Letter to the Editor     July 2021  

Delirium in COVID-19: “New Normal” for Care of Older Adults

By Sadaf Sheikh1

Affiliations

  1. Department of Emergency Medicine, Sultan Qaboos University Hospital, Muscat, Oman

Sir,

SARS-CoV-2 pandemic started in later 2019 from China 1 and poses health and social risks to all ages. This includes adults above 65 years and older, which account for 30-40% of individuals who suffered from COVID-19.1 The Centers for Disease Control and Prevention reported that 81% mortality occurred in persons above 65 years.1 During lockdowns due to COVID-19 pandemic, delirium emerged as one of the complications of COVID-19 with high prevalence and mortality rate. It is also referred as ‘acute brain failure’ and was associated with grim prognosis.

Delirium is one of the presenting symptoms of COVID-19 infection and was found in 28% of 817 patients aged ≥65 years, who came to the emergency department.1,2 Another study showed delirium as primary symptom in 16% patients and 37% among those who had no respiratory symptoms. 2 As there is a high chance of missed diagnosis in COVID-19 infection, it is essential for emergency physicians and other practitioners to recognise such unusual presentations through screening instruments. The ultra-brief confusion assessment method can be completed in one minute to screen delirium in older patients.2,3

Direct neurologic invasion of the central nervous system by COVID-19 virus could be the etiology of delirium; however, other factors include cytokine storm, immune irregularity, hypercoagulability, neuro-inflammation, psychoactive medications, ICU stay, mechanical ventilation, sleep disturbances and social isolation.2-4 Hospital policies to ban visiting hours for families enhance the emotional stress of patients, resulting in severe social isolation, which could be thought of opposite strategies to what are usually considered as well known factors to avoid delirium in elderly.

These reversible factors causing delirium could be addressed with creative strategies such as introducing computers for remote communication with family members and caregivers.4 Patients need to be encouraged to move around in the room and frequent medication review to avoid psychotropic effects of medications. Delirium should be screened in all older adults and there is a need to actively look into the causative factors of delirium. Meanwhile, strategies should be developed to prevent it. Family members could play a vital role in it and should be allowed to be a part of care-provision for these vulnerable adults.

PATIENTS’ CONSENT:
Not applicable.

CONFLICT OF INTEREST: 
None to declare.

AUTHOR’S CONTRIBUTION:
SS: Drafted and edited the manuscript solely.

REFERENCES

  1. Garcez FB, Aliberti  MJR, Poco  PCE, Hiratsuka M, Takahashi SDF, Coelho VA, et al.  Delirium and adverse outcomes in hospitalised patients with COVID-19. J Am Geriatr Soc 2020; 68(11):2440-6. doi: 10.1111/jgs.16803.
  2. Helms J, Kremer  S, Merdji  H, Clere-Jehl R, Schenck M,  Kummerlen C, et al.  Neurologic features in severe SARS-CoV-2 infection. N Engl J Med 2020; 382(23):2268-70. doi: 10.1056/NEJMc2008597.
  3. Poloni TE, Carlos  AF, Cairati  M, Cutaia C, Medici V, Marelli E, et al.  Prevalence and prognostic value of delirium as the initial presentation of COVID-19 in the elderly with dementia: An Italian retrospective study. E Clin Med  2020; 26:100490. doi: 10.1016/j.eclinm.2020.100490.  
  4. Kennedy M, Helfand  BKI, Gou  RY, Gartaganis SL, Webb M, Moccia JM, et al. Delirium in older patients with COVID-19 presenting to the emergency department. JAMA Netw Open 2020; 3(11):e2029540. doi: 10.1001/jamanetworkopen. 2020.29540