The Elephant in the Room: Delirium is an Often-Missed COVID Symptom

Delirium is a medical emergency in frail, elderly people, and it often is the only presenting sign of COVID-19 in this population. However, delirium is often overlooked or misinterpreted. I remember a friend telling me that when she reported signs of delirium in her hospitalized elderly mother, the nurse shrugged it off and said she was probably just ‘tired.’ Delirium needs immediate attention now more than ever; and when delirium is the presenting and only sign of COVID-19, the assessment and management challenges take on even greater urgency.

One recently published study in JAMA Network Open provides adequate support for screening for COVID-19 when delirium is the presenting sign of this serious infection for older adults coming to the emergency department, especially from a nursing home or assisted living setting.


The Evidence Is In: Follow the Delirium 

This study enrolled patients, aged 65 years or older, presenting to the emergency department and diagnosed with COVID-19:

  • 817 patients were examined, 213 (26%) resided in a skilled nursing facility
  • 226 patients (28%) had delirium at presentation
  • 37 (16%) had delirium as a primary presenting complaint
  • 84 (37%) patients with delirium had no fever or shortness of breath 

In all, 14 chronic comorbid conditions were tabulated and the most frequent 6 were diabetes, cognitive impairment/dementia, mental health conditions, COPD, chronic kidney disease, and stroke. All of the conditions impact either function or cognition and are accounted for in the calculation of the Frailty Risk Score. The presence of 4 or more of the 14 chronic conditions was associated with a significant 1.58-fold increased risk for delirium.  

Of the 226 patients with delirium as their only presenting symptom:

  • 213 (84%) were admitted to the hospital
  • 72 (34%) spent time in ICU
  • 42 (58%) received mechanical ventilation
  • 84 (37%) of the 213 admitted died in hospital


How Should We Respond

This study clearly suggests that delirium is a strong risk factor for poor outcomes, along with the presence of multiple chronic conditions increasing the risk for delirium. Long before the pandemic, delirium has been identified as a geriatric syndrome, significant enough to be considered a medical emergency. Likewise, frailty is known to be the most significant risk factor for adverse outcomes for this population.

Knowing that delirium can be the presenting sign of COVID-19 in a population of frail patients can remind us to refresh our understanding of delirium assessment and management. Knowing that frailty increases the risk for a sudden and significant decline in the face of a new stressor, such as COVID-19, can lead us to consider stratifying our most frail patients and assessing their mental status for subtle changes that may be the precursor of delirium. This combined approach will help to identify patients earlier and allow for a more proactive approach to their care including the discussion of their priorities for future health care.

If you have any questions or are interested in learning more about Patient Pattern, contact our team. We’ll be happy to assist!