The Importance of Delirium and Delirium Prevention in Older Adults during Covid-19

The SARS-CoV-2 outbreak was declared a pandemic on March 11, 2020. While Covid-19 infection poses a risk at all ages, adults 65 and older are at greatest risk of severe disease, hospitalization, intensive care use, and death. Globally, persons over age 65 comprise 9% of the population, yet account for 30–40% of Covid-19 cases. As of December 7, 2020, the Centers for Disease Control and Prevention (CDC) reported that 163,718 (81%) of the 202,121 total U.S. deaths from Covid-19 occurred in persons over age 65.¹

Importance of delirium in Covid-19

During the pandemic, delirium has emerged as a well-recognized complication of Covid-19 infection, with particular importance due to its high prevalence and mortality, its significance as a presenting sign that is easily missed, and its preventable nature. Delirium, also referred to as ‘acute brain failure’, is a common presenting symptom of any severe illness in older adults. Given this, it is not surprising that delirium is a common accompaniment of severe Covid-19 infections in older adults. Recent studies have described occurrence rates of 25–37% in general hospital patients and >65% in ICU patients.^2–4 Development of delirium in patients with Covid-19 has been well-documented to predict a poor prognosis with increased mortality, even after controlling for comorbidity and illness severity.^4–6

Delirium is an important presenting symptom of infection with Covid-19 in older adults. It can be a common, if atypical, presentation and it can be the only presenting symptom. A recent study⁵ found that delirium was present in 28% of 817 older adults with Covid-19 presenting to the ED, and was the sixth most common of all presenting symptoms. Of delirious patients, 16% had delirium as their primary symptom, and importantly, 37% had no typical Covid-19 symptoms (such as fever, cough, or shortness of breath). Yet delirium is not included in the CDC case report criteria for Covid-19, and is often unrecognized by healthcare professionals. The first and most important step in management of delirium is its recognition. Many brief screening instruments are available. The UB-CAM provides a brief cognitive assessment and observer rating which can be completed in under one minute to screen for delirium in high risk settings for older adults, such as emergency department, hospital, intensive care unit (ICU), and nursing home.⁷

Etiology of delirium in Covid-19

Covid-19 contributes to delirium via multiple pathways.⁸ While direct neurologic invasion of the central nervous system compartment occurs, cerebrospinal fluid and autopsy studies indicate it is quite uncommon. Major contributors appear to include the cytokine storm and immune dysregulation accompanying Covid-19 infection which triggers neuroinflammation (in brain and meninges) and hypercoagulability. The hypercoagulable state contributes to cerebral infarction in 1–3% of hospitalized COVID patients, more often from large than small vessel involvement. Severe Covid-19 infection has been associated with multi-organ system involvement, including respiratory failure with prolonged hypoxemia, and renal, liver, and cardiac failure, with accompanying metabolic derangements. Moreover, patients with severe illness from Covid-19 have many other precipitating factors which can contribute to delirium, such as multiple medications with psychoactive effects, mechanical ventilation, ICU stay, immobility, malnutrition, sleep disruption, social isolation, and emotional stress, to name a few. Even amidst Covid-19, it is important to remember that delirium is multifactorial and that reversible factors are contributing.

The hospital environment as a generator of delirium during Covid-19

During Covid-19, mandated infection control procedures in hospitals and ICUs have created the perfect storm of conditions⁹ that predispose to the development of delirium in vulnerable older persons. First, the ban of family members and informal caregivers who would normally provide care and comfort at the bedside, has resulted in intense social isolation. Second, staff are often rushed and stressed, wearing protective equipment which masks faces and muffles voices --making communication and human connection difficult, particularly for those with hearing or vision impairments. To minimize exposure, nursing staff often limit the number of times they enter patients’ rooms, leaving prolonged periods where older patients are alone and isolated. Moreover, potentially harmful psychoactive medications, such as sedatives and antipsychotics are being widely prescribed to minimize anxiety but also because of concerns about spreading infection through agitation or wandering behaviors.

These factors are exactly the opposite of strategies we know to be effective for prevention and management of delirium¹⁰: presence of family and staff to provide comfort, communication, and connection; regular orientation and therapeutic activities; frequent mobilization and exercise; and avoidance of psychoactive medications in favor of nonpharmacologic approaches for anxiety and sleep. The importance of social connection and engagement, the human elements of care, cannot be underestimated.

Delirium interventions during Covid-19

Even during Covid-19, reversible contributors to delirium must be addressed, and approaches for delirium prevention and management can be built into routine clinical care. Many hospitals with delirium prevention programs, such as the Hospital Elder Life Program¹⁰, have developed creative approaches to provide needed interventions (Table). The use of “Toolkits” or activity boxes delivered to patients’ rooms, tablet computers for remote coaching and communication by trained staff or volunteers, and remote visits with family members can provide much needed orientation, communication, and comfort throughout hospitalization. These approaches can and should be used in those with delirium risk factors, whether or not they are affected with Covid-19.

Table.

Delirium Interventions: Adaptations from Hospital Elder Life Program (HELP)^*

Intervention	Description
Orientation	Communication boards in room Orientation sheet delivered daily Remote visits with family or trained volunteers
Therapeutic activities	Therapeutic activities kit to bedside (e.g., crosswords, games, activities) Remote activities 3 times daily with family or trained volunteers
Sleep enhancement	Provide ear plugs, eye masks, and patient instructions about sleep hygiene and relaxation approaches Provide sunlight during day and dark/quiet room at night Nursing education to minimize nighttime interruptions
Early mobilization	Minimize restraints, tethers (e.g., intravenous lines, bladder catheters, telemetry, oximetry) Encourage mobility and exercise in room. Provide instructions and assistive devices in room
Hearing/vision adaptations	Provide eyeglasses and adaptive equipment and instruct patient/staff in use
Maintaining oral intake and fluids	Patient information sheet about nutrition and hydration Remote encouragement and socialization during meals
Minimize social isolation	Remote visits and communication with family Family caregiver involvement when possible
Psychoactive medications	Medication review and staff education about adverse effects in older adults

^*Adapted from the Hospital Elder Life Program https://www.americangeriatrics.org/programs/ags-cocarer-help. For more information on creating a HELP Covid-19 Toolkit: https://help.agscocare.org/chapter-abstract/chapter/H00107/H00107_PART001_002

Delirium is of heightened importance during Covid-19, with the disease disproportionately affecting older adults. The ability to recognize and manage delirium will directly impact clinical outcomes in this population. All older patients with suspected Covid-19 infection should be screened for delirium, since atypical presentations are typical and since delirium is the sixth most common presenting symptom. Delirium remains multifactorial, with important reversible contributors. Nonpharmacologic multicomponent strategies remain the mainstay of prevention and management, and finding creative ways to build a “new normal” for care of older adults will be essential. Approaches involving family members—remotely or with careful in-person visits—will be critical to provide comfort, communication, and connection for older adults. Families should be involved as part of the caregiving team to enhance both short-term and long-term outcomes of delirium for this vulnerable population.