Prevalence and prognostic value of Delirium as the initial presentation of COVID-19 in the elderly with dementia: An Italian retrospective study

Abstract

Background Delirium may be one of the presenting symptoms of COVID-19, complicating diagnosis and care of elderly patients with dementia. We aim to identify the prevalence and prognostic significance of delirium as the sole onset manifestation of COVID-19. Methods This is a retrospective single-centre study based on review of medical charts, conducted during the outbreak peak (March 27-April 18, 2020) in a Lombard dementia facility, including 59 elderly subjects with dementia and laboratory-confirmed COVID-19. Findings Of the 59 residents, 57 (96⋅6%) tested positive (mean age: 82⋅8; women: 66⋅7%). Comorbidities were present in all participants, with 18/57 (31⋅6%) having three or more concomitant diseases. Delirium -Onset COVID-19 (DOC) was observed in 21/57 (36⋅8%) subjects who were chiefly older (mean age: 85⋅4 y/o) and with multiple comorbidities. Eleven/21 DOC patients (52⋅4%) had hypoactive delirium , while hyperactive delirium occurred in ten/21 (47⋅6%). Lymphopenia was present in almost all subjects (median: 1⋅3 × 10 9 /L). Overall mortality rate was 24⋅6% (14/57) and dementia severity per se had no impact on short-term mortality due to COVID-19. DOC was strongly associated with higher mortality ( p <0⋅001). Also, DOC and male gender were independently associated with increased risk of mortality (OR: 17⋅0, 95% CI: 2⋅8–102⋅7, p = 0⋅002 and 13⋅6, 95% CI: 2⋅3–79⋅2, p = 0⋅001 respectively). Interpretation Delirium occurrence in the elderly with dementia may represent a prodromal phase of COVID-19, and thus deserves special attention, especially in the presence of lymphopenia. Hypoxia and a severe inflammatory state may develop subsequently. DOC cases have higher short-term mortality rate. Funding None.

Psychological and neuropsychiatric implications of COVID-19

“…Although delirium onset does not appear to be related to gender, it is more frequent with older age, and male gender is an independent risk factor for poor outcome, including mortality [65]. Having said that, case reports also draw the attention to COVID-19 positive older people asymptomatic or with non-specific clinical features, who develop delirium as first clinical symptoms of the viral infection [66,67] and in some instances related to leukoencephalopathy, as seen on CT brain scans [68].…”

Clinical Characteristics, Frailty, and Mortality of Residents With COVID-19 in Nursing Homes of a Region of Madrid

“…According to recent studies, and in line with our findings, delirium has been described as a clinical manifestation in older patients with COVID-19. 11 , 24 In this regard, we did not evaluate the other items of the Confusion Assessment Method (ie, acute and fluctuating course, inattention, or disorganized thinking); however, we suspect that the incidence of delirium was high due to the large number of patients presenting altered level of consciousness and the prevalence of dementia in our sample. These data also reveal the importance of identifying atypical presentations of this disease in the older population.…”

Characteristics and outcomes of COVID-19 inpatients who underwent psychiatric consultations

“… Bianchetti et al (2020) found that the most frequent symptom of onset was delirium (67%) among dementia patients diagnosed with COVID-19. Similarly, Poloni et al (2020) emphasized that delirium may be representative of an early-phase clinical feature of COVID-19, especially in elderly patients. In this context, it becomes clear that clinicians should be alert of the fact that delirium may develop, especially in the first days of hospitalization.…”