Introduction
Delirium in patients with COVID-19 can cause multiple adverse functional outcomes. However, the adverse cognitive effect in the elderly with dementia after surviving COVID-19 has not been widely described. We report a Case of a severe COVID-19 infection resulting in persistent cognitive decline.
Case Description
An 81-year-old male LTC resident with dementia, congestive heart failure, ischemic cardiomyopathy, diabetes, hypertension, depression, chronic urinary retention, depression, and anxiety who at baseline was wheelchair ambulatory, able to self-feed, and able to follow simple commands contracted the COVID-19 infection in July 2020. He developed pneumonia with acute hypoxic respiratory failure requiring high flow oxygen. He received a course of remdesivir and dexamethasone. In the initial phase of his illness, he developed acute severe hyperactive delirium. He became combative with staff and was severely agitated, requiring transfer to the ICU for multimodal management including intravenous dexmedetomidine, antipsychotics, and anxiolytics. CT Head on admission and post-fall (which resulted from his severe agitation) revealed advanced volume loss and moderate periventricular small vessel ischemic disease consistent with his diagnosis of dementia, but no acute abnormalities. On day 21 of admission, he stabilized and was transferred out of ICU. He remained somnolent despite discontinuation of his psychotropic medications and sedatives. His hospitalization was further complicated by Proteus mirabilis urinary tract infection, acute parotitis, and deep vein thrombosis of the left leg for which he was treated. His persistent somnolent state prompted the placement of a percutaneous gastroenterostomy tube. The patient was discharged to subacute rehabilitation on day 45 of admission. Presently he is over 100 days out from contracting COVID-19 infection and despite slow improvements remains both cognitively and functionally below his prior baseline.
Discussion
Delirium is an indicator of severe illness in older adults. Moreover, delirium can present as the sole onset manifestation of COVID-19 infection in older patients with dementia. Delirium occurring at the onset of infection is predictive of high short-term mortality and significantly worse physical function. Moreover, cognitive impairment can persist and affect 70%-100% of patients at discharge. We present our Case with baseline dementia who developed a significant worsening of baseline cognition after a turbulent 45-day hospitalization for COVID-19 infection. Despite an aggressive approach in addressing delirium, the patient had a significant decline in his baseline cognition. The pathophysiology of this persistent decline is unclear. Etiology is likely multifactorial, including the possibility of this decline being related to the viral infection. The effect of COVID-19 on the cognition of patients with dementia needs further study.
Disclosures
All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.