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Emergency Medicine

Delirium in Older Patients With COVID-19 Presenting to the Emergency Department

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
JAMA Network Open
November 19, 2020
Original Investigation
Maura Kennedy, MD, MPH1,2;
Benjamin K. I. Helfand, MSc3,4,5;
Ray Yun Gou, MA6;
Sarah L. Gartaganis, MSW, MPH6;
Margaret Webb, BA6;
J. Michelle Moccia, DNP, ANP-BC, GS-C7;
Stacey N. Bruursema, LMSW-C7;
Belinda Dokic, MHA7;
Brigid McCulloch, DO7;
Hope Ring, MD7;
Justin D. Margolin, BS1;
Ellen Zhang, BA8;
Robert Anderson, MD9;
Rhonda L. Babine, MS, APRN, ACNS-BC9,10;
Tammy Hshieh, MD, MPH11;
Ambrose H. Wong, MD, MSEd12;
R. Andrew Taylor, MD, MHS12;
Kathleen Davenport, MD13;
Brittni Teresi, BA13;
Tamara G. Fong, MD, PhD6,8;
Sharon K. Inouye, MD, MPH6,14
Author Affiliations
  • 1Department of Emergency Medicine, Massachusetts General Hospital, Boston
  • 2Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
  • 3Department of Emergency Medicine, University of Massachusetts Medical School, Worcester
  • 4Department of Psychiatry and Human Behavior and Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
  • 5Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
  • 6Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
  • 7Emergency Medicine, St Mary Mercy Livonia Hospital, Livonia, Michigan
  • 8Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
  • 9Department of Emergency Medicine, Maine Medical Center, Portland
  • 10Department of Clinical Nursing Resources, Maine Medical Center, Portland
  • 11Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 12Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
  • 13Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
  • 14Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Key Points

Question  How frequently do older adults (aged ≥65 years) with coronavirus disease 2019 (COVID-19) present to the emergency department (ED) with delirium?

Findings  In this cohort study of 817 older ED patients with COVID-19, 28% had delirium at presentation, and delirium was the sixth most common of all presenting symptoms and signs. 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.

Meaning  These findings suggest that older adults with COVID-19 commonly present to the ED with delirium and that delirium should be considered an important presenting symptom of COVID-19.

Abstract

Importance  Delirium is common among older emergency department (ED) patients, is associated with high morbidity and mortality, and frequently goes unrecognized. Anecdotal evidence has described atypical presentations of coronavirus disease 2019 (COVID-19) in older adults; however, the frequency of and outcomes associated with delirium in older ED patients with COVID-19 infection have not been well described.

Objective  To determine how frequently older adults with COVID-19 present to the ED with delirium and their associated hospital outcomes.

Design, Setting, and Participants  This multicenter cohort study was conducted at 7 sites in the US. Participants included consecutive older adults with COVID-19 presenting to the ED on or after March 13, 2020.

Exposure  COVID-19 was diagnosed by positive nasal swab for severe acute respiratory syndrome coronavirus 2 (99% of cases) or classic radiological findings (1% of cases).

Main Outcomes and Measures  The primary outcome was delirium as identified from the medical record according to a validated record review approach.

Results  A total of 817 older patients with COVID-19 were included, of whom 386 (47%) were male, 493 (62%) were White, 215 (27%) were Black, and 54 (7%) were Hispanic or Latinx. The mean (SD) age of patients was 77.7 (8.2) years. Of included patients, 226 (28%) had delirium at presentation, and delirium was the sixth most common of all presenting symptoms and signs. Among the patients with delirium, 37 (16%) had delirium as a primary symptom and 84 (37%) had no typical COVID-19 symptoms or signs, such as fever or shortness of breath. Factors associated with delirium were age older than 75 years (adjusted relative risk [aRR], 1.51; 95% 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). Delirium was associated with intensive care unit stay (aRR, 1.67; 95% CI, 1.30-2.15) and death (aRR, 1.24; 95% CI, 1.00-1.55).

Conclusions and Relevance  In this cohort study of 817 older adults with COVID-19 presenting to US emergency departments, delirium was common and often was seen without other typical symptoms or signs. In addition, delirium was associated with poor hospital outcomes and death. 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.

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Emergency Medicine Geriatrics Coronavirus (COVID-19)
Article Information

Accepted for Publication: October 19, 2020.

Published: November 19, 2020. doi:10.1001/jamanetworkopen.2020.29540

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Kennedy M et al. JAMA Network Open.

Corresponding Author: Maura Kennedy, MD, MPH, Department of Emergency Medicine, Massachusetts General Hospital, 5 Emerson Pl, 119B, Boston, MA 02114 (mkennedy8@partners.org).

Author Contributions: Ms Gou and Dr Inouye had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Dr Kennedy and Mr Helfand contributed equally as co–first authors. Drs Fong and Inouye contributed equally as co–senior authors.

Concept and design: Kennedy, Helfand, Moccia, Ring, Babine, Hshieh, Inouye.

Acquisition, analysis, or interpretation of data: Kennedy, Helfand, Gou, Gartaganis, Webb, Bruursema, Dokic, McCulloch, Ring, Margolin, Zhang, Anderson, Babine, Hshieh, Wong, Taylor, Davenport, Teresi, Fong, Inouye.

Drafting of the manuscript: Kennedy, Helfand, Gou, Gartaganis, Moccia, Margolin, Babine, Taylor, Fong, Inouye.

Critical revision of the manuscript for important intellectual content: Kennedy, Helfand, Gou, Webb, Bruursema, Dokic, McCulloch, Ring, Zhang, Anderson, Babine, Hshieh, Wong, Davenport, Teresi, Fong, Inouye.

Statistical analysis: Kennedy, Gou, McCulloch, Ring, Inouye.

Obtained funding: Inouye.

Administrative, technical, or material support: Kennedy, Gartaganis, Webb, Hshieh, Wong, Taylor, Davenport, Teresi, Inouye.

Supervision: Dokic, Ring, Fong, Inouye.

Conflict of Interest Disclosures: Mr Helfand participates in an MD/PhD training program that is supported by a grant from the National Institute of General Medical Sciences. Dr Wong reported receiving grants from National Center for Advancing Translational Sciences and Robert E. Leet and Clara Guthrie Patterson Trust outside the submitted work. Dr Inouye holds the Milton and Shirley F. Levy Family Chair at Hebrew SeniorLife/Harvard Medical School. No other disclosures were reported.

Funding/Support: This work was supported in part by grant R24AG054259 (to Dr Inouye) from the National Institute on Aging and grant T32GM107000 (to Mr Helfand) from the MSTP Training Program at the University of Massachusetts Medical School.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Dr Inouye is an associate editor of JAMA Network Open but was not involved in any of the decisions regarding review of the manuscript or its acceptance.

Additional Contributions: This work is dedicated to the memory of Joshua B. I. Helfand, Steven F. Hamilton, and Daniel S. Snyder who inspired this work. We thank the full research teams at each of the study sites whose timely and dedicated assistance helped to make this expedited coronavirus disease 2019 study possible.

References
1.
World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19. Published March 11, 2020. Accessed June 22, 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
2.
Trump  DJ . Proclamation on declaring a national emergency concerning the novel coronavirus disease (COVID-19) outbreak. White House website. Published March 13, 2020. Accessed September 1, 2020. https://www.whitehouse.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/
3.
United Nations Department of Economic and Social Affairs. UNStats COVID-19 response. Published 2020. Accessed September 14, 2020. https://covid-19-data.unstatshub.org/
4.
Stokes  EK , Zambrano  LD , Anderson  KN ,  et al.  Coronavirus disease 2019 case surveillance: United States, January 22-May 30, 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(24):759-765. doi:10.15585/mmwr.mm6924e2PubMedGoogle ScholarCrossref
5.
US Census Bureau. National population by characteristics: 2010–2019. Published June 17, 2020. Accessed October 18, 2020. https://www.census.gov/data/tables/time-series/demo/popest/2010s-national-detail.html
6.
Centers for Disease Control and Prevention. Provisional COVID-19 death counts by sex, age, and state. Published 2020. Accessed June 26, 2020. https://data.cdc.gov/NCHS/Provisional-COVID-19-Death-Counts-by-Sex-Age-and-S/9bhg-hcku
7.
Kennedy  M , Enander  RA , Tadiri  SP , Wolfe  RE , Shapiro  NI , Marcantonio  ER .  Delirium risk prediction, healthcare use and mortality of elderly adults in the emergency department.   J Am Geriatr Soc. 2014;62(3):462-469. doi:10.1111/jgs.12692PubMedGoogle ScholarCrossref
8.
Suffoletto  B , Miller  T , Frisch  A , Callaway  C .  Emergency physician recognition of delirium.   Postgrad Med J. 2013;89(1057):621-625. doi:10.1136/postgradmedj-2012-131608PubMedGoogle ScholarCrossref
9.
MacLullich  AM , Hall  RJ .  Who understands delirium?   Age Ageing. 2011;40(4):412-414. doi:10.1093/ageing/afr062PubMedGoogle ScholarCrossref
10.
Oh  ES , Fong  TG , Hshieh  TT , Inouye  SK .  Delirium in older persons: advances in diagnosis and treatment.   JAMA. 2017;318(12):1161-1174. doi:10.1001/jama.2017.12067PubMedGoogle ScholarCrossref
11.
Ahmad  I , Rathore  FA .  Neurological manifestations and complications of COVID-19: a literature review.   J Clin Neurosci. 2020;77:8-12. doi:10.1016/j.jocn.2020.05.017PubMedGoogle ScholarCrossref
12.
Perry  A , Macias Tejada  J , Melady  D .  An approach to the older patient in the emergency department.   Clin Geriatr Med. 2018;34(3):299-311. doi:10.1016/j.cger.2018.03.001PubMedGoogle ScholarCrossref
13.
Alkeridy  WA , Almaghlouth  I , Alrashed  R ,  et al.  A unique presentation of delirium in a patient with otherwise asymptomatic COVID-19.   J Am Geriatr Soc. 2020;68(7):1382-1384. doi:10.1111/jgs.16536PubMedGoogle ScholarCrossref
14.
Beach  SR , Praschan  NC , Hogan  C ,  et al.  Delirium in COVID-19: a case series and exploration of potential mechanisms for central nervous system involvement.   Gen Hosp Psychiatry. 2020;65:47-53. doi:10.1016/j.genhosppsych.2020.05.008PubMedGoogle ScholarCrossref
15.
Butt  I , Sawlani  V , Geberhiwot  T .  Prolonged confusional state as first manifestation of COVID-19.   Ann Clin Transl Neurol. 2020;7(8):1450-1452. doi:10.1002/acn3.51067PubMedGoogle ScholarCrossref
16.
Hosseini  AA , Shetty  AK , Sprigg  N , Auer  DP , Constantinescu  CS .  Delirium as a presenting feature in COVID-19: neuroinvasive infection or autoimmune encephalopathy?   Brain Behav Immun. 2020;88:68-70. doi:10.1016/j.bbi.2020.06.012PubMedGoogle ScholarCrossref
17.
Tay  HS , Harwood  R .  Atypical presentation of COVID-19 in a frail older person.   Age Ageing. 2020;49(4):523-524. doi:10.1093/ageing/afaa068PubMedGoogle ScholarCrossref
18.
Docherty  AB , Harrison  EM , Green  CA ,  et al.  Features of 20,133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study.   BMJ. 2020;369:m1985. doi:10.1136/bmj.m1985PubMedGoogle ScholarCrossref
19.
Garcez  FB , Aliberti  MJR , Poco  PCE ,  et al.  Delirium and adverse outcomes in hospitalized patients with COVID-19.   J Am Geriatr Soc. Published online August 24, 2020. doi:10.1111/jgs.16803PubMedGoogle Scholar
20.
Helms  J , Kremer  S , Merdji  H ,  et al.  Neurologic features in severe SARS-CoV-2 infection.   N Engl J Med. 2020;382(23):2268-2270. doi:10.1056/NEJMc2008597PubMedGoogle ScholarCrossref
21.
Chen  T , Wu  D , Chen  H ,  et al.  Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study.   BMJ. 2020;368:m1091. doi:10.1136/bmj.m1091PubMedGoogle ScholarCrossref
22.
Inouye  SK , Leo-Summers  L , Zhang  Y , Bogardus  ST  Jr , Leslie  DL , Agostini  JV .  A chart-based method for identification of delirium: validation compared with interviewer ratings using the confusion assessment method.   J Am Geriatr Soc. 2005;53(2):312-318. doi:10.1111/j.1532-5415.2005.53120.xPubMedGoogle ScholarCrossref
23.
Fong  TG , Jones  RN , Shi  P ,  et al.  Delirium accelerates cognitive decline in Alzheimer disease.   Neurology. 2009;72(18):1570-1575. doi:10.1212/WNL.0b013e3181a4129aPubMedGoogle ScholarCrossref
24.
Fong  TG , Jones  RN , Marcantonio  ER ,  et al.  Adverse outcomes after hospitalization and delirium in persons with Alzheimer disease.   Ann Intern Med. 2012;156(12):848-856. doi:10.7326/0003-4819-156-12-201206190-00005PubMedGoogle ScholarCrossref
25.
Gross  AL , Jones  RN , Habtemariam  DA ,  et al.  Delirium and long-term cognitive trajectory among persons with dementia.   Arch Intern Med. 2012;172(17):1324-1331. doi:10.1001/archinternmed.2012.3203PubMedGoogle ScholarCrossref
26.
Saczynski  JS , Kosar  CM , Xu  G ,  et al.  A tale of two methods: chart and interview methods for identifying delirium.   J Am Geriatr Soc. 2014;62(3):518-524. doi:10.1111/jgs.12684PubMedGoogle ScholarCrossref
27.
Davis  DHJ , Muniz Terrera  G , Keage  H ,  et al.  Delirium is a strong risk factor for dementia in the oldest-old: a population-based cohort study.   Brain. 2012;135(pt 9):2809-2816. doi:10.1093/brain/aws190PubMedGoogle ScholarCrossref
28.
Zou  G .  A modified Poisson regression approach to prospective studies with binary data.   Am J Epidemiol. 2004;159(7):702-706. doi:10.1093/aje/kwh090PubMedGoogle ScholarCrossref
29.
Barron  EA , Holmes  J .  Delirium within the emergency care setting, occurrence and detection: a systematic review.   Emerg Med J. 2013;30(4):263-268. doi:10.1136/emermed-2011-200586PubMedGoogle ScholarCrossref
30.
Inouye  SK , Westendorp  RG , Saczynski  JS .  Delirium in elderly people.   Lancet. 2014;383(9920):911-922. doi:10.1016/S0140-6736(13)60688-1PubMedGoogle ScholarCrossref
31.
Han  JH , Morandi  A , Ely  EW ,  et al.  Delirium in the nursing home patients seen in the emergency department.   J Am Geriatr Soc. 2009;57(5):889-894. doi:10.1111/j.1532-5415.2009.02219.xPubMedGoogle ScholarCrossref
32.
Joseph  NP , Reid  NJ , Som  A ,  et al.  Racial/ethnic disparities in disease severity on admission chest radiographs among patients admitted with confirmed COVID-19: a retrospective cohort study.   Radiology. Published online July 6, 2020. doi:10.1148/radiol.2020202602PubMedGoogle Scholar
33.
Zhu  J , Ji  P , Pang  J ,  et al.  Clinical characteristics of 3062 COVID-19 patients: a meta-analysis.   J Med Virol. Published online April 15, 2020. doi:10.1002/jmv.25884PubMedGoogle Scholar
34.
El Chakhtoura  NG , Bonomo  RA , Jump  RLP .  Influence of aging and environment on presentation of infection in older adults.   Infect Dis Clin North Am. 2017;31(4):593-608. doi:10.1016/j.idc.2017.07.017PubMedGoogle ScholarCrossref
35.
O’Hanlon  S , Inouye  SK .  Delirium: a missing piece in the COVID-19 pandemic puzzle.   Age Ageing. 2020;49(4):497-498. doi:10.1093/ageing/afaa094PubMedGoogle ScholarCrossref
36.
Burke  RM , Killerby  ME , Newton  S ,  et all; Case Investigation Form Working Group.  Symptom profiles of a convenience sample of patients with COVID-19—United States, January–April 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(28):904-908. doi:10.15585/mmwr.mm6928a2PubMedGoogle ScholarCrossref
37.
Kuhn  E , Du  X , McGrath  K ,  et al.  Validation of a consensus method for identifying delirium from hospital records.   PLoS One. 2014;9(11):e111823. doi:10.1371/journal.pone.0111823PubMedGoogle Scholar
38.
Inouye  SK , Bogardus  ST  Jr , Charpentier  PA ,  et al.  A multicomponent intervention to prevent delirium in hospitalized older patients.   N Engl J Med. 1999;340(9):669-676. doi:10.1056/NEJM199903043400901PubMedGoogle ScholarCrossref
39.
Marra  A , Ely  EW , Pandharipande  PP , Patel  MB .  The ABCDEF bundle in critical care.   Crit Care Clin. 2017;33(2):225-243. doi:10.1016/j.ccc.2016.12.005PubMedGoogle ScholarCrossref
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