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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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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

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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.

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