Study suggests delirium is common in older patients with COVID-19 presenting to emergency department

DG Alerts

Findings from a study published in JAMA Network Open suggest that delirium is common and often seen without other typical symptoms or signs in older adults with coronavirus disease 2019 (COVID-19) presenting to the emergency department. In addition, delirium was associated with poor hospital outcomes and death.

“In this cohort study of 817 older patients with COVID-19, 28% had delirium at presentation, and delirium was the sixth most common of all presenting symptoms and signs,” wrote Maura Kennedy, MD, Massachusetts General Hospital, Boston, Massachusetts, and colleagues. “Among delirious patients, 16% presented with delirium as a primary symptom and 37% had no typical COVID-19 symptoms or signs, such as cough or fever.”

Common symptoms of delirium reported included impaired consciousness (54%), disorientation (43%), hypoactive delirium symptoms (20%), and agitation or hyperactive delirium symptoms (16%). Of all patients who had delirium, 50% presented to the emergency department within 2 days of onset of delirium and the vast majority (94%) were hospitalized.

Study data showed that age older than 75 years (adjusted relative risk [aRR], 1.51; 95% confidence interval [CI], 1.17-1.95), living in a nursing home or assisted living (aRR, 1.23; 95% CI, 0.98-1.55), prior use of psychoactive medication (aRR, 1.42; 95% CI, 1.11-1.81), vision impairment (aRR, 1.98; 95% CI, 1.54-2.54), hearing impairment (aRR, 1.10; 95% CI 0.78-1.55), stroke (aRR, 1.47; 95% CI, 1.15-1.88), and Parkinson disease (aRR, 1.88; 95% CI, 1.30-2.58) were associated with delirium.

In addition, delirium was associated with intensive care unit stay (aRR = 1.67; 95% CI, 1.30-2.15), discharge to a rehabilitation facility (aRR, 1.55, 95% CI, 1.07-2.26), and death (aRR = 1.24; 95% CI, 1.00-1.55).

All patients in the study cohort were aged 65 years and older and had presented to emergency departments across 7 sites in the United States on or after March 13, 2020, and subsequently tested positive for severe acute respiratory syndrome coronavirus 2 by nasal swab (99% of cases) or classic radiological findings (1%). Of the patients, 386 (47%) were male, 493 (62%) were White, 215 (27%) were Black, and 54 (7%) were Latino. The mean age of the patients was 77.7 years and 213 (26%) resided in a skilled nursing facility.

“These findings suggest the clinical importance of including delirium on checklists of presenting signs and symptoms of COVID-19 that guide screening, testing, and evaluation,” the authors wrote. “Our study demonstrates that it is critical to recognize that older adults with COVID-19 may present with delirium as the primary or sole symptom. In addition, delirium is an important risk marker to identify patients at high risk for poor outcomes, including death.”

“Future studies will be critical to evaluate the preventable nature of delirium in COVID-19 and the effectiveness of tested intervention strategies, such as the Hospital Elder Life Program or the ABCDEF bundle, to reduce the severity and duration of delirium and the occurrence of associated complications,” the authors noted. “Adding delirium as a common presenting symptom of COVID-19 will keep important cases from being missed and allow earlier identification and management of vulnerable patients at high risk for poor outcomes.”