Delirium – A Vital Sign for COVID-19

While many adults infected with COVID-19 will present with a fever, cough, and varying degrees of respiratory distress, the presentation for those with dementia might be quite different and include delirium or altered mental status. Current guidelines for diagnosing COVID-19 do not call for an assessment of delirium, but for healthcare professionals caring for this population, delirium is routinely considered and can be identified quickly at the bedside.

Why is this significant? Early diagnosis is essential for survival and for mitigating the spread of the virus in senior living communities and post-acute and long-term care facilities. Waiting for a fever or cough to appear will delay treatment and for the frail elderly, especially those in these settings. 

Residents with moderate to severe frailty are at risk for delirium with any acute physical illness and deteriorate quickly. Those residing in congregate housing settings are at risk for increased contagion and easy spread of the virus. For these reasons, delirium — as a “vital sign” for COVID-19 — should be considered. Without an index of suspicion:

  • The diagnosis is missed while the infection is spreading.
  • The risk of mortality increases up to tenfold from delirium.
  • The sequelae will impact cognitive and functional abilities post-infection.

Contact us to learn more about bedside tools that can enable more efficient, productive telemedicine visits.

For more information: 

Shane O’Hanlon, Sharon K Inouye, Delirium: a missing piece in the COVID-19 pandemic puzzle, Age and Ageing, Volume 49, Issue 4, July 2020, Pages 497–498, https://doi.org/10.1093/ageing/afaa094

Christine F.Ward, Gary S.Figiel, William M.McDonald. Altered Mental Status as a Novel Initial Clinical Presentation for COVID-19 Infection in the Elderly. Am J of Geriatric Psychiatry 28;8 (2020) 808-811.  https://doi.org/10.1016/j.jagp.2020.05.013

 

Stories from the Field

Our COVID positive residents were cohorted on a unit separate from the dementia wing to prevent the spread of infection and limit the risk of contamination. Nonetheless, we had to watch our residents with dementia carefully. They all require extensive assistance with all their ADLs and rarely cooperate with wearing a mask during care or when moving about their unit. 

Because of these issues, it was not a surprise when two residents became ill and tested positive for COVID-19. What was surprising was that their only sign of change was the presence of an altered mental status. Our protocol was to test for COVID with any change in condition and so it was that these two residents were diagnosed. Chest x-rays were also ordered and were initially unremarkable.

Both residents had completed advance care planning (ACP) documents and did not want to be hospitalized. In notifying each of their health care agents of the diagnosis, their ACP decisions were again discussed:

  • One agent chose to have their mother treated in place, remaining in the setting where she was most familiar and with staff who would care for her and keep the family as engaged as possible. 
  • The other agent chose to have their mother sent to the hospital for care because so many residents have died in the nursing home that they thought their mother might do better in an acute care facility. 
  • These decisions are not easy for the family or the staff and everyone wants what is best for the resident who is vulnerable now due to underlying frailty and cognitive impairment.
  • Both residents are recovering from the infection but it is uncertain whether they will return to their pre-illness functional and cognitive status.

These cases show that COVID-19 can’t be addressed in a vacuum and that it may manifest in different ways for different patients. The key is to be alert to the variety of presentations of illness, to have a clearly communicated and consistently followed diagnostic protocol, effective and up-to-date ACP, and engagement of family members.

“Altered Mental Status may be one of the first signs of COVID-19 infection in individuals with dementia.” (Ward, 2020)