. .. The mean age of the patients was 77.7 years (standard deviation, 8.2). Their age was at risk for chronic comorbidities and cognitive impairment. In fact, 15% had at least four chronic illnesses and 30% had pre-existing cognitive impairment.

The authors state that of the 226 patients (28%) who suffered from delirium at the time of presentation, 60 (27%) experienced delirium for 2-7 days.

In addition, of the 226 patients who showed delirium as the main symptom, 84 (37%) did not show typical COVID-19 symptoms or signs such as cough, fever, and shortness of breath.

The presence of delirium did not correlate with any of the particularly typical COVID-19 symptoms. Kennedy said that only 56% of patients in the cohort had a fever in the presentation.

Delirium at presentation was median hospital stay greater than 8 days (aRR, 1.14; 95% CI, .97 – 1.35) and increased risk of discharge to rehabilitation facilities (aRR, 1.55; 95% CI, 1.07). Was significantly associated with. – 2.26). Factors associated with delirium include age 75 and older, living in a nursing home or living support facility, previous use of psychotropic drugs, visual impairment, Hearing impairment, Stroke, and Parkinson’s disease..

Kennedy stated that the rate of delirium observed in this study was much higher than that commonly reported in emergency department studies conducted prior to the COVID-19 pandemic. In these studies, delirium rates ranged from 7% to 20%. However, the associated risk factors are similar.

“The increased evidence confirms the high incidence of delirium and other neuropsychiatric symptoms with COVID-19, with previously reported 22% to 33% of hospitalized patients,” Kennedy and his colleagues said. Is writing.

In Carpenter’s view, in contrast to delirium at the time of presentation, the onset of accidental delirium while receiving care in the emergency department is exacerbated by the non-visitor policy mandated by the pandemic and is exacerbated by the individual’s. It even prevents visits from caregivers. Patients with moderate to severe dementia. “Healthcare systems need to be aware of the risks that spread to uninfected caregivers, but having one caregiver at the bedside can prevent delirium in patients with cognitive impairment, which is a risk. We need to find a balance of interests, “Carpenter said. I am involved in my current research.

Among the barriers to improving the situation, Carpenter cited the lack of regular delirium screening and the lack of quality evidence to support emergency department intervention to alleviate delirium.

“When these challenges are layered on COVID-19’s rapidly evolving diagnostic environment, frequent atypical symptoms, and asymptomatic carriers across all age groups, the negative effects of delirium are exacerbated,” Carpenter said. Stated.

When elderly patients are hospitalized, Kennedy recommends non-pharmacological guidelines Hospital Eelder Help Program To reduce the risk of delirium. Recommendations include proper sleep, hydration, and nutrition, as well as functional recovery, sediment avoidance, and diversion.

This study was partially supported by the National Institute on Aging and the Massachusetts Medical College. The authors Carpenter, Hung, and Catic do not disclose the relevant financial relationships.

JAMA network opened. Published online on November 19, 2020. Full text

Diana Swift is a medical journalist based in Toronto, Canada.She can reach at [email protected]..

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