A rapid review of the pathoetiology, presentation, and management of delirium in adults with COVID-19

Cognitive Sequelae of COVID-19: Mechanistic Insights and Therapeutic Approaches

BACKGROUND

The COVID-19 pandemic has left an indelible mark on the world, with mounting evidence suggesting that it not only posed acute challenges to global healthcare systems but has also unveiled a complex array of long-term consequences, particularly cognitive impairment (CI). As the persistence of post-COVID-19 neurological syndrome could evolve into the next public health crisis, it is imperative to gain a better understanding of the intricate pathophysiology of CI in COVID-19 patients and viable treatment strategies.

METHODS

This comprehensive review explores the pathophysiology and management of cognitive impairment across the phases of COVID-19, from acute infection to Long-COVID, by synthesizing findings from clinical, preclinical, and mechanistic studies to identify key contributors to CI, as well as current therapeutic approaches.

RESULTS

Key mechanisms contributing to CI include persistent neuroinflammation, cerebrovascular complications, direct neuronal injury, activation of the kynurenine pathway, and psychological distress. Both pharmacological interventions, such as anti-inflammatory therapies and agents targeting neuroinflammatory pathways, and non-pharmacological strategies, including cognitive rehabilitation, show promise in addressing these challenges. Although much of the current evidence is derived from preclinical and animal studies, these findings provide foundational insights into potential treatment approaches.

CONCLUSION

By synthesizing current knowledge, this review highlights the importance of addressing COVID-19-related cognitive impairment and offers actionable insights for mitigation and recovery as the global community continues to grapple with the pandemic's long-term impact.

Neuroleptics used in critical COVID associated with moderate-severe dyspnea after hospital discharge

Dyspnea is a prominent symptom in patients with long COVID due to its high prevalence and significant clinical impact. However, the influence of commonly used medications in critically ill patients on long-term dyspnea remains unclear. This study aimed to identify risk factors and assess the impacts associated with moderate to severe dyspnea in COVID-19 survivors. This study evaluated patients admitted to a university hospital between April 2020 and April 2021. Data were collected on clinical preconditions, hospital and ICU stays, and the use of corticosteroids, neuroleptics, neuromuscular blockers, midazolam, fentanyl, and noradrenaline. Post-discharge evaluations were conducted at 1 and 12 months, assessing dyspnea, frailty, quality of life, functional capacity, anxiety, and depression. Descriptive statistics, including frequencies and percentages, were used, and logistic regression analysis was performed to identify factors associated with moderate to severe dyspnea at 1 and 12 months post-discharge. Statistical significance was defined as P < 0.05. A total of 100 patients were prospectively included in the study; all underwent the 1-month evaluation, and 63 completed the 12-month evaluation. Limiting dyspnea, defined as an mMRC score > 1, was observed in 56.6% of patients at 1 month and 33.9% at 12 months post-discharge. Independent factors associated with limiting dyspnea at 1 month included the total dose of neuroleptics administered during hospitalization and the presence of pre-existing comorbidities. The use of corticosteroids, neuromuscular blockers, midazolam, fentanyl, and noradrenaline showed no significant association with limiting dyspnea. Dyspnea at 1 month post-discharge was an independent risk factor for the persistence of limiting dyspnea at 12 months. Patients with limiting dyspnea at 12 months exhibited higher levels of depression, anxiety, and frailty, alongside reduced quality of life and functionality. Patients with severe COVID-19 exhibit a high prevalence of limiting dyspnea in the long term. The total dose of neuroleptics administered during hospitalization and the presence of comorbidities were independently associated with limiting dyspnea after discharge. At 12 months post-discharge, individuals with persistent limiting dyspnea frequently demonstrated additional physical and mental health impairments, underscoring the need for comprehensive evaluation and management to mitigate the burden of long-term disabilities.

Cross-Section of Neurological Manifestations Among SARS-CoV-2 Omicron Subvariants-Single-Center Study

Background/Objectives: The Omicron variant of SARS-CoV-2 is undergoing constant mutation. New strains vary in neuropathogenicity and the neurological spectrum of disease. The aim of this study was to assess the frequency and clinical characteristics of neurological manifestations during the Omicron dominance among hospitalized patients, including the differences between three subsequent periods. Methods: This retrospective single-center study included 426 hospitalized adults with confirmed COVID-19 divided into three periods (O1, O2, and O3) dependent on the dominance of Omicron subvariants in Poland. Demographic and clinical data, in particular neurological manifestations, were collected and compared. Results: The median age of the group was 74, older in subsequent (later) periods. The number of patients with a history of previous SARS-CoV-2 infection or vaccination increased with the duration of the pandemic. The severity of COVID-19 became lower in successive periods. Neurological manifestations were observed in 55.4% of patients, and the most frequent were delirium, headache, myalgia, dizziness, cerebrovascular diseases, and encephalopathy. In subsequent periods of Omicron dominance, a higher frequency of neurological manifestations such as delirium, transient ischemic attack (TIA), and encephalopathy was observed. Headache or myalgia was related to a shorter hospitalization while delirium, cerebrovascular diseases, and ischemic stroke were linked with an increased risk of death. Conclusions: The Omicron variant of SARS-CoV-2 presents a wide spectrum of neurological manifestations. Although there is an improvement in the survival rate of patients with COVID-19, the frequency of neurological manifestations increases. The occurrence of delirium, cerebrovascular diseases, and ischemic stroke results in higher mortality.

COVID-19 and the Impact on Delirium Care of Hospitalized Older Adults: A Qualitative Study

BACKGROUND

Older adult patients with COVID-19 and delirium experience higher rates of adverse outcomes. Early recognition of at-risk patients and implementation of management strategies improve outcomes, though understanding barriers to acute care nurses implementing these strategies is limited.

PURPOSE

This study's purpose was to understand the experiences of acute care nurses providing care to older adults with COVID-19 and delirium. Experiences explored included assessment, nursing management interventions, and barriers to care.

METHODS

Purposive sampling to recruit nurses for semistructured focus groups was performed, and thematic analysis was generated by 4 members of the research team.

RESULTS

Twenty-one nurses participated in focus groups. Thematic analysis revealed themes of increased patient social isolation, barriers to delirium assessment and prevention, increased staff demands, and stressful work environments.

CONCLUSION

Rich findings reveal the profound impact of the pandemic on assessment for delirium and implementation of strategies for prevention and management in older adult patients.

Discovery of Delirium Biomarkers through Minimally Invasive Serum Molecular Fingerprinting

Delirium presents a significant clinical challenge, primarily due to its profound impact on patient outcomes and the limitations of the current diagnostic methods, which are largely subjective. During the COVID-19 pandemic, this challenge was intensified as the frequency of delirium assessments decreased in Intensive Care Units (ICUs), even as the prevalence of delirium among critically ill patients increased. The present study evaluated how the serum molecular fingerprint, as acquired by Fourier-Transform InfraRed (FTIR) spectroscopy, can enable the development of predictive models for delirium. A preliminary univariate analysis of serum FTIR spectra indicated significantly different bands between 26 ICU patients with delirium and 26 patients without, all of whom were admitted with COVID-19. However, these bands resulted in a poorly performing Naïve-Bayes predictive model. Considering the use of a Fast-Correlation-Based Filter for feature selection, it was possible to define a new set of spectral bands with a wider coverage of molecular functional groups. These bands ensured an excellent Naïve-Bayes predictive model, with an AUC, a sensitivity, and a specificity all exceeding 0.92. These spectral bands, acquired through a minimally invasive analysis and obtained rapidly, economically, and in a high-throughput mode, therefore offer significant potential for managing delirium in critically ill patients.

[Interaction of somatic findings and psychiatric symptoms in COVID-19. A scoping review]

An infection with SARS-CoV‑2 can affect the central nervous system, leading to neurological as well as psychiatric symptoms. In this respect, mechanisms of inflammation seem to be of much greater importance than the virus itself. This paper deals with the possible contributions of organic changes to psychiatric symptomatology and deals especially with delirium, cognitive symptoms, depression, anxiety, posttraumatic stress disorder and psychosis. Processes of neuroinflammation with infection of capillary endothelial cells and activation of microglia and astrocytes releasing high amounts of cytokines seem to be of key importance in all kinds of disturbances. They can lead to damage in grey and white matter, impairment of cerebral metabolism and loss of connectivity. Such neuroimmunological processes have been described as a organic basis for many psychiatric disorders, as affective disorders, psychoses and dementia. As the activation of the glia cells can persist for a long time after the offending agent has been cleared, this can contribute to long term sequalae of the infection.

Identification of risk factors for the onset of delirium associated with COVID-19 by mining nursing records

COVID-19 has a range of complications, from no symptoms to severe pneumonia. It can also affect multiple organs including the nervous system. COVID-19 affects the brain, leading to neurological symptoms such as delirium. Delirium, a sudden change in consciousness, can increase the risk of death and prolong the hospital stay. However, research on delirium prediction in patients with COVID-19 is insufficient. This study aimed to identify new risk factors that could predict the onset of delirium in patients with COVID-19 using machine learning (ML) applied to nursing records. This retrospective cohort study used natural language processing and ML to develop a model for classifying the nursing records of patients with delirium. We extracted the features of each word from the model and grouped similar words. To evaluate the usefulness of word groups in predicting the occurrence of delirium in patients with COVID-19, we analyzed the temporal changes in the frequency of occurrence of these word groups before and after the onset of delirium. Moreover, the sensitivity, specificity, and odds ratios were calculated. We identified (1) elimination-related behaviors and conditions and (2) abnormal patient behavior and conditions as risk factors for delirium. Group 1 had the highest sensitivity (0.603), whereas group 2 had the highest specificity and odds ratio (0.938 and 6.903, respectively). These results suggest that these parameters may be useful in predicting delirium in these patients. The risk factors for COVID-19-associated delirium identified in this study were more specific but less sensitive than the ICDSC (Intensive Care Delirium Screening Checklist) and CAM-ICU (Confusion Assessment Method for the Intensive Care Unit). However, they are superior to the ICDSC and CAM-ICU because they can predict delirium without medical staff and at no cost.

Delirium in the Era of COVID-19

BACKGROUND

Delirium has been associated with poor outcomes in hospitalized older adults. Rates of delirium have increased in the context of coronavirus disease 2019 (COVID-19).

PURPOSE

To explore the prevalence of delirium in older adult patients hospitalized with COVID-19 as well as correlations with age, gender, length of stay (LOS), occurrence of an intensive care unit admission or transfer, and in-hospital mortality in 2 hospitals in the southeast United States.

METHODS

A retrospective study of 1502 patients admitted between 2020 and 2021 was completed.

RESULTS

Older adult patients hospitalized with delirium and COVID-19 demonstrated significantly prolonged LOS (14.1 days vs 7.1 days, P < .0001) and higher rates of in-hospital mortality (33.5% vs 12.8%, P < .0001).

CONCLUSIONS

Findings of this study add to the growing literature on delirium in hospitalized patients and support the need for future initiatives to create protocols for monitoring and nursing care management of delirium to improve care delivery.

Risk factors for delirium among hospitalized adults with COVID-19: A systematic review and meta-analysis of cohort studies

OBJECTIVES

This study aims to systematically assess the risk factors, the overall strength of association, and evidence quality related to delirium among adults hospitalized with COVID-19.

METHODS

A comprehensive search was conducted in thirteen databases from inception to February 10, 2023. The included databases were thoroughly searched, including PubMed, Web of Science, Proquest, Ovid MEDLINE, CINAHL, Scopus, the Cochrane Library, FMRS, Wanfang Database, Chinese Biomedical Database (CBM), China Knowledge Resource Integrated Database (CNKI), Weipu Database (VIP), and Embase. The search was limited to articles published in English and Chinese. The selected studies were screened, data were extracted, and the quality was evaluated using the Newcastle-Ottawa Scale. Meta-analysis was performed using RevMan 5.4 software. The certainty of the evidence was assessed using the GRADE criteria.

RESULTS

A total of 22 cohort studies with a sample size of 11,957 individuals were included in the analysis. Among these studies, 20 were of high quality, while the remaining 2 were of moderate quality. The risk factors that showed the strongest association with delirium were prior cognitive impairment (including dementia), mechanical ventilation, and ICU admission. Age, frailty (Clinical Frailty Scale score > 5), antipsychotic use, benzodiazepine use, neutrophil-to-lymphocyte ratio, and vasopressor use were identified as moderate risk factors for delirium. According to the GRADE evaluation, ICU admission, benzodiazepine use, neutrophil-to-lymphocyte ratio, and vasopressor use had a high-quality body of evidence, while antipsychotic usage had an intermediate-quality body of evidence. All other risk factors had a low-quality body of evidence.

CONCLUSIONS

This systematic review and meta-analysis identified several medium- to high-intensity risk factors for delirium in hospitalized adults with COVID-19. ICU admission, benzodiazepine usage, neutrophil-to-lymphocyte ratio, antipsychotic use, and vasopressor use were associated with delirium and were supported by medium- to high-quality evidence. These findings provide healthcare professionals with an evidence-based basis for managing and treating delirium in hospitalized adults with COVID-19.

Delirium in hospitalized COVID-19 patients: a prospective, multicenter, cohort study

BACKGROUND

Delirium is a prevalent symptom of acute brain dysfunction caused by Coronavirus disease 2019 (COVID-19). However, the understanding of delirium in COVID-19 patients is currently limited. This study aimed to investigate the prevalence of delirium and its risk factors in hospitalized COVID-19 patients for early identification and management of delirium.

METHODS

This cohort study included hospitalized patients with SARS-CoV-2 infection at seven tertiary hospitals from January to February 2023. Delirium was assessed at a single time point using the 3-Minute Diagnostic Assessment for Delirium by trained research assistants. Demographic data, clinical characteristics, in-hospital mortality and other variables were collected from health information system. Multivariate regression analyses were conducted to investigate the risk factors for delirium and the impact of delirium on in-hospital mortality.

RESULTS

A total of 4589 COVID-19 patients were included, out of which 651 cases (14.2%) were identified as delirium. In the multivariable analysis, aging (OR 3.58 [95%CI 2.75-4.67], p < 0.001), higher aspartic transaminase/alanine transaminase ratio (OR = 1.11, [95%CI 1.02-1.21], p = 0.018), Mg2+ (OR = 3.04, [95%CI 2.56-3.62], p < 0.001), blood urea nitrogen (OR = 1.01, [95%CI 1.00, 1.02], p = 0.024), and indwelling urethral catheterization (OR = 1.59, [95%CI 1.21, 2.09], p < 0.001) were associated with an increased risk of delirium. After adjusting for age, sex, and CCI, delirium was found to be associated with an increased risk of in-hospital mortality (OR = 2.42, [95%CI 1.59, 3.67], p < 0.001).

CONCLUSION

Delirium was a frequent complication among hospitalized COVID-19 patients and was related to unfavorable outcomes. It is crucial to reduce delirium and its long-term effects by addressing the modifiable risk factors.

Associations between delirium and SARS-CoV-2 pandemic visitor restrictions among hospitalized patients

OBJECTIVES

Delirium is associated with increased morbidity and mortality, but environmental and behavioral factors may decrease the risk of developing delirium and thus must be considered. To investigate trends in delirium prevalence and examine associations of visitor restrictions with delirium diagnoses among all patients hospitalized during and prior to the novel coronavirus SARS-CoV-2 (COVID-19) pandemic.

STUDY DESIGN

Retrospective epidemiological assessment.

METHODS

The medical records of all patients (n = 33,141) hospitalized within a three-hospital academic medical center system in a large Midwestern metropolitan area from March 20, 2019, through March 19, 2021, were analyzed.

RESULTS

The overall prevalence of delirium during COVID-19 was 11.26% (confidence interval [CI]: 10.79%, 11.73%) compared to 9.28% (CI: 8.82%, 9.73%) before COVID-19. From our adjusted logistic regression analyses, we observed that the odds of delirium among non-isolated patients were significantly higher during COVID-19 visitor restrictions (adjusted odds ratio [aOR]: 1.354; 95% CI: 1.233, 1.488; P < 0.0001) than before. The odds of delirium among isolated patients were not significantly higher during COVID-19 visitor restrictions (aOR: 1.145; 95% CI: 0.974, 1.346; P = 0.1006) than before.

CONCLUSIONS

Medically isolated patients remained at high risk of developing delirium both prior to and during COVID-19 era visitor restrictions. However, non-medically isolated patients had a significantly increased risk of delirium during the social isolation of visitor restrictions compared to prior to visitor restrictions.

Catatonia after COVID-19 infection: scoping review

AIMS AND METHOD

Catatonia has been increasingly described in cases of COVID-19; we therefore aimed to investigate the evidence for catatonia in patients with COVID-19. We searched PubMed, EMBASE, PsycINFO, BIN and CINAHL databases for articles published in English, from the initial descriptions of the COVID-19 pandemic to January 2022.

RESULTS

A total 204 studies were identified, 27 (13%) of which met the inclusion criteria. The evidence available was based on case reports. The articles included in this review identified a total of 42 patients, ranging from the ages of 12 to ≥70 years, with confirmed or possible catatonia during or after a COVID-19 infection.

CLINICAL IMPLICATIONS

This review provides valuable information to clinicians in medical practice for treating patients with COVID-19, and a foundation for further research for this uncommon syndrome of COVID-19.

A Case of New-Onset Obsessive-Compulsive Disorder and Schizophrenia in a 14-Year-Old Male following the COVID-19 Pandemic

The post-COVID-19 era has introduced novel cases of psychiatric complications that are either organic or purely psychological in nature due to social isolation. This report details a case of new-onset obsessive-compulsive disorder (OCD) and schizophrenia following the COVID-19 pandemic. The novelty of this case lies in the onset of the patient's symptoms in the context of the COVID-19 pandemic, without prior predisposing risks in the environmental, social, or biological aspects. We provided therapeutic treatment to the patient in an inpatient setting, while examining the patient to decipher the root cause of his symptoms. While there is substantial data suggesting exacerbations of OCD during the COVID-19 pandemic in the general population and a new onset of schizophrenia due to the virus itself, very little is known about the prevalence of either OCD or schizophrenia after the pandemic. With this in mind, we hope to provide more information regarding new-onset psychosis and OCD within the adolescent population. A considerable amount of studies and data are needed in this subset of the population.

Delirium in Medically Hospitalized Patients: Prevalence, Recognition and Risk Factors: A Prospective Cohort Study

BACKGROUND

Delirium is a common neuropsychiatric syndrome in hospitalized elderly patients and is associated with poor clinical outcomes. We aimed to determine the prevalence, recognition, risk factors, and course of delirium among hospitalized elderly (65 years of age or older) patients at Sultan Qaboos University Hospital (SQUH).

METHODS

A prospective cohort study included 327 elderly patients (65 years of age or older) admitted to the medical wards at SQUH. Patients were screened for delirium using the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM). Additionally, medical records were reviewed to identify possible associated factors.

RESULTS

The prevalence of delirium was 55.4% (95% CI 49.9-60.7), and 35.4% of patients with delirium were not recognized by the treating team. Hypoactive delirium is the most common type of delirium. The logistic regression analyzes demonstrated that pre-existing cognitive impairment (OR = 4.0); poor functional status (OR = 1.9); the use of medications that are known to precipitate delirium (OR = 2.3); polypharmacy (OR = 5.7); urinary catheterization (OR = 2.2); dehydration (OR = 3.1); and electrolytes derangements (OR = 2.0) were independent risk factors for delirium. Furthermore, 56.9% of patients with delirium continued to have delirium upon discharge from the hospital.

CONCLUSIONS

Delirium is common among elderly patients hospitalized in general medical wards. Implementing effective preventive strategies for delirium during the hospital stay, including early recognition using standard sensitive and specific screening tools (i.e., 3D-CAM) and developing geriatric wards, is crucial.

[Post-COVID-19 syndrome]

In the aftermath of acute infection with the severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2), a large number of symptoms persist or appear, constituting a real syndrome called "long COVID-19" or "post-COVID- 19" or "post-acute COVID-19 syndrome". Its incidence is very high, half of patients showing at least one symptom at 4-6 months after Coronarovirus infectious disease 2019 (COVID-19). They can affect many organs. The most common symptom is persistent fatigue, similar to that seen after other viral infections. Radiological pulmonary sequelae are relatively rare and not extensive. On the other hand, functional respiratory symptoms, primarily dyspnoea, are much more frequent. Dysfunctional breathing is a significant cause of dyspnoea. Cognitive disorders and psychological symptoms are also very common, with anxiety, depression and post-traumatic stress symptoms being widely described. On the other hand, cardiac, endocrine, cutaneous, digestive or renal sequelae are rarer. The symptoms generally improve after several months, even if their prevalence at two years remains significant. Most of the symptoms are favored by the severity of the initial illness, and the psychic symptoms by the female sex. The pathophysiology of most symptoms is poorly understood. The influence of the treatments used in the acute phase is also important. Vaccination, on the other hand, seems to reduce their incidence. The sheer number of affected patients makes long-term COVID-19 syndrome a public health challenge.

COVID-19 delirium and encephalopathy: Pathophysiology assumed in the first 3 years of the ongoing pandemic

Background

The coronavirus disease (COVID-19) continues to spread worldwide. It has a high rate of delirium, even in young patients without comorbidities. Infected patients required isolation because of the high infectivity and virulence of COVID-19. The high prevalence of delirium in COVID-19 primarily results from encephalopathy and neuroinflammation caused by acute respiratory distress syndrome (ARDS)-associated cytokine storm. Acute respiratory distress syndrome has been linked to delirium and psychotic symptoms in the subacute phase (4 to 12 weeks), termed post-acute COVID-19 syndrome (PACS), and to brain fog, cognitive dysfunction, and fatigue, termed "long COVID," which persists beyond 12 weeks. However, no review article that mentions "COVID-19 delirium" have never been reported.

Basic Procedures

This narrative review summarizes data on delirium associated with acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and related neurological symptoms of persistent post-infection illness (PACS or long COVID) after persistence of cognitive dysfunction. Thus, we describe the pathophysiological hypothesis of COVID-19 delirium and its continuation as long COVID. This review also describes the treatment of delirium complicated by COVID-19 pneumonia.

Main Findings

SARS-CoV-2 infection is associated with encephalopathy and delirium. An association between COVID-19 infection and Alzheimer's disease has been suggested, and studies are being conducted from multiple facets including genetics, cytology, and postmortem study.

Principal Conclusions

This review suggests that COVID-19 has important short and long-term neuropsychiatric effects. Several hypotheses have been proposed that highlight potential neurobiological mechanisms as causal factors, including neuronal-inflammatory pathways by cytokine storm and cellular senescence, and chronic inflammation.

Sepsis-Associated Delirium: A Narrative Review

Delirium is characterized by an acutely altered mental status accompanied by reductions in cognitive function and attention. Delirium in septic patients, termed sepsis-associated delirium (SAD), differs in several specific aspects from the other types of delirium that are typically encountered in intensive care units. Since sepsis and delirium are both closely associated with increased morbidity and mortality, it is important to not only prevent but also promptly diagnose and treat SAD. We herein reviewed the etiology, pathogenesis, risk factors, prevention, diagnosis, treatment, and prognosis of SAD, including coronavirus disease 2019 (COVID-19)-related delirium. Delirium by itself not only worsens long-term prognosis, but it is also regarded as an important factor affecting the outcome of post-intensive care syndrome. In COVID-19 patients, the difficulties associated with adequately implementing the ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials: Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; Family engagement/empowerment) and the need for social isolation are issues that require the development of conventional care for SAD.

Delirium in hospitalized COVID-19 patients: Predictors and implications for patient outcome

INTRODUCTION

Delirium is recognized as a severe complication of coronavirus-disease-2019 (COVID-19). COVID-19-associated delirium has been linked to worse patient outcomes and is considered to be of multifactorial origin. Here we sought to evaluate the incidence and risk factors of delirium in hospitalized COVID-19 patients, along with its impact on clinical outcome.

METHODS

Consecutive adult COVID-19 patients admitted to a tertiary academic referral hospital between March 1st and December 31st, 2020 were included. Potential risk factors for delirium were evaluated, including: age, gender, disease severity (as per the highest WHO grading reached during admission), laboratory parameters for infection and renal function (as per their most extreme values), and presence of comorbidities. To assess the relative strength of risk factors for predicting the occurrence of delirium, we performed a random-forest survival analysis.

RESULTS

347 patients with positive COVID-19 PCR test and median age 68.2 [IQR 55.5, 80.5] years were included. Of those, 79 patients (22.8%) developed delirium, 81 (23.3%) were transferred to ICU, 58 (16.7%) died. 163 (73.8%) patients were discharged home, 13 (5.9%) to another hospital, 32 (14.5%) to nursing homes, 13 (5.9%) to rehabilitation with an overall median admission-to-discharge time of 53 [IQR 14, 195] days. The strongest predictors for the occurrence of delirium were blood urea nitrogen (minimal depth value (MD): 3.33), age (MD: 3.75), disease severity (as captured by WHO grading; MD: 3.93), leukocyte count (MD: 4.22), the presence of a neurodegenerative history (MD: 4.43), ferritin (MD: 4.46) and creatinine (MD: 4.59) levels.

CONCLUSION

The risk of delirium in COVID-19 can be stratified based on COVID-19 disease severity and-similar to delirium associated with other respiratory infections-the factors advanced age, neurodegenerative disease history, and presence of elevated infection and renal-retention parameters. Screening for these risk factors may facilitate early identification of patients at high-risk for COVID-19-associated delirium.

Cognitive Impairment after Post-Acute COVID-19 Infection: A Systematic Review of the Literature

The present study aims to provide a critical overview of the literature on the relationships between post-acute COVID-19 infection and cognitive impairment, highlighting the limitations and confounding factors. A systematic search of articles published from 1 January 2020 to 1 July 2022 was performed in PubMed/Medline. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only studies using validated instruments for the assessment of cognitive impairment were included. Out of 5515 screened records, 72 studies met the inclusion criteria. The available evidence revealed the presence of impairment in executive functions, speed of processing, attention and memory in subjects recovered from COVID-19. However, several limitations of the literature reviewed should be highlighted: most studies were performed on small samples, not stratified by severity of disease and age, used as a cross-sectional or a short-term longitudinal design and provided a limited assessment of the different cognitive domains. Few studies investigated the neurobiological correlates of cognitive deficits in individuals recovered from COVID-19. Further studies with an adequate methodological design are needed for an in-depth characterization of cognitive impairment in individuals recovered from COVID-19.

Delirium in COVID-19 and post-liver transplant patients: an observational study

OBJECTIVE

Delirium is a major complication in hospitalised patients. This study aimed to compare the mortality trends of patients with delirium according to the underlying physical condition.

METHODS

Hospitalised patients diagnosed with delirium by the Modena Consultation-Liaison Psychiatry Service (Italy) during 2020 were enrolled. Three groups were identified: COVID; after orthotopic liver transplant (OLT); other conditions. The full medical records were screened to retrieve socio-demographic and clinical data. INTERMED score and Delirium Rating Scale were used to retrospectively rate bio-social-complexity and delirium severity. Early (20 days) and end of study (31^st January 2021) mortality were ascertained for each subject.

RESULTS

A total of 103 patients were enrolled. Patients hospitalised for COVID showed higher INTERMED scores (two-tailed t-test, p = 0.019) and higher 20-day mortality (HR = 3.68, p = 0.014). When considering a 1-year follow-up, the main predictor of mortality was patients' age in all three subgroups (HR = 1.06; p = 0.003).

CONCLUSION

Our results suggest that patients hospitalised for COVID-19 with delirium showed higher bio-psycho-social complexity and higher short-term mortality, regardless of the severity of delirium. OLT patients showed lower mortality and bio-psycho-social complexity, despite being still considered as 'complex', according to the INTERMED score. Future research should focus on understanding the underlying mechanisms in the relationship between delirium and mortality.Key pointsPatients hospitalised for COVID-19 with delirium were found at risk of higher short-term mortality and higher bio-psycho-social complexity.OLT patients showed lower overall mortality and lower bio-psycho-social complexity than the other two groups, despite being still in the 'complex' range according to the INTERMED score.Future research should assess the areas of impact of delirium in patients affected by COVID-19, considering short- and long-term outcomes.

Delirium in older COVID-19 patients: Evaluating risk factors and outcomes

OBJECTIVES

A high incidence of delirium has been reported in older patients with Coronavirus disease 2019 (COVID-19). We aimed to identify determinants of delirium, including the Clinical Frailty Scale, in hospitalized older patients with COVID-19. Furthermore, we aimed to study the association of delirium independent of frailty with in-hospital outcomes in older COVID-19 patients.

METHODS

This study was performed within the framework of the multi-center COVID-OLD cohort study and included patients aged ≥60 years who were admitted to the general ward because of COVID-19 in the Netherlands between February and May 2020. Data were collected on demographics, co-morbidity, disease severity, and geriatric parameters. Prevalence of delirium during hospital admission was recorded based on delirium screening using the Delirium Observation Screening Scale (DOSS) which was scored three times daily. A DOSS score ≥3 was followed by a delirium assessment by the ward physician In-hospital outcomes included length of stay, discharge destination, and mortality.

RESULTS

A total of 412 patients were included (median age 76, 58% male). Delirium was present in 82 patients. In multivariable analysis, previous episode of delirium (Odds ratio [OR] 8.9 [95% CI 2.3-33.6] p = 0.001), and pre-existent memory problems (OR 7.6 [95% CI 3.1-22.5] p < 0.001) were associated with increased delirium risk. Clinical Frailty Scale was associated with increased delirium risk (OR 1.63 [95%CI 1.40-1.90] p < 0.001) in univariable analysis, but not in multivariable analysis. Patients who developed delirium had a shorter symptom duration and lower levels of C-reactive protein upon presentation, whereas vital parameters did not differ. Patients who developed a delirium had a longer hospital stay and were more often discharged to a nursing home. Delirium was associated with mortality (OR 2.84 [95% CI1.71-4.72] p < 0.001), but not in multivariable analyses.

CONCLUSIONS

A previous delirium and pre-existent memory problems were associated with delirium risk in COVID-19. Delirium was not an independent predictor of mortality after adjustment for frailty.

Inflammatory and blood gas markers of COVID-19 delirium compared to non-COVID-19 delirium: a cross-sectional study

OBJECTIVES

We aimed to find the association of inflammation and respiratory failure with delirium in COVID-19 patients. We compare the inflammatory and arterial blood gas markers between patients with COVID-19 delirium and delirium in other medical disorders.

METHODS

This cross-sectional study used the CHART-DEL, a validated research tool, to screen patients for delirium retrospectively from clinical notes. Inflammatory markers C-reactive protein (CRP) and white cell count (WBC), and the partial pressures of oxygen (PO₂) and carbon dioxide (PCO₂) were compared between patients with COVID-19 delirium and delirium in other medical disorders.

RESULTS

In bivariate analysis, CRP (mg/L) was significantly higher in the COVID-19 group, (81.7 ± 80.0 vs. 58.8 ± 87.7, p = 0.04), and WBC (10⁹/L) was significantly lower (7.44 ± 3.42 vs. 9.71 ± 5.45, p = 0.04). The geometric mean of CRP in the COVID-19 group was 140% higher in multiple linear regression (95% CI = 7-439%, p = 0.03) with age and sex as covariates. There were no significant differences in pO₂ or pCO₂ across groups.

CONCLUSION

The association between higher CRP and COVID-19 in patients with delirium may suggest an inflammatory basis for delirium in COVID-19. Our findings may assist clinicians in establishing whether delirium is due to COVID-19, which may improve management and outcomes of infected patients.

Cytokine profiles in intensive care unit delirium

Background

Neuroinflammation causing disruption of the blood-brain barrier and immune cell extravasation into the brain parenchyma may cause delirium; however, knowledge of the exact pathophysiologic mechanism remains incomplete. The purpose of our study was to determine whether cytokine profiles differ depending on whether delirium occurs in the setting of sepsis, coronavirus disease 2019 (COVID-19), or recent surgery.

Methods

This prospective observational cohort study involved 119 critically ill patients admitted to a multidisciplinary intensive care unit (ICU) during 2019 and 2020. Delirium was identified using the validated confusion assessment method for the ICU. Multiple delirium risk factors were collected daily including clinical characteristics, hospital course, lab values, vital signs, surgical exposure, drug exposure, and COVID-19 characteristics. Serums samples were collected within 12 hours of ICU admission and cytokine levels were measured.

Results:

The following proinflammatory cytokines were elevated in our delirium population: tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-18, C-C motif ligand (CCL) 2, CCL3, C-X-C motif chemokine ligand (CXCL)1, CXCL10, IL-8, IL-1 receptor antagonist, and IL-10. Analysis of relative cytokine levels in those patients that developed delirium in the setting of sepsis, COVID-19, and recent surgery showed elevations of CCL2, CXCL10, and TNF-α in both the sepsis and COVID-19 group in comparison to the postsurgical population. In the postsurgical group, granulocyte colony-stimulating factor was elevated and CXCL10 was decreased relative to the opposing groups.

Conclusions

We identify several cytokines and precipitating factors known to be associated with delirium. However, our study suggests that the cytokine profile associated with delirium is variable and contingent upon delirium precipitating factors.

Liaison psychiatry before and after the COVID-19 pandemic

INTRODUCTION

the COVID-19 pandemic had an impact on hospital admissions. The clinical profiles of patients referred to liaison psychiatry teams (LPT) remained stable over the last few decades. We postulate changes in patient profiles due to the COVID-19 pandemic.

MATERIALS AND METHODS

a total of 384 patients admitted to a tertiary care University Hospital in Madrid (Spain) and referred to LPTs were recruited. Patients referred 5 months before and after the first admission for COVID-19 were included. Clinical and sociodemographic characteristics were collected, and non-parametric hypothesis contrast tests were used to study possible differences between both periods.

RESULTS

patients referred during the pandemic were significantly older (U = 2.006; p = .045), most of them were admitted to medical hospitalization units (χ2 (2) = 5.962; p = 015), and with a different reason for admission. There was an increase in the rate of adjustment disorders (χ2 (1) =7.893; p = 005) and delirium (χ2 (1) =9.413; p = 002), as well as psychiatric comorbidity (χ2 (2) = 9.930; p = .007), and a reduction in the proportion of patients treated for substance misuse (χ2 (5) = 19.152; p = .002). The number of deaths increased significantly (χ2 (1) = 6.611; p = .010). In persons over 65 years inappropriate prescription was significantly lower (χ2 (1) = 8.200; p = .004).

CONCLUSIONS

the pandemic had an impact on the activity of the LPTs due to the change in the clinical profile and evolution of referred patients, maintaining standards of care that are reflected through prescription.

COVID-19-related psychiatric manifestations requiring hospitalization: Analysis in older vs. younger patients

The complex manifestations of COVID-19 include psychiatric symptoms, having multifaceted profiles with varying severity during the acute phase and further during the recovery period. Limited data exist which have analyzed whether there are any age-related differences. A study lot of 89 COVID-19 patients with mild-to-moderate SARS-CoV-2 infection requiring hospitalization for mental issues provided comparative data from two age groups below and above 60 years. The majority of patients had new onset of a mental issue during COVID-19, 24.7% of the total lot being diagnosed with depressive disorder. The senior patient set had a significantly higher prevalence of sleep disorder vs. the younger study group (53.3 vs. 28.8%), depression (33.3 vs. 10.2%) and cognitive impairment (26.7 vs. 8.5%), while patients <60 years of age had a higher prevalence of hallucinations, delirium and bizarre behavior. Psychiatric manifestations are an important part of the symptomatology of COVID-19, sometimes requiring hospitalization. Age-related neuropsychiatric substrate could explain some of these differences between the two study subgroups. Further data are needed to complete the acute and long-term distinctive profiles of COVID-19-related mental illness in older and younger patients.

Long-term cognitive functioning is impaired in ICU-treated COVID-19 patients: a comprehensive controlled neuropsychological study

Background

Cognitive impairment has emerged as a common post-acute sequela of coronavirus disease 2019 (COVID-19). We hypothesised that cognitive impairment exists in patients after COVID-19 and that it is most severe in patients admitted to the intensive care unit (ICU).

Methods

This prospective controlled cohort study of 213 participants performed at the Helsinki University Hospital and the University of Helsinki, Finland, comprised three groups of patients—ICU-treated (n = 72), ward-treated (n = 49), and home-isolated (n = 44)—with confirmed COVID-19 between March 13 and December 31, 2020, participating in a comprehensive neuropsychological evaluation six months after the acute phase. Our study included a control group with no history of COVID-19 (n = 48). Medical and demographic data were collected from electronic patient records and interviews carried out four months after the acute phase. Questionnaires filled six months after the acute phase provided information about change in cognitive functioning observed by a close informant, as well as the presence of self-reported depressive and post-traumatic symptoms.

Results

The groups differed (effect size η²_p = 0.065, p = 0.004) in the total cognitive score, calculated from neuropsychological measures in three domains (attention, executive functions, and memory). Both ICU-treated (p = 0.011) and ward-treated patients (p = 0.005) performed worse than home-isolated patients. Among those with more than 12 years of education, ICU-treated patients performed worse in the attention domain than ward-treated patients (p = 0.021) or non-COVID controls (p = 0.045); ICU-treated male patients, in particular, were impaired in executive functions (p = 0.037).

Conclusions

ICU-treated COVID-19 patients, compared to patients with less severe acute COVID-19 or non-COVID controls, showed more severe long-term cognitive impairment. Among those with more than 12 years of education, impairment existed particularly in the domains of attention and for men, of executive functions.

Trial registration number: ClinicalTrials.gov NCT04864938, retrospectively registered February 9, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04092-z.

Delirium in COVID-19: An Atypical Case Managed With Quetiapine

Coronavirus disease 2019 (COVID-19) can present without the typical symptoms of respiratory tract infection. Delirium has been reported as a prominent feature leading to an atypical presentation in older adults infected with COVID-19. Here, we present the case of a 65-year-old female who came to our hospital with confusion and altered mental status. The patient maintained an asymptomatic course of illness after testing positive for COVID-19 two weeks prior to the hospital visit. An appropriate workup was done to rule out other causes of the patient’s symptoms. During the next couple of days, the patient developed classic symptoms suggestive of delirium. The patient was eventually treated based on the general guidelines for delirium management due to the absence of adequate medical literature specifying the management of delirium in the population of interest. Thus, the patient was given a trial of an atypical antipsychotic, quetiapine, to which she responded well and was subsequently discharged one week later.

Increased risk of transurethral and suprapubic catheter self-extraction in COVID-19 patients: real-life experience

INTRODUCTION

This study evaluated the prevalence of transurethral catheter self-removal in critically-ill COVID-19 non-sedated adult patients compared with non-COVID-19 controls.

METHODS

COVID-19 patients who self-extracted transurethral or suprapubic catheters needing a urological intervention were prospectively included (group A). Demographic data, medical and nursing records, comorbidities and nervous system symptoms were evaluated. Agitation, anxiety and delirium were assessed by the Richmond Agitation and Sedation Scale (RASS). The control group B were non-COVID-19 patients who self-extracted transurethral/suprapubic catheter in a urology unit (subgroup B1) and geriatric unit (subgroup B2), requiring a urological intervention in the same period.

RESULTS

37 men and 11 women were enrolled in group A. Mean RASS score was 3.1 ± 1.8. There were 5 patients in subgroup B1 and 11 in subgroup B2. Chronic comorbidities were more frequent in group B than the COVID-19 group (P<0.01). COVID-19 patients had a significant difference in RASS score (P<0.006) and catheter self-extraction events (P<0.001). Complications caused by traumatic catheter extractions (severe urethrorrhagia, longer hospital stay) were greater in COVID-19 patients.

CONCLUSION

This is the first study focusing on the prevalence and complications of catheter self-removal in COVID-19 patients. An increased prevalence of urological complications due to agitation and delirium related to COVID-19 has been demonstrated-the neurological sequelae of COVID-19 must be considered during hospitalisation.

Changes in cognitive functioning after COVID-19: A systematic review and meta-analysis

Introduction

We conducted a systematic review and meta‐analysis of the cognitive effects of coronavirus disease 2019 (COVID‐19) in adults with no prior history of cognitive impairment.

Methods

Searches in Medline/Web of Science/Embase from January 1, 2020, to December 13, 2021, were performed following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines.  A meta‐analysis of the Montreal Cognitive Assessment (MoCA) total score comparing recovered COVID‐19 and healthy controls was performed.

Results

Oof 6202 articles, 27 studies with 2049 individuals were included (mean age = 56.05 years, evaluation time ranged from the acute phase to 7 months post‐infection). Impairment in executive functions, attention, and memory were found in post‐COVID‐19 patients.  The meta‐analysis was performed with a subgroup of 290 individuals and showed a difference in MoCA score between post‐COVID‐19 patients versus controls (mean difference = −0.94, 95% confidence interval [CI] −1.59, −0.29; P = .0049).

Discussion

Patients recovered from COVID‐19 have lower general cognition compared to healthy controls up to 7 months post‐infection.

New-Onset Mania and Psychosis in Adolescents in the Context of COVID-19 Infection

There is a growing body of evidence that coronavirus disease 2019 (COVID-19) is linked with neuropsychiatric complications such as psychosis and delirium in adults. Much less is known about the neuropsychiatric manifestations of this virus in the child and adolescent population. This case series discusses two unique adolescent patients who presented with new-onset mania and psychosis in the context of an otherwise asymptomatic COVID-19 infection, which raises several questions about whether and how the virus precipitates mania and psychosis, whether these symptoms are transient or predisposes patients to a chronic psychiatric disorder, and confounding variables that may have contributed to the symptoms. These questions can then be points for future research and longitudinal follow-up that can better improve our knowledge about the relationship between this complicated virus and how it affects children psychiatrically.

Treating the body to prevent brain injury: lessons learned from the coronavirus disease 2019 pandemic

PURPOSE OF REVIEW

We aim to provide the current evidence on utility and application of neuromonitoring tools including electroencephalography (EEG), transcranial Doppler (TCD), pupillometry, optic nerve sheath diameter (ONSD), cerebral near-infrared spectroscopy (cNIRS), somatosensory-evoked potentials (SSEPs), and invasive intracranial monitoring in COVID-19. We also provide recent evidence on management strategy of COVID-19-associated neurological complications.

RECENT FINDINGS

Despite the common occurrence of neurological complications, we found limited use of standard neurologic monitoring in patients with COVID-19. No specific EEG pattern was identified in COVID-19. Frontal epileptic discharge was proposed to be a potential marker of COVID-19 encephalopathy. TCD, ONSD, and pupillometry can provide real-time data on intracranial pressure. Additionally, TCD may be useful for detection of acute large vessel occlusions, abnormal cerebral hemodynamics, cerebral emboli, and evolving cerebral edema at bedside. cNIRS was under-utilized in COVID-19 population and there are ongoing studies to investigate whether cerebral oxygenation could be a more useful parameter than peripheral oxygen saturation to guide clinical titration of permissive hypoxemia. Limited data exists on SSEPs and invasive intracranial monitoring.

SUMMARY

Early recognition using standardized neuromonitoring and timely intervention is important to reduce morbidity and mortality. The management strategy for neurological complications is similar to those without COVID-19.

COVID-19 smart diagnosis in the Emergency Department: all-in in practice

Introduction

Coronavirus Disease 19 (COVID-19) diagnosis has been a major problem in most Emergency Departments (EDs) and other senior care facilities. Various clinical manifestations, and the several radiologic and laboratory data combined with the misleading test results to identify the virus, are responsible for certain misdiagnoses, especially in suspected cases needing urgent management and treatment. Although emergency and other front-line physicians struggle to manage COVID-19 patients, still existent cases with ambiguous diagnosis trammel the ED safety and responsibility.

Areas Covered

This review article summarizes on a large scale the common information for the medical history, clinical examinations, radiology and laboratory data for SARS-CoV-2. We summarize the available literature using the PubMed, Science Direct and EMBASE databases published until December 2021 on the general information for COVID-19 diagnosis, and, finally, we propose algorithms for a precise and on-the-spot diagnosis the disease.

Expert Opinion

COVID-19 diagnosis has appeared to be such ambiguous, and physicians need to correlate medical history, medical examination, potential extrapulmonary manifestations, along with laboratory and radiologic data, for a prompt COVID-19 diagnosis.

Dementia Clinical Care in Relation to COVID-19

PURPOSE OF REVIEW

This review discusses the complex relationship between COVID-19 and dementia and how the pandemic has affected the management of patients with dementia. This population resulted particularly susceptible to SARS-CoV-2 infection and its effects and also to the negative effects of the measures taken worldwide to control the spread of the virus.

RECENT FINDINGS

Patients with dementia were at increased risk for COVID-19 compared to patients without dementia, and diagnosis of dementia represents an independent risk factor for hospitalization in COVID-19 patients. Mortality due to SARS-CoV2 infection in subjects with dementia is 2-5 times higher than in the general population. Cognitive impairment and delirium have been described in COVID-19 survivors. SARS-COV2 pandemic exacerbates the vulnerability of dementia patients and their caregivers, due to the morbidity and mortality from COVID-19, the indirect effects of the pandemic on the social supports, and the effects on healthcare system on which they depend.

SUMMARY

The COVID-19 pandemic requires people with dementia to move from traditional models of health care to innovative models for home care, to support caregivers' burden, and to improve long term care.

Factors Associated with Delirium in COVID-19 Patients and Their Outcome: A Single-Center Cohort Study

Background: A significant proportion of patients with coronavirus disease 2019 (COVID-19) suffer from delirium during hospitalization. This single-center observational study investigates the occurrence of delirium, the associated risk factors and its impact on in-hospital mortality in an Italian cohort of COVID 19 inpatients. Methods: Data were collected in the COVID units of a general medical hospital in the South of Italy. Socio-demographic, clinical and pharmacological features were collected. Diagnosis of delirium was based on a two-step approach according to 4AT criteria and DSM5 criteria. Outcomes were: dates of hospital discharge, Intensive Care Unit (ICU) admission, or death, whichever came first. Univariable and multivariable proportional hazards Cox regression models were estimated, and risks were reported as hazard ratios (HR) along with their 95% confidence intervals (95% CI). Results: A total of 47/214 patients (22%) were diagnosed with delirium (21 hypoactive, 15 hyperactive, and 11 mixed). In the multivariable model, four independent variables were independently associated with the presence of delirium: dementia, followed by age at admission, C-reactive protein (CRP), and Glasgow Coma Scale. In turn, delirium was the strongest independent predictor of death/admission to ICU (composite outcome), followed by Charlson Index (not including dementia), CRP, and neutrophil-to-lymphocyte ratio. The probability of reaching the composite outcome was higher for patients with the hypoactive subtype than for those with the hyperactive subtype. Conclusions: Delirium was the strongest predictor of poor outcome in COVID-19 patients, especially in the hypoactive subtype. Several clinical features and inflammatory markers were associated with the increased risk of its occurrence. The early recognition of these factors may help clinicians to select patients who would benefit from both non-pharmacological and pharmacological interventions in order to prevent delirium, and in turn, reduce the risk of admission to ICU or death.

Significant cognitive impairment likely associated with COVID-19 infection with relatively nonsevere symptoms

COVID-19 infection may involve the nervous system and has been associated with a number of neuropsychiatric complications, including impairment of cognition and dementia. Such complications are more likely to occur in (but are not limited to) patients with severe COVID-19 infections and those with concomitant risk factors. In this case report, the authors describe a normally functioning 51-year-old woman who developed cognitive impairment of a degree that rendered her unable to care for herself most likely related to a relatively nonsevere infection with COVID-19 about 2 months earlier. A detailed report of her deficits of different areas of cognitive functioning is provided. This report aims to make clinicians more aware of the potential for cognitive impairment in patients who have suffered from COVID-19, including those with infections that were not severe.

Candidate Psychotropics against SARS - CoV - 2: A Narrative Review

Since few therapeutic options are clinically accessible for coronavirus disease 2019 (COVID-19), effective, safe, and globally available pharmaceuticals need to be urgently developed to prevent severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) and alleviate the severity of COVID-19. In this regard, the present paper is intended to provide an extensive review of the clinical and preclinical evidence on the psychotropics' anti-SARS-CoV-2 effects, giving an insight into their potential applications for patients with a proven or high likelihood of COVID-19 pneumonia. The results showed that psychotropic drugs such as melatonin, lithium carbonate, valproate, olanzapine, quetiapine, clozapine, fluoxetine, escitalopram, fluvoxamine, and cannabidiol could help lower the mortality due to SARS-CoV-2 infection. According to these medications' direct immunomodulatory actions against the destructive cytokine storm, as well as other direct/indirect mechanisms (e. g., the endolysosomal pathway modulation, interactions with specific receptors, and membrane fusion), it was perceived that such drugs could effectively weaken the worsened immune response and avoid adult respiratory distress syndrome and acute lung injury. According to the author's analysis of the currently available evidence, there is significant support for psychotropics as complementary interventions during SARS-CoV-2 infection. However, further studies need to be carried out to assess the effects of the above psychotropic drugs in vitro and clinical settings.

Intensive care unit delirium in patients with severe COVID-19: A prospective observational cohort study

Background:

Delirium is common in patients with severe coronavirus disease-19 (COVID-19). The purpose of our study was to determine whether severe COVID-19 is an independent risk factor for the development of delirium in patients treated in the intensive care unit (ICU).

Methods:

This prospective observational cohort study involved 162 critically ill patients admitted to a multidisciplinary ICU during 2019 and 2020. A validated screening tool was used to diagnose delirium. Multiple delirium risk factors were collected daily including clinical characteristics, hospital course, lab values, vital signs, surgical exposure, drug exposure, and COVID-19 characteristics. After univariate analysis, a multivariate logistic regression analysis was performed to determine independent risk factors associated with the development of delirium.

Results:

In our study population, 50 (31%) patients developed delirium. A total of 39 (24.1%) tested positive for COVID-19. Initial analysis showed COVID-19 to be more prevalent in those patients that developed delirium (40% vs. 17%; P = 0.003). Multivariate analysis showed opioid use (odds ratio [OR]: 24 [95% confidence intervals (CI): 16–27]; P ≤ 0.001), benzodiazepine use (OR: 23 [95% CI: 16–63] P = 0.001), and estimated mortality based on acute physiology and chronic health evaluation IV score (OR: 1.04 [95% CI: 1.01–1.07] P = 0.002) to be independently associated with delirium development. COVID-19 (OR: 1.44 [95% CI: 0.13–10.6]; P = 0.7) was not found to be associated with delirium.

Conclusion:

Delirium is prevalent in critically ill patients admitted to the ICU, including those with COVID-19. However, after adjustment for important covariates, we found in this cohort that COVID-19 was not an independent risk factor for delirium.

Delirium and Associated Factors in a Cohort of Hospitalized Patients With Coronavirus Disease 2019

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic dramatically increased the number of patients requiring treatment in an intensive care unit or invasive mechanical ventilation worldwide. Delirium is a well-known neuropsychiatric complication of patients with acute respiratory diseases, representing the most frequent clinical expression of acute brain dysfunction in critically ill patients, especially in those undergoing invasive mechanical ventilation. Among hospitalized patients with COVID-19, delirium incidence ranges from 11% to 80%, depending on the studied population and hospital setting.

OBJECTIVE

To determine risk factors for the development of delirium in hospitalized patients with COVID-19 pneumonia.

METHODS

We retrospectively studied consecutive hospitalized adult (≥18 y) patients with confirmed COVID-19 pneumonia from March 15 to July 15, 2020, in a tertiary-care hospital in Mexico City. Delirium was assessed by the attending physician or trained nurse, with either the Confusion Assessment Method for the Intensive Care Unit or the Confusion Assessment Method brief version, according to the appropriate diagnostic tool for each hospital setting. Consultation-liaison psychiatrists and neurologists confirmed all diagnoses. We calculated adjusted hazard ratios (aHR) with 95% confidence interval (CI) using a Cox proportional-hazards regression model.

RESULTS

We studied 1017 (64.2% men; median age, 54 y; interquartile range 44-64), of whom 166 (16.3%) developed delirium (hyperactive in 75.3%); 78.9% of our delirium cases were detected in patients under invasive mechanical ventilation. The median of days from admission to diagnosis was 14 (interquartile range 8-21) days. Unadjusted mortality rates between delirium and no delirium groups were similar (23.3% vs. 24.1; risk ratio 0.962, 95% CI 0.70-1.33). Age (aHR 1.02, 95% CI 1.01-1.04; P = 0.006), an initial neutrophil-to-lymphocyte ratio ≥9 (aHR 1.81, 95% CI 1.23-2.65; P = 0.003), and requirement of invasive mechanical ventilation (aHR 3.39, 95% CI 1.47-7.84; P = 0.004) were independent risk factors for in-hospital delirium development.

CONCLUSIONS

Delirium is a common in-hospital complication of patients with COVID-19 pneumonia, associated with disease severity; given the extensive number of active COVID-19 cases worldwide, it is essential to detect patients who are most likely to develop delirium during hospitalization. Improving its preventive measures may reduce the risk of the long-term cognitive and functional sequelae associated with this neuropsychiatric complication.

Prospective Analysis Between Neutrophil-to-Lymphocyte Ratio on Admission and Development of Delirium Among Older Hospitalized Patients With COVID-19

Objective: To examine any prospective association between neutrophil-to-lymphocyte ratio (NLR) at hospital admission and subsequent delirium in older COVID-19 hospitalized patients comparing by sex and age groups. Methods: The sample consisted of 1,785 COVID-19 adult inpatients (minimum sample size required of 635 participants) admitted to a public general hospital in Madrid (Spain) between March 16th and April 15th, 2020. Variables were obtained from electronic health records. Binary logistic regression models were performed between baseline NLR and delirium adjusting for age, sex, medical comorbidity, current illness severity, serious mental illness history and use of chloroquine and dexamethasone. An NLR cut-off was identified, and stratified analyses were performed by age and sex. Also, another biomarker was tested as an exposure (the systemic immune-inflammation index -SII). Results: 55.3% of the patients were men, with a mean age of 66.8 years. Roughly 13% of the patients had delirium during hospitalization. NLR on admission predicted subsequent delirium development (adjusted OR = 1.02, 95 percent CI: 1.00-1.04, p = 0.024). Patients between 69 and 80 years with NLR values > 6.3 presented a twofold increased risk for delirium (p = 0.004). There were no sex differences in the association between baseline NLR and delirium (p > 0.05) nor SII predicted delirium development (p = 0.341). Conclusion: NLR is a good predictor of delirium during hospitalization, especially among older adults, independently of medical comorbidity, illness severity, and other covariates. Routine blood tests on admission might provide valuable information to guide the decision-making process to be followed with these especially vulnerable patients.

A scientometric study of publications on delirium from 2001 to 2020

AIM

This study aims to evaluate the publications on delirium by using bibliometric analysis.

METHODOLOGY

The Scopus database was evaluated for publications on delirium, during the period of 2001-20. The search results were analyzed for the origin of country, origin of institution, authorship, collaborations, type of article, source of funding, and number of citations.

RESULTS

The searches of Scopus database yielded 22,941 publications, originating from 139 countries. Compared to the decade of 2001-2010, the number of publications on delirium doubled in the decade of 2011-2020. The majority of the papers were research articles (58.26%), and the papers were cited for mean number of 20.53 times. Only a small proportion of the papers were based on funding (13.14%). Maximum number of papers emerged from United States of America. In terms of institutional affiliations, among the authors from top 20 institutes, 15 were from United States, 2 from Netherlands and 1 each from Canada, Germany and United Kingdom. In terms of authors, the research productivity of the top 20 most productive authors varied from 172 to 612 publications with 12 authors belonging to United States, 2 from Italy and 1 each from Canada, Greece, India, Ireland, Netherland and the United Kingdom. The maximum number of papers were published in Journal of the American Geriatric Society and based on the number of citations the New England Journal of Medicine was the most impactful journal.

CONCLUSION

Over the years number of publications on delirium have increased, majority of the publications have emerged from United States.

COVID-19 Infection: A Neuropsychiatric Perspective

As a potentially life-threatening disease with no definitive treatment and without fully implemented population-wide vaccination, COVID-19 has created unprecedented turmoil in socioeconomic life worldwide. In addition to physical signs from the respiratory and many other systems, the SARS-CoV-2 virus produces a broad range of neurological and neuropsychiatric problems, including olfactory and gustatory impairments, encephalopathy and delirium, stroke and neuromuscular complications, stress reactions, and psychoses. Moreover, the psychosocial impact of the pandemic and its indirect effects on neuropsychiatric health in noninfected individuals in the general public and among health care workers are similarly far-ranging. In addition to acute neuropsychiatric manifestations, COVID-19 may also produce late neuropsychiatric sequelae as a function of the psychoneuroimmunological cascade that it provokes. The present article presents a state-of-the-science review of these issues through an integrative review and synthesis of case series, large-cohort studies, and relevant meta-analyses. Heuristics for evaluation and further study of the neuropsychiatric manifestations of SARS-CoV-2 infection are offered.

Delirium symptoms duration and mortality in SARS-COV2 elderly: results of a multicenter retrospective cohort study

Background

Since the occurrence of the SARS-COV2 pandemic, there has been an increasing interest in investigating the epidemiology of delirium. Delirium is frequent in SARS-COV2 patients and it is associated with increased mortality; however, no information is available on the association between delirium duration in SARS-COV2 patients and related outcomes.

Aims

The aim of this study is to investigate the association between the duration of delirium symptoms and in-hospital mortality in older patients with SARS-COV2 infection.

Methods

Retrospective cohort study of patients 65 years of age and older with SARS-CoV 2 infection admitted to two acute geriatric wards and one rehabilitation ward. Delirium symptoms duration was assessed retrospectively with a chart-based validated method. In-hospital mortality was ascertained via medical records.

Results

A total of 241 patients were included. The prevalence of delirium on admission was 16%. The median number of days with delirium symptoms was 4 (IQR 2–6.5) vs. 0 (IQR 0–2) in patients with and without delirium on admission. In the multivariable Cox regression model, each day with a delirium symptom in a patient with the same length of stay was associated with a 10% increase in in-hospital mortality (Hazard ratio 1.1, 95% Confidence interval 1.01–1.2; p = 0.03). Other variables associated with increased risk of in-hospital death were age, comorbidity, CPAP, CRP levels and total number of drugs on admission.

Conclusions

The study supports the necessity to establish protocols for the monitoring and management of delirium during emergency conditions to allow an appropriate care for older patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01899-8.

[COVID-19 in the Intensive Care Unit: Medical, Nursing, and Physical Therapy Challenges]

COVID-19 in the Intensive Care Unit: Medical, Nursing, and Physical Therapy Challenges Abstract. The treatment of patients with COVID-19 is a big challenge for intensive care units: substantial additional staff and material is needed to treat the surge of patients admitted in short time. Treatment is difficult as many patients present with multiple organ failure, including acute respiratory distress syndrome (ARDS). Mostly, oxygenation is substantially impaired and compliance low, and many patients need prone positioning. This article deals with the difficulties during the first surge of patients with COVID-19. The suffering of the relatives who were not allowed to visit must also be considered.

Guidelines: Discharge Instructions for Covid-19 Patients

INTRODUCTION/OBJECTIVES

Clinicians treating COVID-19 patients face a major challenge in providing an effective relationship with patients who are discharged to return to home in order to optimize patient self-management after discharge. The purpose of these discharge instructions is to assist and provide guidance for physicians, nurses, and other health care personnel involved in discharging COVID-19 patients to home after encounters at hospitals, emergency departments, urgent care settings, and medical offices.

METHODS

A systematic literature-search of studies evaluating both symptoms and signs of COVID-19 was performed in order to establish specific optimal performance criteria in monitoring a patient's status with regard to disease safety. These optimal performance criteria parameters were considered with regard to the severity of morbidity and mortality. Strategies used to develop the discharge instructions included review of a broad spectrum of literature to develop the discharge criteria.

RESULTS

These guidelines are presented for patient education and should achieve the essential goals including: enabling patients to understand their medical situation, preventing complications, supporting patients by providing instructions, helping patients make more effective use of available health services, and managing patient stress by giving patients comfort through the knowledge of specific recommendations including how to respond to situations.

CONCLUSION

The COVID-19 pandemic requires clinicians to efficiently teach their patients self-management strategies and to provide a safe educated response to the patient and the surrounding community environment. The primary goal of the patient education discharge-instructions (PEDI) is to provide self-management strategies for preventing complications and disease transmission.