Prevalence, incidence and mortality of delirium in patients with COVID-19: a systematic review and meta-analysis

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.

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.

[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.

[Epidemiological, clinical, and functional characteristics of patients older than 75 years admitted to a tertiary hospital during the first wave of the SARS-CoV-2 pandemic]

BACKGROUND

The objective of the present study is to analyze the epidemiological, clinical and functional characteristics of patients admitted to the University Hospital of Navarra due to SARS-CoV-2 infection, as well as the predictors of mortality, during the first wave of the pandemic caused by this virus.

METHODOLOGY

An observational, retrospective study was performed, including all hospitalized patients older than 75 years. Information has been obtained on multiple variables, among which it is worth mentioning previous geriatric syndromes or those that have appeared during hospitalization, or past medical history considered relevant in SARS-CoV-2 infection. A descriptive analysis of the data, comparisons according to various factors of interest and multivariate analysis to analyze factors associated with mortality were carried out.

RESULTS

Data have been obtained from a total of 426 patients with a mean age of 83.2 years (52.6% men). 34.7% died in hospital and 4.5% within 1 month after hospital discharge. The factors related to mortality were: worse baseline functional status, chronic kidney disease, and fever or dyspnea as forms of presentation. The most frequent typical symptoms were: fever, dyspnea, cough, asthenia and hyporexia. Up to 42.1% presented delirium as a symptom of atypical onset. We observed a functional deterioration that was not recover after a month of follow-up (baseline Barthel index 81.12; 70.08 at discharge; 75.55 after a month).

CONCLUSIONS

SARS-CoV-2 infection has caused high mortality rates in older adults. In this age group, the atypical presentation of this disease and functional deterioration during hospitalization are frequent. In the present study, a worse previous functional status has been identified as a predictor of mortality. More studies are needed to evaluate the impact that the disease and hospitalization have on the older patient, with the aim of implementing preventive, diagnostic and therapeutic measures that are necessary to avoid functional deterioration and adverse health events related to it.

Delirium is frequently underdiagnosed among older hospitalised patients despite available information in hospital medical records

BACKGROUND

In-hospital delirium is associated with adverse outcomes and is underdiagnosed, limiting research and clinical follow-up.

OBJECTIVE

To compare the incidence of in-hospital delirium determined by chart-based review of electronic medical records (D-CBR) with delirium discharge diagnoses (D-DD). Furthermore, to identify differences in symptoms, treatments and delirium triggers between D-CBR and D-DD.

METHOD

The community-based cohort included 2,115 participants in the Hordaland Health Study born between 1925 and 1927. Between 2018 and 2022, we retrospectively reviewed hospital electronic medical records from baseline (1997-99) until death prior to 2023. D-DD and D-CBR were validated using The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for delirium.

RESULTS

Of the 2,115 participants, 638 had in-hospital delirium. The incidence rate (IR) of D-CBR was 29.8 [95% confidence interval 28, 32] per 1,000 person-years, whereas the IR by D-DD was 3.4 [2.8, 4.2]. The IR ratio was 9.14 (P < 0.001). Patients who received pharmacological treatment for delirium (n = 121, odds ratio (OR) 3.4, [2.1, 5.4], P < 0.001), who were affected by acute memory impairment (n = 149, OR 2.8, [1.8, 4.5], P < 0.001), or change in perception (n = 137, OR 2.9, [1.8, 4.6] P < 0.001) had higher odds for D-DD. In contrast, post-operative cases (OR 0.2, [0.1, 0.4], P < 0.001) had lower odds for D-DD.

CONCLUSION

Underdiagnosis of in-hospital delirium was a major issue in our study, especially in less severe delirium cases. Our findings emphasise the need for integrating systematic delirium diagnostics and documentation into hospital admission and discharge routines.

Impact of Low Muscle Mass on Hepatocellular Carcinoma Patients Undergoing Transcatheter Liver-Directed Therapies: Systematic Review & Meta-Analysis

BACKGROUND AND AIM

Transcatheter liver-directed intra-arterial therapies are mainstream treatment options for intermediate-stage hepatocellular carcinoma (HCC). However, the effect of low skeletal muscle mass (LSMM) on overall survival (OS) in these patients remains uncertain. We aimed to ascertain the prevalence and prognostic effect of LSMM in this population.

METHOD

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a comprehensive search was performed in the PubMed and Embase databases until Oct 2023. Random-effects meta-analysis was performed to determine the pooled prevalence of LSMM and calculate the hazard ratio (HR) for OS with a 95% confidence interval (CI) in patients with intermediate-stage HCC undergoing various transarterial therapies, comparing those with and without LSMM.

RESULTS

Twelve studies involving 2450 patients were included. The pooled prevalence of LSMM was 46% (95% CI, 38-55%), and the results were consistent across different treatments, regions, and age subgroups. The meta-analysis indicated that LSMM was significantly associated with decreased OS (HR, 1.78; 95% CI, 1.36-2.33; I2, 75%). Subgroup analyses reassured the main findings across various therapies, including transarterial chemoembolization (TACE) (HR, 1.68; 95% CI, 1.23-2.30; I2, 81%), transarterial embolization (TAE) (HR, 2.45; 95% CI, 1.42-4.22; I2, 0%), and transarterial radioembolization (TARE) (HR, 1.94; 95% CI, 1.01-3.73; I2, 0%).

CONCLUSIONS

In intermediate-stage HCC, LSMM is common and associated with reduced OS. To achieve an optimal prognosis, clinicians should incorporate routine LSMM measurement into practice, while caring for patients with intermediate-stage HCC, irrespective of TACE, TAE, and TARE.

Predicting delirium and the effects of medications in hospitalized COVID-19 patients using machine learning: A retrospective study within the Korean Multidisciplinary Cohort for Delirium Prevention (KoMCoDe)

Objective

Delirium is commonly reported from the inpatients with Coronavirus disease 2019 (COVID-19) infection. As delirium is closely associated with adverse clinical outcomes, prediction and prevention of delirium is critical. We developed a machine learning (ML) model to predict delirium in hospitalized patients with COVID-19 and to identify modifiable factors to prevent delirium.

Methods

The data set (n = 878) from four medical centers was constructed. Total of 78 predictors were included such as demographic characteristics, vital signs, laboratory results and medication, and the primary outcome was delirium occurrence during hospitalization. For analysis, the extreme gradient boosting (XGBoost) algorithm was applied, and the most influential factors were selected by recursive feature elimination. Among the indicators of performance for ML model, the area under the curve of the receiver operating characteristic (AUROC) curve was selected as the evaluation metric.

Results

Regarding the performance of developed delirium prediction model, the accuracy, precision, recall, F1 score, and the AUROC were calculated (0.944, 0.581, 0.421, 0.485, 0.873, respectively). The influential factors of delirium in this model included were mechanical ventilation, medication (antipsychotics, sedatives, ambroxol, piperacillin/tazobactam, acetaminophen, ceftriaxone, and propacetamol), and sodium ion concentration (all p < 0.05).

Conclusions

We developed and internally validated an ML model to predict delirium in COVID-19 inpatients. The model identified modifiable factors associated with the development of delirium and could be clinically useful for the prediction and prevention of delirium in COVID-19 inpatients.

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.

Incidence of delirium in older people with cancer: Systematic review and meta-analysis

PURPOSE

Delirium is a prevalent neuropsychiatric syndrome in older people with cancer. However, there are no meta-analyses assessing its incidence exclusively in this population. This study aims to assess the incidence proportion of delirium in older people with cancer in the hospital area.

METHODS

A systematic review and meta-analysis were carried out. MEDLINE, Scopus, and EBSCO were searched from inception to December 2021. PRISMA guidelines were followed. Inclusion criteria were original peer-reviewed studies with experimental (randomised controlled trials), observational, and cross-sectional designs assessing delirium older inpatients (≥65 years) with oncological diseases in medical and post-surgical hospital areas and using validated screening or diagnostic methods. A web-based system was used to manage the screening process. Study quality was assessed with Joanna Briggs Institute Critical Appraisal tools. The statistical analysis was performed in RevMan v5.4.0 (Cochrane Collaboration, Oxford, UK), using a random-effects model to calculate incidence and 95% confidence intervals (CIs).

RESULTS

Based on 37 included articles, the incidence proportion of delirium ranged from 3.8% to 61.4%, in a total of 11,847 older patients with cancer. Meta-analysis showed a pooled incidence of 22.6% (95% confidence interval 18.5%, 26.7%; I2 = 97%, p < 0.001). The main tools for detection were the Diagnostic Statistical Manual criteria and the Confusion Assessment Methods scale.

CONCLUSIONS

The incidence proportion of delirium in older inpatients with cancer is 22.6%. Incidence in the medical setting was higher than in the post-surgical areas. There is a need for high-quality studies examining delirium in older people with cancer.

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 older patients with COVID-19: Prevalence, risk factors and clinical outcomes across the first three waves of the pandemic

OBJECTIVES

Delirium is a serious condition, which poses treatment challenges during hospitalisation for COVID-19. Improvements in testing, vaccination and treatment might have changed patient characteristics and outcomes through the pandemic. We evaluated whether the prevalence and risk factors for delirium, and the association of delirium with in-hospital mortality changed through the pandemic.

METHODS

This study was part of the COVID-OLD study in 19 Dutch hospitals including patients ≥70 years in the first (spring 2020), second (autumn 2020) and third wave (autumn 2021). Multivariable logistic regression models were used to study risk factors for delirium, and in-hospital mortality. Differences in effect sizes between waves were studied by including interaction terms between wave and risk factor in logistic regression models.

RESULTS

1540, 884 and 370 patients were included in the first, second and third wave, respectively. Prevalence of delirium in the third wave (12.7%) was significantly lower compared to the first (22.5%) and second wave (23.5%). In multivariable-adjusted analyses, pre-existing memory problems was a consistent risk factor for delirium across waves. Previous delirium was a risk factor for delirium in the first wave (OR 4.02), but not in the second (OR 1.61) and third wave (OR 2.59, p-value interaction-term 0.028). In multivariable-adjusted analyses, delirium was not associated with in-hospital mortality in all waves.

CONCLUSION

Delirium prevalence declined in the third wave, which might be the result of vaccination and improved treatment strategies. Risk factors for delirium remained consistent across waves, although some attenuation was seen in the second wave.

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.

Delirium and IL-6 added to clinical scores improves their performance: a prospective analysis of CALL, PREDI-CO, MRS score applied to a population of patients admitted to internal medicine ward

This study aimed to evaluate the effectiveness of various scoring systems in predicting in-hospital mortality for COVID-19 patients admitted to the internal medicine ward. We conducted a prospective collection of clinical data from patients admitted to the Internal Medicine Unit at Santa Maria Nuova Hospital in Florence, Italy, with confirmed pneumonia caused by SARS-CoV-2. We calculated three scoring systems: the CALL score, the PREDI-CO score, and the COVID-19 in-hospital Mortality Risk Score (COVID-19 MRS). The primary endpoint was in-hospital mortality. : A total of 681 patients were enrolled in the study, with a mean age of 68.8 ± 16.1 years, and 54.8% of them were male. Non-survivors had significantly higher scores in all prognostic systems compared to survivors (MRS: 13 [12- 15] vs. 10 [8-12]; CALL: 12 [10-12] vs. 9 [7-11]; PREDI-CO: 4 [3-6] vs. 2 [1-4]; all p<0.001). The receiver operating characteristic (ROC) analysis yielded the following area under the curve (AUC) values: MRS 0.85, CALL 0.78, PREDI-CO 0.77. The addition of Delirium and IL6 to the scoring systems improved their discriminative ability, resulting in AUC values of 0.92 for MRS, 0.87 for CALL, and 0.84 for PREDI-CO. The mortality rate increased significantly across increasing quartiles (p<0.001). In conclusion the COVID-19 in-hospital Mortality Risk Score (MRS) demonstrated reasonable prognostic stratification for patients admitted to the internal medicine ward with SARS-CoV-2-induced pneumonia. The inclusion of Delirium and IL6 as additional prognostic indicators in the scoring systems enhanced their predictive performance, specifically in determining in-hospital mortality among COVID-19 patients.

Cognitive concerns are a risk factor for mortality in people with HIV and coronavirus disease 2019

BACKGROUND

Data supporting dementia as a risk factor for coronavirus disease 2019 (COVID-19) mortality relied on ICD-10 codes, yet nearly 40% of individuals with probable dementia lack a formal diagnosis. Dementia coding is not well established for people with HIV (PWH), and its reliance may affect risk assessment.

METHODS

This retrospective cohort analysis of PWH with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) PCR positivity includes comparisons to people without HIV (PWoH), matched by age, sex, race, and zipcode. Primary exposures were dementia diagnosis, by International Classification of Diseases (ICD)-10 codes, and cognitive concerns, defined as possible cognitive impairment up to 12 months before COVID-19 diagnosis after clinical review of notes from the electronic health record. Logistic regression models assessed the effect of dementia and cognitive concerns on odds of death [odds ratio (OR); 95% CI (95% confidence interval)]; models adjusted for VACS Index 2.0.

RESULTS

Sixty-four PWH were identified out of 14 129 patients with SARS-CoV-2 infection and matched to 463 PWoH. Compared with PWoH, PWH had a higher prevalence of dementia (15.6% vs. 6%, P  = 0.01) and cognitive concerns (21.9% vs. 15.8%, P  = 0.04). Death was more frequent in PWH ( P  < 0.01). Adjusted for VACS Index 2.0, dementia [2.4 (1.0-5.8), P  = 0.05] and cognitive concerns [2.4 (1.1-5.3), P  = 0.03] were associated with increased odds of death. In PWH, the association between cognitive concern and death trended towards statistical significance [3.92 (0.81-20.19), P  = 0.09]; there was no association with dementia.

CONCLUSION

Cognitive status assessments are important for care in COVID-19, especially among PWH. Larger studies should validate findings and determine long-term COVID-19 consequences in PWH with preexisting cognitive deficits.

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.

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.

Risk Factors and Outcomes Associated With Re-Intubation Secondary to Respiratory Failure in Patients With COVID-19 ARDS

BACKGROUND

COVID-19 is associated with variable symptoms and clinical sequelae. Studies have examined the clinical course of these patients, finding a prolonged need for invasive ventilation and variable re-intubation rates. However, no research has investigated factors and outcomes related to re-intubation secondary to respiratory failure among patients with COVID-19 with ARDS.

METHODS

We conducted a single-center, retrospective study on subjects intubated for ARDS secondary to COVID-19. The primary outcome was re-intubation status; secondary outcomes were hospital and ICU stay and mortality. Data were analyzed using between-group comparisons using chi-square testing for categorical information and Student t test for quantitative data. Univariate and multivariate logistic regression was performed to determine factors related to re-intubation and mortality as dependent variables.

RESULTS

One hundred and fourteen subjects were included, of which 32% required re-intubation. No between-group differences were detected for most demographic variables or comorbidities. No differences were detected in COVID-19 treatments, noninvasive respiratory support, mechanical circulatory support, or duration of ventilation. Midazolam (odds ratio [OR] 5.55 [95% CI 1.83-16.80], P = .002), fentanyl (OR 3.64 [95% CI 1.26-10.52], P = .02), and APACHE II scores (OR 1.08 [95% CI 1.030-1.147], P = .005) were independently associated with re-intubation (area under the curve = 0.81). Re-intubated subjects had extended hospital (36.7 ± 22.7 d vs 26.1 ± 12.1 d, P = .01) and ICU (29.6 ± 22.4 d vs 15.8 ± 10.4 d, P < .001) stays. More subjects died who failed extubation (49% vs 3%, P < .001). Age (OR 1.07 [95% CI 1.02-1.23], P = .005), male sex (OR 4.9 [95% CI 1.08-22.35], P = .041), positive Confusion Assessment Method for the ICU (CAM-ICU) (OR 5.43 [95% CI 1.58-18.62], P = .007), and re-intubation (OR 12.75 [95% CI 2.80-57.10], P < .001) were independently associated with death (area under the curve = 0.93).

CONCLUSIONS

Midazolam, fentanyl, and higher APACHE II scores were independently associated with re-intubation secondary to respiratory failure in subjects with COVID-19-related ARDS. Furthermore, age, male sex, positive CAM-ICU, and re-intubation were independently associated with mortality. Re-intubation also correlated with prolonged hospital and ICU stay.

Clinicians' Perceptions of a Modified Hospital Elder Life Program for Delirium Prevention During COVID-19

The Hospital Elder Life Program (HELP) is a multicomponent delirium prevention program targeting delirium risk factors of cognitive impairment, vision and hearing impairment, malnutrition and dehydration, immobility, sleep deprivation, and medications. We created a modified and extended version of the program, HELP-ME, deployable under COVID-19 conditions, for example, patient isolation and restricted staff and volunteer roles. We explored perceptions of interdisciplinary clinicians who implemented HELP-ME to inform its development and testing. Qualitative descriptive study of HELP-ME among older adults on medical and surgical services during the COVID-19 pandemic. HELP-ME staff at 4 pilot sites across the United States who implemented HELP-ME.We held five 1-hour video focus groups (5-16 participants/group) to review specific intervention protocols and the overall program. We asked participants open-endedly about positive and challenging aspects of protocol implementation. Groups were recorded and transcribed. We used directed content analysis to analyze data. Participants identified general, technology-related, and protocol-specific positive and challenging aspects of the program. Overarching themes included the need for enhanced customization and standardization of protocols, need for increased volunteer staffing, digital access to family members, patient technological literacy and comfort, variation in the feasibility of remote delivery among intervention protocols, and preference for a hybrid program model. Participants offered related recommendations. Participants felt that HELP-ME was successfully implemented, with some modifications needed to address limitations of remote implementation. A hybrid model combining remote and in-person aspects was recommended as the preferred option.

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.

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.

The possible role of gut microbiota dysbiosis in the pathophysiology of delirium in older persons

Delirium is a clinical syndrome characterized by an acute change in attention, awareness and cognition with fluctuating course, frequently observed in older patients during hospitalization for acute medical illness or after surgery. Its pathogenesis is multifactorial and still not completely understood, but there is general consensus on the fact that it results from the interaction between an underlying predisposition, such as neurodegenerative diseases, and an acute stressor acting as a trigger, such as infection or anesthesia. Alterations in brain insulin sensitivity and metabolic function, increased blood-brain barrier permeability, neurotransmitter imbalances, abnormal microglial activation and neuroinflammation have all been involved in the pathophysiology of delirium. Interestingly, all these mechanisms can be regulated by the gut microbiota, as demonstrated in experimental studies investigating the microbiota-gut-brain axis in dementia. Aging is also associated with profound changes in gut microbiota composition and functions, which can influence several aspects of disease pathophysiology in the host. This review provides an overview of the emerging evidence linking age-related gut microbiota dysbiosis with delirium, opening new perspectives for the microbiota as a possible target of interventions aimed at delirium prevention and treatment.

Impact of risk for severe COVID-19 illness on physical activity during the pandemic

BACKGROUND

Precautions to mitigate spread of COVID-19 such as the closing of exercise facilities impacted physical activity behaviors. Varied risks for severe COVID-19 may have influenced participation in regular physical activity to maintain precautions.

OBJECTIVE

Describe differences in the amount and intensity of physical activity between adults at high versus low risk for severe COVID-19 illness during the pandemic. We hypothesized that over 13 months, 1) high-risk adults would have greater odds of inactivity than low-risk adults, and 2) when active, high-risk adults would have lower metabolic equivalent of task minutes (MET-min) than low-risk adults.

METHODS

This longitudinal observational cohort study surveyed U.S. adults' demographics, health history, and physical activity beginning March 2020 using REDCap. Using self-report, health history was assessed with a modified Charlson Comorbidity Index and physical activity with the International Physical Activity Questionnaire. Repeated physical activity measurements were conducted in June, July, October, and December of 2020, and in April of 2021. Two models, a logistic model evaluating physical inactivity (hypothesis 1) and a gamma model evaluating total MET-min for physically active individuals (hypothesis 2), were used. Models were controlled for age, gender, and race.

RESULTS

The final sample consisted of 640 participants (mean age 42.7 ± 15.7, 78% women, 90% white), with n = 175 categorized as high-risk and n = 465 as low-risk. The odds of inactivity for the high-risk adults were 2.8 to 4.1 times as high than for low-risk adults at baseline and 13 months. Active high-risk adults had lower MET-min levels than low-risk adults in March (28%, p = 0.001), June (29%, p = 0.002), and July of 2020 (30%, p = 0.005) only.

CONCLUSIONS

Adults at high risk of severe COVID-19 illness were disproportionately more likely to be physically inactive and exhibit lower MET-min levels than adults at low risk during the early months of the COVID-19 pandemic.

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.

Impact of frailty on the performance of the National Early Warning Score 2 to predict poor outcome in patients hospitalised due to COVID-19

BACKGROUND

The National Early Warning Score 2 (NEWS2) is a scoring tool predictive of poor outcome in hospitalised patients. Older patients with COVID-19 have increased risk of poor outcome, but it is not known if frailty may impact the predictive performance of NEWS2. We aimed to investigate the impact of frailty on the performance of NEWS2 to predict in-hospital mortality in patients hospitalised due to COVID-19.

METHODS

We included all patients admitted to a non-university Norwegian hospital due to COVID-19 from 9 March 2020 until 31 December 2021. NEWS2 was scored based on the first vital signs recorded upon hospital admission. Frailty was defined as a Clinical Frailty Scale score ≥ 4. The performance of a NEWS2 score ≥ 5 to predict in-hospital mortality was assessed with sensitivity, specificity and area under the receiver operating characteristic curve (AUROC) according to frailty status.

RESULTS

Out of 412 patients, 70 were aged ≥ 65 years and with frailty. They presented less frequently with respiratory symptoms, and more often with acute functional decline or new-onset confusion. In-hospital mortality was 6% in patients without frailty, and 26% in patients with frailty. NEWS2 predicted in-hospital mortality with a sensitivity of 86%, 95% confidence interval (CI) 64%-97% and AUROC 0.73, 95% CI 0.65-0.81 in patients without frailty. In older patients with frailty, sensitivity was 61%, 95% CI 36%-83% and AUROC 0.61, 95% CI 0.48-0.75.

CONCLUSION

A single NEWS2 score at hospital admission performed poorly to predict in-hospital mortality in patients with frailty and COVID-19 and should be used with caution in this patient group. Graphical abstract summing up study design, results and conclusion.

Risk factors and outcomes of delirium in hospitalized older adults with COVID-19: A systematic review and meta-analysis

Background

Older adults with COVID-19 are more likely to present with atypical symptoms, notably delirium. The main objective of this meta-analysis is to identify risk factors for delirium and outcomes of delirium in hospitalized older adults (65 years or above) with COVID-19.

Methods

Comprehensive literature search of Embase, CINAHIL, Medline and Web of Science was performed for published literature until 31st August 2021. Two independent researchers evaluated study eligibility and assessed study quality using the Newcastle Ottawa Scale (NOS) for cohort studies and Joanna Briggs Institute (JBI) critical appraisal tools for case series. The association of various predisposing factors with delirium in this cohort was reported as odds ratio (OR) and its 95% confidence interval (CI).

Results

A total of 31 studies from 11 countries were included in this review. Most of the included studies investigated patients from non-ICU settings (n = 24; 77.4%). Frailty (OR 3.52, 95% CI: 1.96-6.31, p<0.0001, I²=71.63%), cognitive impairment including dementia (OR 6.17, 95% CI: 2.92-13.07, p<0.00001, I²=88.63%) and being nursing home residents (OR 1.72, 95% CI: 1.31-2.24, p<0.0001, I²=0) were significantly associated with increased likelihood of developing delirium in older adults with COVID-19. The presence of delirium also significantly increases mortality risk in hospitalized older adults with COVID-19 (OR 2.51, 95% CI: 1.51-4.17, p<0.0001, I²=89.3%).

Conclusion

Our review identifies key factors associated with increased risk of developing delirium in hospitalized older adults with COVID-19. Identification of patients at risk of delirium and attention to these factors early during admission may improve outcomes for this vulnerable cohort.

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.

The impact of COVID-19 pandemic on the geriatric inpatient unit

OBJECTIVE

We aimed to determine the effects of the pandemic on the inpatients in the geriatric unit by comparing the demographic and clinical characteristics, reasons for hospitalization, morbidity, and mortality of the patients before and during the pandemic.

METHODS

The population of this retrospective, cross-sectional study consisted of inpatients in the geriatric unit for two years (11 March 2019-10 March 2021). The patients were separated into two groups according to the hospitalization time as pre-COVID-19 and COVID-19 period. Hospitalization types, reasons for hospitalization, length of stay, demographic data, chronic diseases, drugs, developed morbidities, discharge, and 1-year mortality status of the patients were recorded.

RESULTS

Three hundred and fifty patients were included in our study. The mean age was 80.4 ± 8.02. It was observed that the number of hospitalized patients decreased by ∼50% in the COVID-19 period. However, there was a significant decrease in hospitalization due to the control of chronic diseases during the COVID-19 period (p = .008). The number of inpatients from the emergency department was found to be higher during the COVID-19 period (p < .001). Regarding the presence of geriatric syndromes, polypharmacy (p = .011) and delirium (p = .035) were found to be significantly less in the pre-COVID-19 period. The percentage of malnutrition was also detected as lower, but it was not statistically significant. In terms of 1-year mortality, although not statistically significant, the all-cause mortality rate was higher during the COVID-19 period (p = .08).

CONCLUSIONS

Pandemic has greatly affected the geriatric unit. The prognosis of the patients has worsened and mortality rates have increased. Physiological and psychological deterioration caused by quarantine measures, worsening chronic diseases, and immunosenescence affected the prognosis of geriatric patients. This adds to the previous literature by proving the fact that older individuals are the most vulnerable group in the pandemic.

European Working Group on SARS-CoV-2: Current Understanding, Unknowns, and Recommendations on the Neurological Complications of COVID-19

The emergence of COVID-19 was rapidly followed by infection and the deaths of millions of people across the globe. With much of the research and scientific advancement rightly focused on reducing the burden of severe and critical acute COVID-19 infection, the long-term effects endured by those who survived the acute infection has been previously overlooked. Now, an appreciation for the post-COVID-19 condition, including its neurological manifestations, is growing, although there remain many unknowns regarding the aetiology and risk factors of the condition, as well as how to effectively diagnose and treat it. Here, drawing upon the experiences and expertise of the clinicians and academics of the European working group on COVID-19, we have reviewed the current literature to provide a comprehensive overview of the neurological sequalae of the post-COVID-19 condition. In this review, we provide a summary of the neurological symptoms associated with the post-COVID-19 condition, before discussing the possible mechanisms which may underly and manifest these symptoms. Following this, we explore the risk factors for developing neurological symptoms as a result of COVID-19 and the post-COVID-19 condition, as well as how COVID-19 infection may itself be a risk factor for the development of neurological disease in the future. Lastly, we evaluate how the post-COVID condition could be accurately diagnosed and effectively treated, including examples of the current guidelines, clinical outcomes and tools that have been developed to aid in this process, as well as addressing the protection provided by COVID-19 vaccines against post-COVID-19 condition. Overall, this review provides a comprehensive overview of the neurological sequalae of the post-COVID-19 condition.

[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.

Poor prognostic impact of delirium: especially on mortality and institutionalisation

The course of delirium is associated with increased hospital costs, healthcare complications, increased mortality, and long-term poor outcomes. Despite delirium being long recognised as one of the most important prognostic components of patients with illnesses, delirium remains poorly understood, effective management options are limited, and no effective treatment has yet been established. This review evaluated the effects of delirium on mortality, institutionalisation, and dementia in various situations to clarify its prognostic seriousness to elucidate important areas for clinical practice and future research. The effect of delirium on mortality in COVID-19 patients was similar to that in other diseases. The effect of delirium on mortality in patients with delirium between the ages of 18 and 65 may be higher than in those with delirium aged over 65, but studies are scarce. Promoting recognition of delirium at all ages is needed. With careful attention to the specific factors in younger patients that contribute to delirium, healthcare providers may be able to decrease the poor impact of delirium on clinical outcomes. Evaluation of the association between interventions for delirium such as sedation in present clinical practice and the prognosis of delirium is lacking, and further clinical studies are essential.

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.

Geriatric syndromes and functions in older adults with COVID-19 hospitalized in sub-acute care: a multicenter study

OBJECTIVE

Alternatives to conventional acute hospitalizations have been particularly useful during the COVID-19 pandemic. However, little is known on the management and outcomes of COVID-19 in older patient admitted to non-acute settings. The main aim of this study was to determine the effect of geriatrics syndromes on functional outcomes in older COVID-19 patients cared in sub-acute units.

METHODS

Prospective multicenter observational cohort study of patients aged 65 years and older with COVID-19, admitted to sub-acute units in Italy and Spain. Multivariable logistic regression models were used to test the association between geriatric syndromes and other clinical variables, and the functional status at discharge, defined by a Barthel Index >  = 80.

RESULTS

A total of 158 patients were included in the study with a median age of 82 [Interquartile Range 81, 83]; of these 102 (65%) patients had a Barthel Index ≥ 80 at discharge. In the main multivariable logistic regression model a higher severity of frailty-measured with the Clinical Frailty Scale-(OR 0.30; CI 0.18-0.47), and the presence of delirium (OR 0.04; CI 0.00-0.35) at admission were associated with lower odds of a higher functional status at discharge. Other variables associated with lower functional status were female gender (OR 0.36; CI 0.13-0.96), and a higher number of comorbidities (OR 0.48; CI 0.26-0.82).

CONCLUSION

The study reports a relatively high prevalence of functional recovery for older COVID-19 patients admitted to sub-acute units. Additionally, it underlines the importance of targeting geriatrics syndromes, in particular frailty and delirium, for their possible effects on functional recovery.

Co-Occurring Catatonia and COVID-19 Diagnoses Among Hospitalized Individuals in 2020: A National Inpatient Sample Analysis

BACKGROUND

COVID-19 is associated with a range of neuropsychiatric manifestations. While case reports and case series have reported catatonia in the setting of COVID-19 infection, its rate has been poorly characterized.

OBJECTIVE

This study reports the co-occurrence of catatonia and COVID-19 diagnoses among acute care hospital discharges in the United States in 2020.

METHODS

The National Inpatient Sample, an all-payors database of acute care hospital discharges, was queried for patients of any age discharged with a diagnosis of catatonia and COVID-19 in 2020.

RESULTS

Among 32,355,827 hospitalizations in the 2020 National Inpatient Sample, an estimated 15,965 (95% confidence interval: 14,992-16,938) involved a diagnosis of catatonia without COVID-19 infection, 1,678,385 (95% confidence interval: 1,644,738-1,712,022) involved a diagnosis of COVID-19 without a co-occurring catatonia diagnosis, and 610 (95% confidence interval: 578-642) involved both catatonia and COVID-19 infection. In an adjusted model, a diagnosis of COVID-19, but not a diagnosis of catatonia or the combination of catatonia and COVID-19, was associated with increased mortality. Patients with catatonia and COVID-19 were frequently diagnosed with encephalopathy and delirium codes.

CONCLUSIONS

Catatonia and COVID-19 were rarely co-diagnosed in 2020, and catatonia diagnosis was not associated with increased mortality in patients with COVID-19. Further research is needed to better characterize the phenomenology of catatonia in the setting of COVID-19 infection and its optimal treatment.

Assessment of the Delirium Prevalence among Pediatric Patients Admitted to the Pediatric Intensive Care Unit in West of Iran

Background: Delirium is often not diagnosed or treated in pediatric intensive care unit (PICU). Delirium leads to a longer hospital stay period, which in turn can result in an increase in hospital treatment costs and an increase in the risk of nosocomial infections. Objectives: The present study aimed to determine the prevalence of delirium and its risk factors in PICU pediatric. Methods: This cross-sectional study was conducted in 2021 - 2022 in hospitals affiliated to Kermanshah University of Medical Sciences. The data collection instruments included the Richmond Agitation-Sedation Scale (RASS) and the Cornell Assessment of Pediatric Delirium (CAPD) questionnaire. Delirium was assessed by the researcher twice a day, in the morning and the evening. The assessment was carried out by a trained person, and the examination results were confirmed by an anesthesiologist who was a member of the research team. Data analysis was carried out using SPSS ver. 16. Results: According to our study results, the majority of the 89 examined patients were male (n = 52 cases, 59.8%), aged 13 - 16 years (n = 37 cases, 42.5%), and were admitted due to pneumonia (n = 24 cases, 27.6%). The prevalence of delirium was higher in patients with pain and those requiring oxygen therapy (P < 0.05). Furthermore, the overall prevalence of delirium in PICU patients was 25.3% (n = 22 cases). Conclusions: Investigating the prevalence of delirium in all age groups – pediatric and adolescents, in particular – was found to be extremely important. It was also found that the prevalence of delirium in PICU patients was significant; therefore, it was recommended that necessary preventive and medical interventions should be made to deal with these patients.

Older patients with COVID-19 and neuropsychiatric conditions: A study of risk factors for mortality

BACKGROUND

Little is known about risk factors for mortality in older patients with COVID-19 and neuropsychiatric conditions.

METHODS

We conducted a multicentric retrospective observational study at Assistance Publique-Hôpitaux de Paris. We selected inpatients aged 70 years or older, with COVID-19 and preexisting neuropsychiatric comorbidities and/or new neuropsychiatric manifestations. We examined demographics, comorbidities, functional status, and presentation including neuropsychiatric symptoms and disorders, as well as paraclinical data. Cox survival analysis was conducted to determine risk factors for mortality at 40 days after the first symptoms of COVID-19.

RESULTS

Out of 191 patients included (median age 80 [interquartile range 74-87]), 135 (71%) had neuropsychiatric comorbidities including cognitive impairment (39%), cerebrovascular disease (22%), Parkinsonism (6%), and brain tumors (6%). A total of 152 (79%) patients presented new-onset neuropsychiatric manifestations including sensory symptoms (6%), motor deficit (11%), behavioral (18%) and cognitive (23%) disturbances, gait impairment (11%), and impaired consciousness (18%). The mortality rate at 40 days was 19.4%. A history of brain tumor or Parkinsonism or the occurrence of impaired consciousness were neurological factors associated with a higher risk of mortality. A lower Activities of Daily Living score (hazard ratio [HR] 0.69, 95% confidence interval [CI] 0.58-0.82), a neutrophil-to-lymphocyte ratio ≥ 9.9 (HR 5.69, 95% CI 2.69-12.0), and thrombocytopenia (HR 5.70, 95% CI 2.75-11.8) independently increased the risk of mortality (all p < .001).

CONCLUSION

Understanding mortality risk factors in older inpatients with COVID-19 and neuropsychiatric conditions may be helpful to neurologists and geriatricians who manage these patients in clinical practice.

COVID-19 Clinical Features and Outcomes in Elderly Patients during Six Pandemic Waves

Many elderly patients with severe SARS-CoV-2 infections and COVID-19 infections are admitted to intensive care units. Age was previously identified as an independent risk factor for death and contributed to the greater severity of COVID-19. The elderly may have diminished lung functions, poor reactions to artificial ventilation, and compromised immune systems. However, it is yet uncertain how each pandemic wave and the predominant SARS-CoV-2 strains contribute to varying results and how patient groups such as the elderly are impacted. Comparing six COVID-19 pandemic waves, the objective of this study was to examine the variation in case severity, symptomatology, ICU hospitalizations, and mortality among SARS-CoV-2-infected elderly individuals. The study followed a retrospective design, including 60 eligible patients older than 70 years in each of the six pandemic wave groups, after matching them by the number of comorbidities and gender. SARS-CoV-2 infection during the first, third, and fourth pandemic waves had a significantly higher risk of mortality for hospitalized patients. Confusion and dyspnea at admission were significant risk factors for ICU admission in elderly patients (β = 1.92, respectively β = 3.65). The laboratory parameters identified decreased lymphocytes (β = 2.11), elevated IL-6 (β = 1.96), and procalcitonin (β = 2.46) as the most significant risk factors. The third and fourth COVID-19 waves had considerably more severe infections (31.7% and 26.7%) than the sixth wave (13.3%). Median ICU stay and percentage of patients receiving oxygen support also differed across pandemic waves. However, mortality rates between the six pandemic waves were similar. The average length of hospitalization varied dramatically among the six pandemic waves. Although senior patients are more likely to have worse COVID-19 outcomes after hospitalization, this risk is mitigated by the greater prevalence of comorbidities and frailty among the elderly. The six pandemic waves that were specifically evaluated did not reveal considerably disproportionate variations in terms of patient mortality; however, during the fourth pandemic wave, there were likely more hospitalized patients with severe COVID-19 in Romania. It is probable that certain circulating SARS-CoV-2 strains were more infectious, resulting in an increase in infections and a strain on healthcare systems, which might explain the variations found in our research.

The potential benefit of metformin to reduce delirium risk and mortality: a retrospective cohort study

PURPOSE

Metformin has been reported to improve age-related disorders, including dementia, and to lower mortality. This study was conducted to investigate whether metformin use lower delirium risk, as well as long-term mortality.

METHODS

In this retrospective cohort study, previously recruited 1,404 subjects were analyzed. The relationship between metformin use and delirium, and the relationship between metformin use and 3-year mortality were investigated.

MAIN FINDINGS

242 subjects were categorized into a type 2 diabetes mellitus (DM)-without-metformin group, and 264 subjects were categorized into a DM-with-metformin group. Prevalence of delirium was 36.0% in the DM-without-metformin group, and 29.2% in the DM-with-metformin group. A history of metformin use reduced the risk of delirium in patients with DM (OR, 0.50 [95% CI, 0.32 to 0.79]) after controlling for confounding factors. The 3-year mortality in the DM-without-metformin group (survival rate, 0.595 [95% CI, 0.512 to 0.669]) was higher than in the DM-with-metformin group (survival rate, 0.695 [95% CI, 0.604 to 0.770]) (p=0.035). A history of metformin use decreased the risk of 3-year mortality after adjustment for confounding factors (HR, 0.69 [95% CI, 0.48 to 0.98]).

CONCLUSIONS

Metformin use may lower the risk of delirium and mortality in DM patients.

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.

Delirium in Nursing Home Residents: A Narrative Review

Delirium is an important component of the geriatric syndromes and has been recognized to negatively influence the prognosis of older people in hospital and in a post-acute setting. About 2–5% of older people world-wide live in nursing homes and are characterized by functional impairment, cognitive decline, dementia, comorbidities, and polypharmacotherapy, all factors which influence the development of delirium. However, in this setting, delirium remains often understudied. Therefore, in this narrative review, we aimed to describe the latest evidence regarding delirium screening tools, epidemiology characteristics, outcomes, risk factors, and preventions strategies in nursing homes.

Delirium in hospitalized patients with COVID-19 pneumonia: a prospective, cross-sectional, cohort study

Delirium is an acute confusional state characterized by altered level of consciousness and attention. Coronavirus Disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), can manifest itself with this neuropsychiatric disorder. The endpoints of our study were: the frequency of delirium in subjects with COVID-19 pneumonia; the risk factors that predispose to this condition; and the impact of delirium on mortality. Subjects were consecutively enrolled in a Geriatric Unit from January 5th to March 5th, 2021. Inclusion criteria were: diagnosis of SARS-CoV-2 infection, a radiologically documented pneumonia, and the ability of providing informed consent. Exclusion criteria were: absence of radiological evidence of pneumonia, sepsis, and the need of intensive care unit treatment. All subjects were evaluated by means of Richmond Agitation Sedation Scale (RASS) and Confusion Assessment Method-Intensive Care Unit (CAM-ICU) at least twice per day. In the study cohort (n = 71), twenty patients (28.2%) had delirium. Delirium was present on admission in 11.3%, and occurred during hospitalization in 19.0%. Compared to patients without delirium, patients who developed this neuropsychiatric disorder had a higher mortality rate (35% vs 5.9%) and an increased average hospital length of stay (21 days vs 17 days). In the multivariate analysis delirium was associated with frailty (OR = 2.81; CI = 1.4-5.8) and helmet ventilation (OR = 141.05; CI = 4.3-4663.9). Delirium was an independent predictor of mortality. Nearly a third of subjects (28.2%) had delirium during hospitalization for COVID-19. This finding supports the notion that delirium is a common complication of SARS-CoV2 infection. Since delirium is associated with longer hospital stay, and it is an independent marker of increased mortality, clinicians should assess and prevent it.

Characteristics, treatment and delirium incidence of older adults hospitalized with COVID-19: a multicentre retrospective cohort study

BACKGROUND

The COVID-19 pandemic has affected older adults disproportionately, and delirium is a concerning consequence; however, the relationship between delirium and corticosteroid use is uncertain. The objective of the present study was to describe patient characteristics, treatments and outcomes among older adults hospitalized with COVID-19, with a focus on dexamethasone use and delirium incidence.

METHODS

We completed this retrospective cohort study at 7 sites (including acute care, rehabilitation and long-term care settings) in Toronto, Ontario, Canada. We included adults aged 65 years or older, consecutively hospitalized with confirmed SARS-CoV-2 infection, between Mar. 11, 2020, and Apr. 30, 2021. We abstracted patient characteristics and outcomes from charts and analyzed them descriptively. We used a logistic regression model to determine the association between dexamethasone use and delirium incidence.

RESULTS

During the study period, 927 patients were admitted to the acute care hospitals with COVID-19. Patients' median age was 79.0 years (interquartile range [IQR] 72.0-87.0), and 417 (45.0%) were female. Most patients were frail (61.9%), based on a Clinical Frailty Scale score of 5 or greater. The prevalence of delirium was 53.6%, and the incidence was 33.1%. Use of restraints was documented in 20.4% of patients. In rehabilitation and long-term care settings (n = 115), patients' median age was 86.0 years (IQR 78.5-91.0), 72 (62.6%) were female and delirium occurred in 17 patients (14.8%). In patients admitted to acute care during wave 2 of the pandemic (Aug. 1, 2020, to Feb. 20, 2021), dexamethasone use had a nonsignificant association with delirium incidence (adjusted odds ratio 1.38, 95% confidence interval 0.77-2.50). Overall, in-hospital death occurred in 262 (28.4%) patients in acute care settings and 28 (24.3%) patients in rehabilitation or long-term care settings.

INTERPRETATION

In-hospital death, delirium and use of restraints were common in older adults admitted to hospital with COVID-19. Further research should be directed to improving the quality of care for this population with known vulnerabilities during continued waves of the COVID-19 pandemic.

Caring for older adults during the COVID-19 pandemic

BACKGROUND

Elderly patients represent a high-risk group with increased risk of death from COVID-19. Despite the number of published studies, several unmet needs in care for older adults exist.

OBJECTIVES

To discuss unmet needs of COVID-19 in this special population.

SOURCES

A literature review for studies on COVID-19 in elderly patients published between December 2019 and November 2021 was performed. Clinical questions were formulated to guide the literature search. The search was conducted in the MEDLINE database, combining specific search terms. Two reviewers independently conducted the search and selected the studies according to the prespecified clinical questions.

CONTENT

Elderly patients with COVID-19 have peculiar characteristics. They may have atypical clinical presentation, with no fever and with delirium or neurological manifestations as the most common signs, with potential delayed diagnosis and increased risk of death. The reported fatality rates among elderly patients with COVID-19 are extremely high. Several factors, including comorbidities, atypical presentation, and exclusion from intensive care unit care, contribute to this excess of mortality. Age alone is frequently used as a key factor to exclude the elderly from intensive care, but there is evidence that frailty rather than age better predicts the risk of poor outcome in this category. Durability of vaccine efficacy in the elderly remains debated, and the need for a third booster dose is becoming increasingly evident. Finally, efforts to care for elderly patients who have survived after acute COVID-19 should be implemented, considering the high rates of long COVID sequelae and the risk of longitudinal functional and cognitive decline.

IMPLICATIONS

We highlight peculiar aspects of COVID-19 in elderly patients and factors contributing to high risk of poor outcome in this category. We also illuminated gaps in current evidence, suggesting future research directions and underlining the need for further studies on the optimal management of elderly patients with COVID-19.

Impact of renin-angiotensin-aldosterone system inhibitors on COVID-19

Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, the possible roles of renin–angiotensin system (RAS) inhibitors in COVID-19 have been debated as favorable, harmful, or neutral. Angiotensin-converting enzyme 2 (ACE2) not only is the entry route of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection but also triggers a major mechanism of COVID-19 aggravation by promoting tissue RAS dysregulation, which induces a hyperinflammatory state in several organs, leading to lung injury, hematological alterations, and immunological dysregulation. ACE inhibitors and angiotensin II type-1 receptor blockers (ARBs) inhibit the detrimental hyperactivation of the RAS by SARS-CoV-2 and increase the expression of ACE2, which is a counter-regulator of the RAS. Several studies have investigated the beneficial profile of RAS inhibitors in COVID-19; however, this finding remains unclear. Further prospective studies are warranted to confirm the role of RAS inhibitors in COVID-19. In this review, we summarize the potential effects of RAS inhibitors that have come to light thus far and review the impact of RAS inhibitors on COVID-19.

COVID-19 severity and age increase the odds of delirium in hospitalized adults with confirmed SARS-CoV-2 infection: a cohort study

BACKGROUND

Despite recognition of the neurologic and psychiatric complications associated with SARS-CoV-2 infection, the relationship between coronavirus disease 19 (COVID-19) severity on hospital admission and delirium in hospitalized patients is poorly understood. This study sought to measure the association between COVID-19 severity and presence of delirium in both intensive care unit (ICU) and acute care patients by leveraging an existing hospital-wide systematic delirium screening protocol. The secondary analyses included measuring the association between age and presence of delirium, as well as the association between delirium and safety attendant use, restraint use, discharge home, and length of stay.

METHODS

In this single center retrospective cohort study, we obtained electronic medical record (EMR) data using the institutional Epic Clarity database to identify all adults diagnosed with COVID-19 and hospitalized for at least 48-h from February 1-July 15, 2020. COVID-19 severity was classified into four groups. These EMR data include twice-daily delirium screenings of all patients using the Nursing Delirium Screening Scale (non-ICU) or CAM-ICU (ICU) per existing hospital-wide protocols.

RESULTS

A total of 99 patients were diagnosed with COVID-19, of whom 44 patients required ICU care and 17 met criteria for severe disease within 24-h of admission. Forty-three patients (43%) met criteria for delirium at any point in their hospitalization. Of patients with delirium, 24 (56%) were 65 years old or younger. After adjustment, patients meeting criteria for the two highest COVID-19 severity groups within 24-h of admission had 7.2 times the odds of having delirium compared to those in the lowest category [adjusted odds ratio (aOR) 7.2; 95% confidence interval (CI) 1.9, 27.4; P = 0.003]. Patients > 65 years old had increased odds of delirium compared to those < 45 years old (aOR 8.7; 95% CI 2.2, 33.5; P = 0.003). Delirium was associated with increased odds of safety attendant use (aOR 4.5; 95% CI 1.0, 20.7; P = 0.050), decreased odds of discharge home (aOR 0.2; 95% CI 0.06, 0.6; P = 0.005), and increased length of stay (aOR 7.5; 95% CI 2.0, 13; P = 0.008).

CONCLUSIONS

While delirium is common in hospitalized patients of all ages with COVID-19, it is especially common in those with severe disease on hospital admission and those who are older. Patients with COVID-19 and delirium, compared to COVID-19 without delirium, are more likely to require safety attendants during hospitalization, less likely to be discharged home, and have a longer length of stay. Individuals with COVID-19, including younger patients, represent an important population to target for delirium screening and management as delirium is associated with important differences in both clinical care and disposition.

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.

Clinical, Laboratory and Imaging Characteristics of Hospitalized COVID-19 Patients with Neurologic Involvement; a Cross-Sectional Study

Introduction

Although neurologic involvement and neuroimaging abnormalities have been frequently identified in COVID-19 patients, the underlying factors remain unclear. In this study, we assessed the association of the neurological manifestations and neuroimaging features of hospitalized COVID-19 patients with their clinical, laboratory, and imaging characteristics.

Methods

This multicenter cross-sectional study was conducted between September 2020 and March 2021 at two large academic hospitals in Tehran, Iran. We used census sampling from medical records to enroll hospitalized patients with a positive COVID-19 Polymerase chain reaction (PCR) test who underwent brain imaging due to presenting any acute neurologic symptom during hospital stay.

Results

Of the 4372 hospitalized patients with COVID-19, only 211 met the inclusion criteria (35.5% with severe infection). Central nervous system and psychiatric manifestations were significantly more common in severe cases (p ≤ 0.044). Approximately, 30% had a new abnormality on their neuroimaging, with ischemic (38/63) and hemorrhagic (16/63) insults being the most common. The most frequent reasons that provoked cranial imaging were headache (27%), altered consciousness (25.6%), focal neurologic signs (19.9%), and delirium (18%). Analysis revealed a positive correlation for age, neutrophilia, lymphopenia, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) with the emergence of neuroimaging abnormalities (p ≤ 0.018). In addition, patients with new neuroimaging abnormalities had a significantly higher lung CT score than those without any pathologic findings (11.1 ± 4.8 vs. 5.9 ± 4.8, p < 0.001).

Conclusion

Approximately 30% of the study population had various acute neuroimaging findings. The lung CT score, neutrophil count, and age were strong predictors of acute neuroimaging abnormalities in hospitalized COVID-19 patients.