Delirium and Adverse Outcomes in Hospitalized Patients with COVID-19

A pandemic of delirium: an updated systematic review and meta-analysis of occurrence of delirium in older adults with COVID-19

PURPOSE

Delirium has been recognized as an atypical presenting feature of COVID-19 in older adults and is independently associated with mortality. We aimed to perform an updated systematic review of the literature and proportional meta-analysis to assess prevalence and incidence of delirium in older adults with COVID-19, addressing differences according to sex, frailty status, and settings.

METHODS

We searched databases for English-language articles on prevalence and incidence of delirium in older adults with COVID-19, published between March 2020 and January 2023.

RESULTS

Of the 1171 articles identified, 66 met selection criteria and were included in the meta-analysis (n = 35,035 participants, age-range 66-90 years old, 46.6% females). We observed similar pooled prevalence (20.6% [95% Confidence Interval (CI) 17.8-23.8%]) and incidence (21.3% [95% CI 14.7-30%]) of delirium. Pooled occurrence (both prevalence and incidence) of delirium was similar according to sex (females 21.3% [95% CI 16-27.5%] vs. males 23.8%% [95% CI 18.2-30.4%], p-value = 0.55) and study setting (nursing homes 22.5% [95% CI 14.2-33.6%] vs. hospital 20.3% [95% CI 17-24%], p = 0.68), but it was significantly higher in frail versus non-frail patients (37% [95% CI 26.6-48.8%] vs. 12.5% [95% CI 7.8-19.6%], p-value < 0.01). Delirium definitions and assessment tools largely varied across studies.

CONCLUSION

This review delineates delirium as a common feature of COVID-19, particularly in frail older adults, and supports its formal inclusion among COVID-19 symptoms. The considerable heterogeneity in delirium assessment highlights the need for an operational strategy to standardize definitions and tools utilization in the management of frail older adults.

Brain Pathology in COVID-19: Clinical Manifestations and Potential Mechanisms

Neurological manifestations of coronavirus disease 2019 (COVID-19) are less noticeable than the respiratory symptoms, but they may be associated with disability and mortality in COVID-19. Even though Omicron caused less severe disease than Delta, the incidence of neurological manifestations is similar. More than 30% of patients experienced "brain fog", delirium, stroke, and cognitive impairment, and over half of these patients presented abnormal neuroimaging outcomes. In this review, we summarize current advances in the clinical findings of neurological manifestations in COVID-19 patients and compare them with those in patients with influenza infection. We also illustrate the structure and cellular invasion mechanisms of SARS-CoV-2 and describe the pathway for central SARS-CoV-2 invasion. In addition, we discuss direct damage and other pathological conditions caused by SARS-CoV-2, such as an aberrant interferon response, cytokine storm, lymphopenia, and hypercoagulation, to provide treatment ideas. This review may offer new insights into preventing or treating brain damage in COVID-19.

CRP/albumin, Glasgow prognostic score, and prognostic nutritional index as a predictor of mortality among delirium patients

BACKGROUND

With the older populations growing each year, high mortality rates make delirium a valuable topic.

AIM

We aimed to analyze the parameters that could predict 30 days of mortality of the patients diagnosed in the emergency department (ED) with delirium.

METHODS

This retrospective study included 85 patients with a diagnosis of delirium. Glasgow prognostic score (GPS), prognostic nutritional index (PNI), and C-reactive protein (CRP)/albumin values of the patients and 30-day mortality rate were computed. The effectiveness of GPS, PNI, and CRP/albumin parameters in predicting 30-day mortality was analyzed.

RESULTS

The findings showed that the optimal cut-off value for albumin as determined by Youden's index in estimation of 30-day mortality was ≤ 36.8 [AUC: 0.830 (95% CI: 0.733-0.903; p < 0.001), with a sensitivity of 85.71% and specificity of 76.36%], while cut-off value for CRP/albumin was > 0.974 [AUC: 0.753 (95% CI: 0.647-0.840; p < 0.001); with a sensitivity of 85.71% and specificity of 70.51%], and cut-off value for PNI was ≤ 39.05 [AUC: 0.850 (95% CI: 0.756-0.918; p < 0.001) sensitivity 71.43% and specificity 92.31%]. Significant effectiveness of the values of GPS (odds ratio (OR) = 6.69; 95% confidence interval (CI): 1.69-26.37), PNI (OR = 0.83; 95% CI: 0.74-0.95), albumin (OR = 0.82; 95% CI: 0.71-0.94), and CAD (OR = 10.5; 95% CI: 1.85-59.45) was observed for predicting mortality in univariate regression analysis.

CONCLUSIONS

The findings obtained in this study suggest that GPS, PNI, and albumin parameters could be used to guide the clinician in predicting the 30-day mortality of patients diagnosed with delirium.

Nomogram to predict the incidence of delirium in elderly patients with non-severe SARS-CoV-2 infection

Objective

To construct and validate nomogram models that predict the incidence of delirium in elderly patients with non-severe SARS-CoV-2 infection.

Methods

Elderly patients (≥65y) tested positive for SARS-CoV-2 infection at the hospital were included. We used the 3-min diagnostic Confusion Assessment Method for delirium diagnosis. Least absolute shrinkage and selection operator (LASSO) logistical regression analysis was performed to explore potential independent influencing factors of delirium. A predict model visualized by nomogram was constructed based on the confirmed variables. The predictive accuracy and clinical value of the model were evaluated using receiver operating characteristic (ROC) curves.

Results

The data of 311 elderly patients were analyzed, of whom 73 (23.47%) patients were diagnosed with delirium. Three independent influencing factors of delirium were confirmed: age (OR1.16,1.11-1.22), Glomerular filtration rate (OR 0.98,0.97-0.99), platelet-large cell ratio (1.06,1.02-1.10). These parameters were used to create a nomogram to predict the development of delirium, which showed good predictive accuracy confirmed by the ROC curves (AUC 0.82,0.76-0.88).

Conclusion

We construct a credible nomogram to predict the development of delirium in elderly patients with Non-severe SARS-CoV-2 infection. Our finding may be useful to physicians in early prevention and treatment of delirium.

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.

Targeting the mammalian target of rapamycin pathway in neurological manifestations of Covid-19

The diverse and severe nature of neurological manifestations associated with coronavirus disease 2019 (Covid-19) has garnered increasing attention. Exploring the potential to decrease neurological complications in Covid-19 patients involves targeting the mammalian target of rapamycin (mTOR) pathway as a therapeutic strategy. The mTOR pathway, widely recognised for its central role in essential cellular processes like synthesising proteins, facilitating autophagy, and modulating immune responses, has implications in various neurological disorders. Drawing parallels between these disorders and the observed neurological complications in Covid-19, we present a comprehensive review on the current understanding of mTOR signalling in the context of severe acute respiratory syndrome coronavirus 2 infection and neuroinflammation.

Delirium severity and outcomes of critically ill COVID-19 patients

OBJECTIVE

To investigate the impact of delirium severity in critically ill COVID-19 patients and its association with outcomes.

METHODS

This prospective cohort study was performed in two tertiary intensive care units in Rio de Janeiro, Brazil. COVID-19 patients were evaluated daily during the first 7 days of intensive care unit stay using the Richmond Agitation Sedation Scale, Confusion Assessment Method for Intensive Care Unit (CAM-ICU) and Confusion Method Assessment for Intensive Care Unit-7 (CAM-ICU-7). Delirium severity was correlated with outcomes and one-year mortality.

RESULTS

Among the 277 COVID-19 patients included, delirium occurred in 101 (36.5%) during the first 7 days of intensive care unit stay, and it was associated with a higher length of intensive care unit stay in days (IQR 13 [7 - 25] versus 6 [4 - 12]; p < 0.001), higher hospital mortality (25.74% versus 5.11%; p < 0.001) and additional higher one-year mortality (5.3% versus 0.6%, p < 0.001). Delirium was classified by CAM-ICU-7 in terms of severity, and higher scores were associated with higher in-hospital mortality (17.86% versus 34.38% versus 38.46%, 95%CI, p value < 0.001). Severe delirium was associated with a higher risk of progression to coma (OR 7.1; 95%CI 1.9 - 31.0; p = 0.005) and to mechanical ventilation (OR 11.09; 95%CI 2.8 - 58.5; p = 0.002) in the multivariate analysis, adjusted by severity and frailty.

CONCLUSION

In patients admitted with COVID-19 in the intensive care unit, delirium was an independent risk factor for the worst prognosis, including mortality. The delirium severity assessed by the CAM-ICU-7 during the first week in the intensive care unit was associated with poor outcomes, including progression to coma and to mechanical ventilation.

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.

Comorbidities, symptoms and end-of-life medication use in hospitalised decedents before and during the COVID-19 pandemic: a retrospective regional cohort study in Ottawa, Canada

OBJECTIVE

To compare comorbidities, symptoms and end-of-life (EoL) palliative medication (antisecretories, opioids, antipsychotics and sedatives) use among decedents before and during the COVID-19 pandemic.

DESIGN

In a retrospective cohort study, decedent records in three acute care hospitals were abstracted, generating a prepandemic (November 2019-February 2020) group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one without (COVID-ve) and one with COVID-19 infection (COVID+ve). Control group decedents were matched 2:1 on age, sex and care service (medicine/intensive care unit (ICU)) with COVID+ve decedents.

SETTING

Three regional acute care teaching hospitals in Ottawa, Canada PARTICIPANTS: Decedents (N=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170).

MAIN OUTCOME MEASURES

Data were abstracted regarding demographics, admission comorbidities and symptoms, and EoL medication use; opioid doses were standardised to parenteral morphine equivalent daily dose (MEDD), and the predictors of upper quartile MEDD in the last 24 hours of life were examined in multivariable logistic regression with adjusted ORs (aORs) and 95% CIs.

RESULTS

The prevalence of dementia (41% vs 28% and 26%, p=0.03), breathlessness (63.5% vs 42% and 47%, p<0.01), cough (40% vs 27% and 19%, p<0.01) and fever (54% vs 9% and 13.5%) was higher in COVID+ve versus pre-COVID and COVID-ve groups, respectively. The median (IQR) of MEDD over the last 72 hours of life was 16.7 (9-36.5) vs 13.5 (5.7-21.8) and 10.5 (5.3-23.8) for COVID+ve versus pre-COVID and COVID-ve groups, respectively, (p=0.007). Male sex, COVID+ve grouping, ICU death and high-flow nasal cannula use predicted upper quartile MEDD dose, aORs (95% CIs): 1.84 (1.05 to 3.22), 2.62 (1.29 to 5.3), 5.14 (2.47 to 10.7) and 1.93 (1.05 to 3.52), respectively. COVID+ve group decedents used highest lorazepam and propofol doses.

CONCLUSIONS

COVID-19 decedents, particularly those in ICU, required higher EoL opioid and sedating medication doses than matched prepandemic or intrapandemic controls. These findings should inform and guide clinical practice.

Dissipating the fog: Cognitive trajectories and risk factors 1 year after COVID-19 hospitalization

INTRODUCTION

Cognitive impairment is common after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, associations between post-hospital discharge risk factors and cognitive trajectories have not been explored.

METHODS

A total of 1105 adults (mean age ± SD 64.9 ± 9.9 years, 44% women, 63% White) with severe coronavirus disease 2019 (COVID-19) were evaluated for cognitive function 1 year after hospital discharge. Scores from cognitive tests were harmonized, and clusters of cognitive impairment were defined using sequential analysis.

RESULTS

Three groups of cognitive trajectories were observed during the follow-up: no cognitive impairment, initial short-term cognitive impairment, and long-term cognitive impairment. Predictors of cognitive decline after COVID-19 were older age (β = -0.013, 95% CI = -0.023;-0.003), female sex (β = -0.230, 95% CI = -0.413;-0.047), previous dementia diagnosis or substantial memory complaints (β = -0.606, 95% CI = -0.877;-0.335), frailty before hospitalization (β = -0.191, 95% CI = -0.264;-0.119), higher platelet count (β = -0.101, 95% CI = -0.185;-0.018), and delirium (β = -0.483, 95% CI = -0.724;-0.244). Post-discharge predictors included hospital readmissions and frailty.

DISCUSSION

Cognitive impairment was common and the patterns of cognitive trajectories depended on sociodemographic, in-hospital, and post-hospitalization predictors.

HIGHLIGHTS

Cognitive impairment after coronavirus disease 2019 (COVID-19) hospital discharge was associated with higher age, less education, delirium during hospitalization, a higher number of hospitalizations post discharge, and frailty before and after hospitalization. Frequent cognitive evaluations for 12-month post-COVID-19 hospitalization showed three possible cognitive trajectories: no cognitive impairment, initial short-term impairment, and long-term impairment. This study highlights the importance of frequent cognitive testing to determine patterns of COVID-19 cognitive impairment, given the high frequency of incident cognitive impairment 1 year after hospitalization.

Incidence of Delirium in Critically Ill Patients With and Without COVID-19

BACKGROUND

It is known that patients with COVID-19 are at high risk of developing delirium. The aim of the study was to compare the incidence of delirium between critically ill patients with and without a diagnosis of COVID-19.

METHODS

This is a retrospective study conducted in a southern Brazilian hospital from March 2020 to January 2021. Patients were divided into two groups: the COVID-19 group consisted of patients with a diagnosis of COVID-19 confirmed by reverse transcription-polymerase chain reaction (RT-PCR) or serological tests who were admitted to specific ICUs. The non-COVID-19 group consisted of patients with other surgical and medical diagnoses who were admitted to non-COVID ICUs. All patients were evaluated daily using the Intensive Care Delirium Screening Checklist (ICDSC). The two cohorts were compared in terms of the diagnosis of delirium.

RESULTS

Of the 649 patients who remained more than 48 h in the ICU, 523 were eligible for the study (COVID-19 group: 292, non-COVID-19 group: 231). There were 119 (22.7%) patients who had at least one episode of delirium, including 96 (32.9%) in the COVID-19 group and 23 (10.0%) in the non-COVID-19 group (odds ratio [OR] 4.42; 95% confidence interval [CI], 2.69 to 7.26; p < 0.001). Among patients mechanically ventilated for two days or more, the incidence of delirium did not differ between groups (COVID-19: 89/211, 42.1% vs non-COVID-19: 19/47, 40.4%; p  =  0.82). Logistic regression showed that the duration of mechanical ventilation was the only independent factor associated with delirium (p  =  0.001).

CONCLUSION

COVID-19 can be associated with a higher incidence of delirium among critically ill patients, but there was no difference in this incidence between groups when mechanical ventilation lasted two days or more.

One-Year Outcomes of Patients Requiring Tracheostomy Placement Due to Severe Acute Respiratory Syndrome Coronavirus 2 Infection

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease it causes (COVID-19) have resulted in an increase in critical illness and in the prevalence of acute respiratory failure with the need for tracheostomy. The characteristics and long-term outcomes of this patient cohort are not well identified.

RESEARCH QUESTION

What are the characteristics of patients who develop the need for tracheostomy due to SARS-CoV-2 with acute respiratory distress syndrome (ARDS)? What is their 90-day and 1-year survival and are there any identifiable risk factors for mortality and ventilator dependency?

STUDY DESIGN AND METHODS

Retrospective, follow-up cohort study of adult patients with COVID-19 infection and ARDS who required tracheostomy placement in a large healthcare system.

RESULTS

One hundred sixty-four consecutive patients with SARS-CoV-2 admitted to ICUs for ARDS who required tracheostomy placement between March 2020 and March 2021 were identified. One hundred nine (66.5%) were male. Average age was 63.5 years. The most common comorbidities were obesity, hypertension, diabetes mellitus, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease (COPD), atrial fibrillation, and asthma. The most common complications during hospitalization were delirium, secondary infections, acute kidney injury, pneumothorax, and venous thromboembolism. Ninety-day and 1-year mortality were 29.9% and 44.5%, respectively. Ninety-six patients (58.5%) were liberated from the ventilator, and 84 (51.2%) had the tracheostomy tube decannulated. Asthma, COPD, atrial fibrillation, and renal replacement therapy requirement in the ICU correlated with increased risk of ventilator dependency. Among survivors at 1 year, 71 patients (43.3%) were residing at home and 20 patients (12.2%) remained in a skilled nursing facility.

INTERPRETATION

COVID-19 has resulted in a significant burden of acute critical illness and acute respiratory failure with the need for tracheostomy. A significant percentage of patients with SARS-CoV-2 requiring tracheostomy were alive and at home 1 year after tracheostomy placement. Long-term care support, including tracheostomy, beyond 90 days appears to be beneficial in this patient population and warrants further investigation.

Association of Delirium and Depression with Respiratory and Outcome Measures in COVID-19 Inpatients

Delirium (DEL) and depression (DEP) may impair the course and severity of acute respiratory illness. The impact of such syndromes on respiratory and outcome parameters in inpatients with COVID-19 needs clarification. To clarify the relationship between DEL and DEP and respiratory outcome measures, we enrolled 100 inpatients from COVID-19 units of the Fondazione Policlinico Universitario Agostino Gemelli IRCCS of Rome. Participants were divided into those with DEL, DEP, or absence of either delirium or depression (CONT). Delirium severity was assessed with the Neelson and Champagne Confusion Scale (NEECHAM). Psychopathology was assessed with the Hamilton Rating Scale for Depression (HAM-D), the Hamilton Rating Scale for Anxiety (HAM-A), and the Brief Psychiatric Rating Scale (BPRS). Dependent variables include: (a) respiratory parameters, i.e., partial pressure of oxygen in arterial blood (PaO2), oxygen saturation (SpO2), ratio between arterial partial pressure of oxygen (PaO2), and fraction of inspired oxygen (PaO2/FiO2); (b) outcome parameters, i.e., duration of hospitalization and number of pharmacological treatments used during the hospitalization. We investigated between-group differences and the relationships between severity of delirium/depression and the dependent variables. Duration of hospitalization was longer for DEL than for either DEP or CONT and for DEP compared to CONT. NEECHAM and HAM-D scores predicted lower PaO2 and PaO2/FiO2 levels in the DEL and DEP groups, respectively. In DEP, BPRS scores positively correlated with duration of hospitalization. Delirium impacted the course of COVID-19 more severely than depression. The mechanisms by which delirium and depression worsen respiratory parameters differ.

Jujuboside A ameliorates cognitive deficiency in delirium through promoting hippocampal E4BP4 in mice

OBJECTIVE

Delirium (acute brain syndrome) is a common and serious neuropsychiatric disorder characterized by an acute decline in cognitive function. However, there is no effective treatment clinically. Here we investigated the potential effect of jujuboside A (JuA, a natural triterpenoid saponin) on cognitive impairment in delirium.

METHODS

Delirium models of mice were established by injecting lipopolysaccharide (LPS) plus midazolam and implementing a jet lag protocol. Novel object recognition test and Y maze test were used to evaluate the effects of JuA on delirium-associated cognitive impairment. The mRNA and protein levels of relevant clock factors and inflammatory factors were measured by qPCR and Western blotting. Hippocampal Iba1+ intensity was determined by immunofluorescence staining.

KEY FINDINGS

JuA ameliorated delirium (particularly delirium-associated cognitive impairment) in mice, which was proved by the behavioural tests, including a preference for new objects, an increase of spontaneous alternation and improvement of locomotor activity. Furthermore, JuA inhibited the expression of ERK1/2, p-p65, TNFα and IL-1β in hippocampus, and repressed microglial activation in delirious mice. This was attributed to the increased expression of E4BP4 (a negative regulator of ERK1/2 cascade and microglial activation). Moreover, loss of E4bp4 in mice abrogated the effects of JuA on delirium as well as on ERK1/2 cascade and microglial activation in the hippocampus of delirious mice. Additionally, JuA treatment increased the expression of E4BP4 and decreased the expression of p-p65, TNFα and IL-1β in LPS-stimulated BV2 cells, supporting a protective effect of JuA on delirium.

CONCLUSIONS

JuA protects against delirium-associated cognitive impairment through promoting hippocampal E4BP4 in mice. Our findings are of great significance to the drug development of JuA against delirium and related disorders.

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.

Incidence Rate and Factors Associated with Delirium and Subsyndromal Delirium in Patients with COVID-19 in an Intensive Care Unit

BACKGROUND

Delirium subsyndrome (SSD) and delirium (DL) are known complications in the intensive care unit (ICU) and are associated with worse clinical outcomes. The aim of this study was to screen for SSD and DL in individuals with COVID-19 admitted to the ICU and to study the associated factors and clinical outcomes.

METHOD

An observational, longitudinal study was conducted in the reference ICU for COVID-19. All admitted individuals with COVID-19 were screened for SSD and DL during their ICU stay using the Intensive Care Delirium Screening Checklist (ICDSC). Individuals with SSD and/or DL were compared to those without SSD and/or DL.

RESULTS

Ninety-three patients were evaluated, of which 46.7% had SSD and/or DL. The incidence rate was 4.17 cases/100 person-days. Individuals with SSD and/or DL had higher severity of illness on admission to the ICU, as measured by the APACHE II score (median 16 versus 8 points, p < 0.001). SSD and/or DL were associated with longer ICU and hospital stays (median 19 versus 6 days, p < 0.001 and median 22 versus 7 days, p < 0.001, respectively).

CONCLUSION

Individuals with SSD and/or DL had greater disease severity and longer ICU and hospital stays when compared to those without SSD and/or DL. This reinforces the importance of screening for consciousness disorders in the ICU.

Cost-Effectiveness Analysis of COVID-19 Inactivated Vaccines in Reducing the Economic Burden of Ischaemic Stroke after SARS-CoV-2 Infection

Due to significant economic burden and disability from ischaemic stroke and the relationship between ischaemic stroke and SARS-CoV-2 infection, we aimed to explore the cost-effectiveness of the two-dose inactivated COVID-19 vaccination program in reducing the economic burden of ischaemic stroke after SARS-CoV-2 infection. We constructed a decision-analytic Markov model to compare the two-dose inactivated COVID-19 vaccination strategy to the no vaccination strategy using cohort simulation. We calculated incremental cost-effectiveness ratios (ICERs) to evaluate the cost-effectiveness and used number of the ischaemic stroke cases after SARS-CoV-2 infection and quality-adjusted life-years (QALYs) to assess effects. Both one-way deterministic sensitivity analysis and probabilistic sensitivity analysis were performed to assess the robustness of the results. We found that the two-dose inactivated vaccination strategy reduced ischaemic stroke cases after SARS-CoV-2 infection by 80.89% (127/157) with a USD 1.09 million as vaccination program cost, saved USD 3675.69 million as direct health care costs and gained 26.56 million QALYs compared with no vaccination strategy among 100,000 COVID-19 patients (ICER < 0 per QALY gained). ICERs remained robust in sensitivity analysis. The proportion of older patients and the proportion of two-dose inactivated vaccination among older people were the critical factors that affected ICER. This study suggests the importance of COVID-19 vaccination is not only in preventing the spread of infectious diseases, but also in considering its long-term value in reducing the economic burden of non-communicable diseases such as ischaemic stroke after SARS-CoV-2 infection.

Confirmed SARS-CoV-2 infection and mortality: Associated factors in hospitalized people 75 and older

<b>Introduction:</b> COVID-19 infection in the elderly posed challenges in health systems and clinical care by health personnel.<br /> <b>Objective</b>:<b> </b>To<b> </b>describe the factors associated with mortality in persons aged 75 and older with COVID-19 in a high complexity hospital in Bogotá, Colombia.<br /> <b>Methods</b>:<b> </b>Observational, analytical and retrospective study, including 509 patients aged 75 and older hospitalized with COVID-19.<br /> <b>Results</b>:<b> </b>40.47% died during hospital stay. It was found that a shorter time of symptom onset at admission, a respiratory rate greater than 20 breaths per minute, having thrombocytopenia, elevated lactate dehydrogenase and elevated D-dimer were associated with higher in-hospital mortality.<br /> <b>Conclusions</b>:<b> </b>There is an association between mortality and the presence of dyspnea, fever and delirium. Paraclinical results with lactate dehydrogenase &gt;350 (U/L), the presence of elevated D-dimer greater than 1,000 μg/L, as well as a Pa02/Fi02 ratio with a median of less than 90, were associated with higher mortality.

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.

Consensus Clinical Guidance for Diagnosis and Management of Adult COVID-19 Encephalopathy Patients

Encephalopathy, a common condition among patients hospitalized with COVID-19, can be a challenge to manage and negatively affect prognosis. While encephalopathy may present clinically as delirium, subsyndromal delirium, or coma and may be a result of systemic causes such as hypoxia, COVID-19 has also been associated with more prolonged encephalopathy due to less common but nevertheless severe complications, such as inflammation of the brain parenchyma (with or without cerebrovascular involvement), demyelination, or seizures, which may be disproportionate to COVID-19 severity and require specific management. Given the large number of patients hospitalized with severe acute respiratory syndrome coronavirus-2 infection, even these relatively unlikely complications are increasingly recognized and are particularly important because they require specific management. Therefore, the aim of this review is to provide pragmatic guidance on the management of COVID-19 encephalopathy through consensus agreement of the Global COVID-19 Neuro Research Coalition. A systematic literature search of MEDLINE, medRxiv, and bioRxiv was conducted between January 1, 2020, and June 21, 2021, with additional review of references cited within the identified bibliographies. A modified Delphi approach was then undertaken to develop recommendations, along with a parallel approach to score the strength of both the recommendations and the supporting evidence. This review presents analysis of contemporaneous evidence for the definition, epidemiology, and pathophysiology of COVID-19 encephalopathy and practical guidance for clinical assessment, investigation, and both acute and long-term management.

[Prevalence and risk factors of delirium in COVID-19]

OBJECTIVE

To assess the frequency and risk factors of delirium in patients hospitalized with COVID-19.

MATERIAL AND METHODS

Four hundred and forty patients admitted to the Infectious Diseases Hospital of the University Clinical Hospital No.3 of Sechenov University were included in the study. The Patient Health Questionnaire (PHQ-9), the Generalized Anxiety Disorder Screening Questionnaire-7 (GAD-7), the Insomnia Severity Index (ISI), the Delirium severity rating scale (DRS-R-98) were administered.

RESULTS

Delirium was detected in 27.8% of patients. Significant risk factors were age (p=0.002), severity of respiratory failure (p=0.005), concomitant somatic disease (p=0.003), and respiratory therapy (p<0.001). There was an association between severe anxiety (p<0.001) and insomnia (p=0.07) observed at admission with the risk of developing delirium during the hospital stay.

CONCLUSION

The study reveals a high prevalence of delirium in patients with COVID-19. In order to prevent delirium and/or reduce the risk, early diagnosis and identification of preclinical forms are of particular importance.

Demographic Features, Physical Examination Findings, and Medication Use in Hospitalized, Delirious Patients With and Without COVID-19 Infection: A Retrospective Study

BACKGROUND

Delirium is common in the setting of infection with severe acute respiratory syndrome coronavirus 2. Anecdotal evidence and case reports suggest that patients with delirium in the setting of Coronavirus 2019 (COVID-19) may exhibit specific features, including increased tone, abulia, and alogia.

OBJECTIVE

To determine whether differences exist in sociodemographic and medical characteristics, physical examination findings, and medication use in delirious patients with and without COVID-19 infection referred for psychiatric consultation.

METHODS

We undertook an exploratory, retrospective chart review of 486 patients seen by the psychiatry consultation service at a tertiary care hospital from March 10 to May 15, 2020. Delirious patients were diagnosed via clinical examination by a psychiatric consultant, and these patients were stratified by COVID-19 infection status. The strata were described and compared using bivariate analyses across sociodemographic, historical, objective, and treatment-related variables.

RESULTS

A total of 109 patients were diagnosed with delirium during the study period. Thirty-six were COVID-19+. Median age was 63 years and did not differ between groups. COVID-19+ patients with delirium were more likely to present from nursing facilities (39% vs 11%; Fisher's exact test; P = 0.001) and have a history of schizophrenia (11% vs 0%; Fisher's exact test; P = 0.011). Myoclonus (28% vs 4%; P = 0.002), hypertonia (36% vs 10%; P = 0.003), withdrawal (36% vs 15%; P = 0.011), akinesia (19% vs 6%; P = 0.034), abulia (19% vs 3%; P = 0.004), and alogia (25% vs 8%; P = 0.012) were more common in COVID-19+ patients. COVID-19+ delirious patients were significantly more likely to have received ketamine (28% vs 7%; P = 0.006), alpha-adrenergic agents besides dexmedetomidine (36% vs 14%; P = 0.014), and enteral antipsychotics (92% vs 66%; P = 0.007) at some point.

CONCLUSIONS

Patients with COVID-19 delirium referred for psychiatric consultation are more likely to reside in nursing facilities and have a history of schizophrenia than delirious patients without COVID-19. Patients with delirium in the setting of COVID-19 may exhibit features consistent with akinetic mutism. Psychiatrists must assess for such features, as they may influence management choices and the risk of side effects with agents commonly used in the setting of delirium.

Frailty, Comorbidity, and Associations With In-Hospital Mortality in Older COVID-19 Patients: Exploratory Study of Administrative Data

BACKGROUND

Older adults have worse outcomes following hospitalization with COVID-19, but within this group there is substantial variation. Although frailty and comorbidity are key determinants of mortality, it is less clear which specific manifestations of frailty and comorbidity are associated with the worst outcomes.

OBJECTIVE

We aimed to identify the key comorbidities and domains of frailty that were associated with in-hospital mortality in older patients with COVID-19 using models developed for machine learning algorithms.

METHODS

This was a retrospective study that used the Hospital Episode Statistics administrative data set from March 1, 2020, to February 28, 2021, for hospitalized patients in England aged 65 years or older. The data set was split into separate training (70%), test (15%), and validation (15%) data sets during model development. Global frailty was assessed using the Hospital Frailty Risk Score (HFRS) and specific domains of frailty were identified using the Global Frailty Scale (GFS). Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Additional features employed in the random forest algorithms included age, sex, deprivation, ethnicity, discharge month and year, geographical region, hospital trust, disease severity, and International Statistical Classification of Disease, 10th Edition codes recorded during the admission. Features were selected, preprocessed, and input into a series of random forest classification algorithms developed to identify factors strongly associated with in-hospital mortality. Two models were developed; the first model included the demographic, hospital-related, and disease-related items described above, as well as individual GFS domains and CCI items. The second model was similar to the first but replaced the GFS domains and CCI items with the HFRS as a global measure of frailty. Model performance was assessed using the area under the receiver operating characteristic (AUROC) curve and measures of model accuracy.

RESULTS

In total, 215,831 patients were included. The model using the individual GFS domains and CCI items had an AUROC curve for in-hospital mortality of 90% and a predictive accuracy of 83%. The model using the HFRS had similar performance (AUROC curve 90%, predictive accuracy 82%). The most important frailty items in the GFS were dementia/delirium, falls/fractures, and pressure ulcers/weight loss. The most important comorbidity items in the CCI were cancer, heart failure, and renal disease.

CONCLUSIONS

The physical manifestations of frailty and comorbidity, particularly a history of cognitive impairment and falls, may be useful in identification of patients who need additional support during hospitalization with 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.

Prevalence of the Risk Factors of Delirium Among COVID-19 Patients in the Intensive Care Unit at King Abdullah Medical City, Makkah: A Single-Center Study

Background Coronavirus disease 2019 (COVID-19) patients admitted to the intensive care unit (ICU) are at a higher risk of developing delirium. In this study, we estimated the incidence of delirium and its risk factors in ICU patients with COVID-19 at King Abdullah Medical City (KAMC), Makkah, Saudi Arabia. Methodology We conducted a retrospective, analytical, cohort study of adult COVID-19 patients admitted to the ICU of KAMC between May 2020 and July 2021. Data were collected from electronic medical records. Results Of the 406 examined patients with COVID-19 aged >18 years, 55 developed delirium in the ICU setting. The incidence rate was 0.59% per 100 ICU days in these 55 patients; the mean age was 62.36 ± 17.9 years, and 65.5% were men. Binary logistic regression showed that age (p = 0.027), nationality (p = 0.045), presence of infectious diseases other than COVID-19 (p = 0.047), and ICU outcome (p = 0.013) were significant risk factors for developing delirium. The clinical presentation and prognosis of patients who developed delirium were assessed using the Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and the mean scores were 16.13 ± 7.96 and 5.25 ± 3.48, respectively. The mean length of ICU stay was 22.2 ± 33.3 days; 39 (70.9%) patients were discharged and 16 (29.1%) died. Conclusions Older age, nationality, infections, and ICU outcomes were risk factors for developing delirium in hospitalized COVID-19 patients at KAMC. Early detection of cognitive comorbidities and delirium in these patients is important.

[Factors Associated With Delirium In Patients Hospitalized During The COVID-19 Pandemic]

OBJECTIVES

To determine the risk factors associated with delirium in patients admitted to a COVID-19 Hospitalization of a general hospital during the first year of the COVID-19 pandemic.

METHODS

An observational, analytical, case-control study was conducted. We analyzed 50 medical records of patients who presented delirium and 50 who did not present delirium in a COVID Hospitalization area during the period from March 2020 to March 2021. The Odd Ratio of sociodemographic and clinical factors for presenting delirium was evaluated. The logistic regression statistical test was performed using STATA 17.0 software. The protocol was approved by the Research Ethics Committee of the Villa El Salvador Emergency Hospital.

RESULTS

Ventilatory support (p=0.04), especially the use of a reservoir mask (OR=0.34, CI 0.12-0.88) and the presence of systemic complications (p=0.03) such as metabolic acidosis (OR=12.9, CI 1.45-115.58) were statistically significant variables associated with a higher risk of presenting delirium.

CONCLUSIONS

The type of ventilatory support and the presence of systemic complications were significant risk factors for delirium in patients hospitalized in a COVID area. Further studies are required in this field to obtain more evidence in this regard.

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.

Impacting Outcomes in the Hospitalized Oncology Patient: Evidence-Informed Quality and Safety Project to Implement Routine Screening for Delirium

Background: Delirium can occur in cancer patients during an acute hospitalization or in the terminal stages of cancer. Iatrogenic delirium can complicate hospital stays for over 2.6 million older persons by increasing fall risk, restraint use, length of stay, postacute placement, and costs. The purpose of this evidence-based quality improvement project was to implement routine screening for delirium with a consistent instrument and adopt an interprofessional plan of care for delirium. Methods: This project was identified as an interprofessional improvement initiative. The project leader identified a deficiency in the screening for delirium, convened stakeholders, evaluated evidence, reviewed screening instruments, and developed a plan of care for delirium management. Practice changes incorporated routine delirium screening across the inpatient units. A delirium interprofessional plan of care was integrated into the electronic health record for ease of adoption and workflow modification. Results: Routine screening for delirium and early interprofessional interventions reduced length of stay by 2.27 days for patients screening positive for delirium. The percentage of inpatient falls that were linked to an episode of delirium during hospitalization reduced from 23.4% to 17%. Discussions: Routine screening and targeted interventions are a first step in prevention and identification of those inpatients at risk of developing delirium. Delirium prevention is the goal for potential associated iatrogenic conditions.

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.

Continuous Positive Airway Pressure in Elderly Patients with Severe COVID-19 Related Respiratory Failure

The elderly population represents a high percentage of patients hospitalized for COVID-19 pneumonia and severe respiratory failure, for whom CPAP may be a treatment option. The aim of this study was to describe the CPAP support modalities and to explore factors associated with CPAP failure. In this retrospective study, 110 consecutive patients aged ≥ 75 years were enrolled. Median frailty score, baseline partial arterial pressure of oxygen to fraction of inspired oxygen ratio (P/F), and respiratory rate (RR) were 5, 108, and 30 cycles/min, respectively. Of the 110 patients that began CPAP treatment, 17 patients died within 72 h from baseline, while in 2 patients, CPAP was withdrawn for clinical improvement. Thus, of the 91 patients still on CPAP at day 3, 67% of them needed continuous CPAP delivery. Patients with RR ≥ 30 and with frailty score ≥ 5 had an odds ratio of continuous CPAP needing of 3 and 4, respectively. Patients unable to tolerate CPAP-free periods demonstrated higher mortality risk as compared to those able to tolerate intermittent CPAP (OR: 6.04, 95% CI 2.38−16.46, p < 0.001). The overall in-hospital mortality was 63.6%. Delirium occurred in 59.1%, with a mortality rate in this subgroup of 83.1%. In a time-varying Cox model, the hazard ratio of death was 2.9 in patients with baseline RR ≥ 30 cycle/min, 2.4 in those with baseline P/F < 100. In the same model, the hazard ratio of death was 20 in patients with delirium and a frailty score < 5 and 8.8 in those without delirium and with frailty ≥ 5, indicating a competitive effect between these two variables on the death risk. Conclusions: Respiratory impairment, frailty, and delirium predict treatment failure, with the latter two factors demonstrating a competitive effect on mortality risk. CPAP support may represent a feasible therapeutic option in elderly patients, although chances of a therapeutic benefit are markedly reduced in case of severe respiratory impairment, very frail baseline condition or delirium occurrence.

An Overview of Neurological and Psychiatric Complications During Post-COVID Period: A Narrative Review

The coronavirus disease 2019 (COVID-19), induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a multi-organ and multi-system disease with high morbidity and mortality in severe cases due to respiratory failure and severe cardiovascular events. However, the various manifestations of neurological and psychiatric (N/P) systems of COVID-19 should not be neglected. Some clinical studies have reported a high risk of N/P disorders in COVID-19 and post-COVID-19 patients and that their outcomes were positively associated with the disease severity. These clinical manifestations could attribute to direct SARS-CoV-2 invasion into the central nervous system (CNS), which is often complicated by systemic hypoxia, the dysfunctional activity of the renin–angiotensin system and other relevant pathological changes. These changes may remain long term and may even lead to persistent post-COVID consequences on the CNS, such as memory, attention and focus issues, persistent headaches, lingering loss of smell and taste, enduring muscle aches and chronic fatigue. Mild confusion and coma are serious adverse outcomes of neuropathological manifestations in COVID-19 patients, which could be diversiform and vary at different stages of the clinical course. Although lab investigations and neuro-imaging findings may help quantify the disease’s risk, progress and prognosis, large-scale and persistent multicenter clinical cohort studies are needed to evaluate the impact of COVID-19 on the N/P systems. However, we used “Boolean Operators” to search for relevant research articles, reviews and clinical trials from PubMed and the ClinicalTrials dataset for “COVID-19 sequelae of N/P systems during post-COVID periods” with the time frame from December 2019 to April 2022, only found 42 in 254,716 COVID-19-related articles and 2 of 7931 clinical trials involved N/P sequelae during post-COVID periods. Due to the increasing number of infected cases and the incessant mutation characteristics of this virus, diagnostic and therapeutic guidelines for N/P manifestations should be further refined.

Neurological manifestations by sex and age group in COVID-19 inhospital patients

Introduction

Neurological manifestations have been associated with a poorer prognosis in COVID-19. However, data regarding their incidence according to sex and age groups is still lacking.

Methods

This retrospective multicentric cohort collected data from 39 Brazilian hospitals from 17 cities, from adult COVID-19 admitted from March 2020 to January 2022. Neurological manifestations presented at hospital admission were assessed according to incidence by sex and age group.

Results

From 13,603 COVID-19 patients, median age was 60 years old and 53.0% were men. Women were more likely to present with headaches (22.4% vs. 17.7%, p < 0.001; OR 1.36, 95% confidence interval [CI] 1.22–1.52) than men and also presented a lower risk of having seizures (OR 0.43, 95% CI 0.20–0.94). Although delirium was more frequent in women (6.6% vs. 5.7%, p = 0.020), sex was not associated with delirium in the multivariable logistc regresssion analysis. Delirium, syncope and coma increased with age (1.5% [18–39 years] vs. 22.4% [80 years or over], p < 0.001, OR 1.07, 95% CI 1.06–1.07; 0.7% vs. 1.7%, p = 0.002, OR 1.01, 95% CI 1.00–1.02; 0.2% vs. 1.3% p < 0.001, OR 1.04, 95% CI 1.02–1.06), while, headache (26.5% vs. 7.1%, OR 0.98, 95% CI 0.98–0.99), anosmia (11.4% vs. 3.3%, OR 0.99, 95% CI] 0.98–0.99 and ageusia (13.1% vs. 3.5%, OR 0.99, CI 0.98–0.99) decreased (p < 0.001 for all).

Conclusion

Older COVID-19 patients were more likely to present delirium, syncope and coma, while the incidence of anosmia, ageusia and headaches decreased with age. Women were more likely to present headache, and less likely to present seizures.

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Older COVID-19 patients were more likely to present delirium and coma.

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Younger COVID-19 patients were more likely to report anosmia, ageusia and headache.

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Women with COVID-19 are more likely to present headache.

Delirium as a Presenting Symptom of COVID-19

Delirium is a common neurologic manifestation of coronavirus disease 2019 (COVID–19) in older adults who present to the emergency department (ED).

SARS-CoV-2 and neurodegenerative diseases: what we know and what we don’t

Infection of the CNS with the SARS-CoV-2 can occur via different routes and results in para- or post-infectious manifestations with a variety of neurological symptoms. In patients with neurodegenerative diseases, SARS-CoV-2 is often associated with a higher fatality rate, which is a relevant problem in increasingly older populations. Apart from the direct consequences of an infection in patients with neurodegenerative diseases, indirect consequences of the pandemic such as limited access to care facilities and treatment have negative effects on the course of these chronic disorders. The occurrence of long-lasting neurological symptoms after infection with SARS-CoV-2 indicates a prolonged impact on the CNS. However, while it is known that SARS-CoV-2 affects neuronal populations that are relevant in the pathogenesis of neurodegenerative diseases, it is yet unclear whether an infection with SARS-CoV-2 is sufficient to trigger neurodegeneration. Reflecting on the impact of SARS-CoV-2 on neurodegeneration, we provide a concise overview on the current knowledge of SARS-CoV-2-induced pathology in the CNS and discuss yet open questions in the field.

Patient Profile and Management of Delirium in Older Adults Hospitalized Due to COVID-19

SARS-CoV-2 can cause neurologic symptoms, as well as respiratory ones. Older adults are at risk of developing acute delirium in older persons (ADOP). The combination of experiencing respiratory isolation due to COVID-19, as well as other associated risk factors for older adults, may have had an impact on ADOP and ADOP management in the acute hospital setting. This study aimed to analyze the characteristics of ADOP in patients admitted to a COVID-19 unit. An observational prospective study on a sample of 108 patients was carried out between November 2020 and May 2021. The following data were collected: sociodemographic characteristics, risk factors for ADOP, management of ADOP, and impact on ADOP on both functional and cognitive deterioration. A 29.6% proportion of older adults admitted to an acute COVID-19 unit presented hyperactive ADOP, mainly during the night. Management of ADOP in our sample involved mainly pharmacological treatment and had a serious impact on hospital stay and both functional and cognitive deterioration. Preventive strategies and being accompanied by a relative or a carer may be useful to manage ADOP during hospital admission due to COVID-19.

Factors Associated With Severity of Delirium Complicating COVID-19 in Intensive Care Units

The clinical outcome of the disease provoked by the SARS-CoV-2 infection, COVID-19, is largely due to the development of interstitial pneumonia accompanied by an Acute Respiratory Distress Syndrome (ARDS), often requiring ventilatory support therapy in Intensive Care Units (ICUs). Current epidemiologic evidence is demonstrating that the COVID-19 prognosis is significantly influenced by its acute complications. Among these, delirium figures as one of the most frequent and severe, especially in the emergency setting, where it shows a significantly negative prognostic impact. In this regard, the aim of our study is to identify clinical severity factors of delirium complicating COVID-19 related-ARDS. We performed a comparative and correlation analysis using demographics, comorbidities, multisystemic and delirium severity scores and anti-delirium therapy in two cohorts of ARDS patients with delirium, respectively, due to COVID-19 (n = 40) or other medical conditions (n = 39). Our results indicate that delirium in COVID-19-related ARDS is more severe since its onset despite a relatively less severe systemic condition at the point of ICU admission and required higher dosages of antipsychotic and non-benzodiazepinic sedative therapy respect to non-COVID patients. Finally, the correlation analysis showed a direct association between the male gender and maximum dosage of anti-delirium medications needed within the COVID-19 group, which was taken as a surrogate of delirium severity. Overall, our results seem to indicate that pathogenetic factors specifically associated to severe COVID-19 are responsible for the high severity of delirium, paving the way for future research focused on the mechanisms of the cognitive alterations associated with COVID-19.

Risk factors for delirium among SARS-CoV-2 positive veterans

There have been increasing reports of atypical neuropsychological symptoms among patients hospitalized with Coronavirus Disease 2019 (COVID-19). Although numerous pathophysiological mechanisms have been proposed to account for the association between COVID-19 and delirium, few studies have examined factors associated with its development and none have done so in the context of a veteran sample. The current study exploratorily examined demographic and medical variables that might be associated with delirium among a cohort of SARS-CoV-2 positive veterans. Demographic and medical data were extracted from the computerized patient records of 162 veterans who were admitted to a large southeastern Veterans Affairs hospital for COVID-19 complications between March 1, 2020 and April 20, 2020. At the zero-order level, age, a history of cardiovascular illness, length of stay, intensive care unit admission, initiation of new dialysis, and the development of new thromboembolic or cardiac findings were associated with delirium. However, when simultaneously examining the impact of these predictor variables in a logistic regression, only length of stay and new cardiac findings increased the odds of delirium. Findings highlight the importance of continued investigation into factors that may account for neuropsychiatric dysfunction among COVID-19 patients.

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.

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.

Incidence, Predictors and Outcomes of Delirium in Critically Ill Patients With COVID-19

Background and Purpose:

A variety of neurological manifestations have been attributed to COVID-19, but there is currently limited evidence regarding risk factors and outcomes for delirium in critically ill patients with COVID-19. The purpose of this study was to identify delirium in a large cohort of ICU patients with COVID-19, and to identify associated features and clinical outcomes at the time of hospital discharge.

Methods:

This is an observational cohort study of 213 consecutive patients admitted to an ICU for COVID-19 respiratory illness. Delirium was diagnosed by trained abstractors using the CHART-DEL instrument. The associations between key clinical features, sedation and delirium were examined, as were the impacts of delirium on clinical outcomes.

Results:

Delirium was identified in 57.3% of subjects. Delirious patients were more likely to receive mechanical ventilation, had lower P: F ratios, higher rates of renal replacement therapy and ECMO, and were more likely to receive enteral benzodiazepines. Only mechanical ventilation remained a significant predictor of delirium in a logistic regression model. Mortality was not significantly different, but delirious patients experienced greater mechanical ventilation duration, ICU/hospital lengths of stay, worse functional outcomes at discharge, and were less likely to be discharged home.

Conclusions:

Delirium is common in critically ill patients with COVID-19 and appears to be associated with greater disease severity. When present, delirium is associated with worse functional status at discharge, but not increased mortality. Additional studies are necessary to determine the generalizability of these results and the impact of delirium on longer-term cognitive and functional outcomes.

Delirium in older inpatients with COVID-19: impact on service provision

Delirium is a common clinical manifestation of SARS-CoV-2 (COVID-19) in older inpatients. We assessed the prevalence of delirium in inpatients aged over 65 years with confirmed COVID-19 infection to identify its clinical correlations and association with in-hospital mortality and admission duration. Data were extracted retrospectively from electronic health records. The prevalence of delirium was found to be 23.9% (158 out of 662 patients). Factors associated with delirium included older age, dementia (including cases of suspected dementia), frailty and concurrent infection. Delirium was not associated with higher mortality. Admission duration was approximately 1.5 times longer in patients who experienced delirium (median 14 days; interquartile range (IQR) 8-30) compared with those who did not (median 9 days; IQR 5-17; p<0.001). We confirmed that delirium is common in older inpatients with COVID-19 and has significant implications for patient care and planning services and rehabilitation.

Emerging Psychiatric Themes in Post-COVID-19 Patients on a Psychiatry Consultation-liaison Service

The need for consultation-liaison psychiatry on COVID-19 wards has substantially increased since the start of the pandemic. In this cross-sectional study, we aimed to summarize the characteristics of patients admitted to the post-COVID-19 ward of the American University of Beirut Medical Center who received a psychiatric consultation. We collected relevant sociodemographic and medical data, information about past psychiatric history, psychiatry consultation details, hospital course, and disposition outcome. We also conducted chi-square and binary logistic regression analyses to assess the association between the different variables and disposition outcome. A total of 52 patients (mean age 57.33 years; equal gender distribution) were seen by the psychiatry consult-liaison team. Most had medical comorbidities and 21.2% required intubation. The most prevalent psychiatric diagnoses were delirium (30.8%), major depressive episode (15.4%), and other anxiety disorder (15.4%). Pharmacological management was implemented in 90.4% of cases and mainly included second-generation antipsychotics (36.5%). Non-pharmacological interventions consisted of those related to delirium and therapy for anxiety. Only intubation was significantly associated with disposition outcome (p = 0.004). This study highlights the various psychiatric themes emerging during the acute and post-acute periods of hospitalization for COVID-19. Hospitalized individuals recovering from the infection should be diligently screened and referred to the psychiatry consultation-liaison team to ensure the implementation of appropriate interventions.

Acute and post-acute neurological manifestations of COVID-19: present findings, critical appraisal, and future directions

Acute and post-acute neurological symptoms, signs and diagnoses have been documented in an increasing number of patients infected by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which causes Coronavirus Disease 2019 (COVID-19). In this review, we aimed to summarize the current literature addressing neurological events following SARS-CoV-2 infection, discuss limitations in the existing literature and suggest future directions that would strengthen our understanding of the neurological sequelae of COVID-19. The presence of neurological manifestations (symptoms, signs or diagnoses) both at the onset or during SARS-CoV-2 infection is associated with a more severe disease, as demonstrated by a longer hospital stay, higher in-hospital death rate or the continued presence of sequelae at discharge. Although biological mechanisms have been postulated for these findings, evidence-based data are still lacking to clearly define the incidence, range of characteristics and outcomes of these manifestations, particularly in non-hospitalized patients. In addition, data from low- and middle-income countries are scarce, leading to uncertainties in the measure of neurological findings of COVID-19, with reference to geography, ethnicity, socio-cultural settings, and health care arrangements. As a consequence, at present a specific phenotype that would specify a post-COVID (or long-COVID) neurological syndrome has not yet been identified.

Zinc as a Neuroprotective Nutrient for COVID-19-Related Neuropsychiatric Manifestations: A Literature Review

The outbreak of the pandemic associated with Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) led researchers to find new potential treatments, including nonpharmacological molecules such as zinc (Zn2+). Specifically, the use of Zn2+ as a therapy for SARS-CoV-2 infection is based on several findings: 1) the possible role of the anti-inflammatory activity of Zn2+ on the aberrant inflammatory response triggered by COronaVIrus Disease 19 (COVID-19), 2) properties of Zn2+ in modulating the competitive balance between the host and the invading pathogens, and 3) the antiviral activity of Zn2+ on a number of pathogens, including coronaviruses. Furthermore, Zn2+ has been found to play a central role in regulating brain functioning and many disorders have been associated with Zn2+ deficiency, including neurodegenerative diseases, psychiatric disorders, and brain injuries. Within this context, we carried out a narrative review to provide an overview of the evidence relating to the effects of Zn2+ on the immune and nervous systems, and the therapeutic use of such micronutrients in both neurological and infective disorders, with the final goal of elucidating the possible use of Zn2+ as a preventive or therapeutic intervention in COVID-19. Overall, the results from the available evidence showed that, owing to its neuroprotective properties, Zn2+ supplementation could be effective not only on COVID-19-related symptoms but also on virus replication, as well as on COVID-19-related inflammation and neurological damage. However, further clinical trials evaluating the efficacy of Zn2+ as a nonpharmacological treatment of COVID-19 are required to achieve an overall improvement in outcome and prognosis.