Thursday, November 19, 2020

COVID-19 Patients With Delirium in Emergency Department May Experience Worse Outcomes

Nearly 30% of adults aged 65 and older who are diagnosed and treated for COVID-19 in U.S. emergency departments (EDs) may present with delirium, suggests a report published today in JAMA Network Open. These patients appear to have worse outcomes, including longer stays in the intensive care unit (ICU) and in-hospital death than those with COVID-19 who do not show signs of delirium.

“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,” wrote Maura Kennedy, M.D., M.P.H., of Massachusetts General Hospital and colleagues.

Kennedy and colleagues analyzed data from older adults who were seen in one of seven ED study sites across the United States and diagnosed with COVID-19 on or after March 13 (the date COVID-19 was declared a national emergency in the United States). They specifically focused on outcomes in patients whose medical records noted delirium symptoms at the time of arrival to the ED.

A total of 817 patients (mean age 77.7 years) were included in the analysis; 226 patients had delirium at presentation. Common symptoms of delirium noted in the medical record included impaired consciousness (122 patients), disorientation (96 patients), hypoactive delirium symptoms (45 patients), and agitation or hyperactive delirium symptoms (35 patients).

Of patients with delirium, 37 had delirium as a primary presenting complaint. Importantly, 84 of these patients had no fever or shortness of breath. The researchers found that delirium at presentation to the ED was significantly associated with increased risk for spending more than eight days in the ICU, discharge to a rehabilitation facility, and death.

“Our study demonstrates that clinicians must include COVID-19 in the differential diagnosis of delirium among older adults, regardless of whether they have other symptoms of COVID-19 infection. This is important to avoid missing diagnoses altogether and to better identify severe cases of COVID-19 at high risk for poor outcomes and death,” Kennedy and colleagues wrote.

“Furthermore, the data from this multicenter study strongly support an immediate revision in CDC guidance on symptom profiles for COVID-19 to include delirium as an important COVID-19–related symptom. Current CDC guidance lists new confusion as an emergency warning sign only, not as a presenting symptom in COVID-19. Many centers use the CDC guidance to prioritize screening, testing, and evaluation of presenting patients. By continuing to exclude delirium as a known presenting symptom of COVID-19, many cases will be missed or diagnoses delayed, as is already happening on a wide scale, particularly in older adults.”

For related information, see the Psychiatric News article “Do Not Forget Delirium During the COVID-19 Scramble.”

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