How do I manage delirium in older people with COVID-19?

Delirium is now recognised as a common symptom of coronavirus, and older people living in long-term care facilities are at higher risk, especially those with dementia

What is the link between COVID-19 and delirium?

Early in the pandemic, COVID-19 was viewed predominantly as a respiratory disease, with breathlessness, fever and cough the most recognised symptoms. As the pandemic unfolded it became apparent that COVID-19 presents differently in older people, especially in those who are living with frailty. Studies have shown that one third of older patients admitted to hospital with COVID-19 have delirium at the time of presentation.

Delirium is the primary symptom in 16% of cases, with up to 37% of older people displaying no ‘typical’ COVID-19 symptoms (Kennedy et al 2020, Zazzara et al 2020). Delirium is therefore now recognised as a common symptom of COVID-19, one associated with an increased risk of intensive care unit admission and death (Kennedy et al 2020, Marengoni et al 2020, Poloni et al 2020).

In the community, delirium is present in around half of older people with COVID-19, with those living in long-term care facilities at especially high risk (Zazzara et al 2020). When present, delirium increases the likelihood of death in this group (Poloni et al 2020). Extra vigilance is therefore needed to recognise subtle changes, especially for people living with dementia, to facilitate prompt diagnosis and treatment (O’Hanlon and Inouye 2020).

• RELATED: Managing behaviour that challenges in people with dementia in the emergency department

Is delirium in COVID-19 the same as delirium in other situations?

The exact mechanisms of delirium in COVID-19 are not yet fully understood, but are likely to be multifactorial (O’Hanlon and Inouye 2020). Factors that increase the risk of delirium in COVID-19 include (Kennedy et al 2020):

• Frailty.
• Older age.
• Institutional care.
• Sensory impairment.
• Stroke.
• Parkinson’s disease.

The use of personal protective equipment, strict isolation measures and ward moves required to ensure cohorting of COVID-19 patients can also contribute to the development of delirium. Dexamethasone, an essential treatment for COVID-19 patients requiring oxygen therapy, can also cause delirium.

How do I manage delirium in COVID-19?

Approach delirium in COVID-19 the same way as in non-COVID-19 situations. A 4AT assessment (MacLullich et al 2014) should be undertaken in all patients aged 65 and over. The medical team should undertake a thorough physical examination and investigations, with a multidisciplinary approach to treating underlying causes of delirium (Royal College of Psychiatrists (RCPsych) 2020).

• RELATED: How do I manage the care of an older person with delirium?

The PINCH ME mnemonic (Let’s Respect 2014) should be used daily to assess delirium risk factors:

• P = Pain.
• IN = INfection.
• C = Constipation.
• H = deHydration.
• M = Medication.
• E = Environment.

Ensuring patients have access to their glasses and hearing aids, promoting good sleep hygiene, encouraging mobility and ensuring adequate oxygenation are also essential.

Delirium in COVID-19 may lead to behavioural changes that make the management of COVID-19 more challenging, with patients struggling to tolerate care interventions. Where PINCH ME and non-pharmacological interventions are ineffective, or rapid control of symptoms is needed to enable effective care delivery and/or to reduce patient harm, an earlier move to pharmacological treatment may be needed (British Geriatrics Society 2020, RCPsych 2020).

• RELATED: Treat delirium as a medical emergency

It is important to give clear, concise information to patients and families to reduce the psychological effect of delirium, although this is more challenging due to the current visiting restrictions. The usual principles relating to the Mental Capacity Act 2005 must also be upheld.

View our COVID-19 resource centre

Practice Question is written by members of the Nurses and AHPs Council of the British Geriatrics Society

References

• British Geriatrics Society (2020) Coronavirus: Managing Delirium in Confirmed and Suspected Cases

• Kennedy M, Helfand BKI, Gou RY et al (2020) Delirium in older patients with COVID-19 presenting to the emergency department. JAMA Network Open. 3, 11, e2029540

• Let’s Respect (2014) Delirium

• MacLullich A, Ryan T, Cash H (2014) 4AT: Rapid Clinical Test for Delirium Version 1.2

• Marengoni A, Zucchelli A, Grande G et al (2020) The impact of delirium on outcomes for older adults hospitalised with COVID-19. Age and Ageing. 49, 6, 923-926

• O’Hanlon S, Inouye SK (2020) Delirium: a missing piece in the COVID-19 pandemic puzzle. Age and Ageing. 49, 4, 497-498

• Poloni TE, Carlos AF, Cairati M et al (2020) Prevalence and prognostic value of delirium as the initial presentation of COVID-19 in the elderly with dementia: an Italian retrospective study. EClinicalMedicine. 26, 100490

• Royal College of Psychiatrists (2020) Delirium Management Advice for Patients with Confirmed or Suspected COVID-19 in the Acute Trust Setting
• Zazzara MB, Penfold RS, Roberts AL et al (2020) Probable delirium is a presenting symptom of COVID-19 in frail, older adults: a cohort study of 322 hospitalised and 535 community-based older adults. Age and Ageing. afaa223

Additional resources

• Healthcare Improvement Scotland (2019) SIGN 157. Risk Reduction and Management of Delirium

• National Institute for Health and Care Excellence (2010) Delirium: Prevention, Diagnosis and Management. Clinical guideline 103

• Royal College of Nursing (2020) Delirium in Older People

Angeline Price is an advanced clinical practitioner, Ageing and Complex Medicine Department, Salford Royal NHS Foundation Trust, Salford