Benjamin Oseroff, MA, MPhil1
1 Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
Correspondence concerning this article and requests for reprints should be addressed to Benjamin Oseroff (boseroff@gmail.com)
ABSTRACT
The COVID-19 pandemic promises to increase the incidence of delirium among hospitalized, older patients. This viewpoint explores the challenges in treating delirium during COVID-19 and how an increase in delirium might extend the impact of the pandemic. As we move past the early phase of the outbreak, hospitals and postacute care facilities should prioritize adapting existing best practices to treat delirium and manage its long-term effects. Virtual technologies may have a role to play as part of a temporary solution but are unlikely to be sufficient long-term. This perspective is informed by my experiences as a Hospital Delirium Program volunteer at Mount Sinai Morningside in New York City.
The COVID-19 pandemic is disproportionately hospitalizing older patients, promising a marked increase in cases of hospital delirium. Delirium is an acute confusion caused by a medical condition and one of the most common complications for patients over 65, estimated to occur in 29-64% of hospital admissions [1]. The total health care costs associated with delirium in the United States are estimated to be more than $181 billion (2020 dollars) per year [2].
Delirious patients can present as agitated, lethargic, or alternate between the two. Often undiagnosed, delirium is associated with increased morbidity, longer hospitalization, and higher mortality up to 12 months post-hospitalization [3]. Advanced age, visual impairment, poor mobility, and depression are all risk factors associated with delirium, though the underlying mechanism varies from patient to patient [4].
The risk of developing delirium is exacerbated for patients on ventilators, many of whom are prescribed medications for sedation that can increase a patient’s chance of developing delirium. Previous estimates put the incidence of delirium at 60-85% for patients receiving mechanical ventilation [5]. There may also be additional risks specific to this coronavirus. A recent study from Wuhan, China found that nearly 40% of hospitalized patients with COVID-19 developed neurological symptoms, including a smaller subset who experienced consciousness changes consistent with delirium [6]. Delirium may be a key presenting symptom of COVID-19 among older patients who do not exhibit the same symptoms as younger adults [7]. This is consistent with evidence that delirium was common among those infected during the acute stages of the MERS and SARS outbreaks [8].
While common and serious, hospital delirium is not inevitable. Multicomponent interventions, like the Hospital Elder Life Program (HELP), have shown significant promise in treating and preventing delirium. At more than 200 HELP sites worldwide, interdisciplinary health teams screen patients and volunteers provide nonpharmacological interventions to maintain physical and cognitive functioning during hospitalization and through the transition home. A systematic review and meta-analysis of evaluations of HELP showed the program reduced delirium incidence by 53% and achieved average cost savings of $2700 per patient per hospitalization [9]. At Mount Sinai Morningside Hospital in New York City, I am part of a cadre of dedicated volunteers who deliver nonpharmacological interventions, such as therapeutic conversation, music, and sensory supports to promote cognitive stimulation, reorient patients to their environments, and increase mobility.
My experiences as a volunteer lend a personal anecdote to the evidence on treating and preventing delirium. Over the past 12 months, I have seen how nonpharmacologic interventions are key to managing delirium, particularly for patients who may not have consistent visitors to engage with them throughout lengthy hospital stays. Often alone for much of the day, elderly hospitalized patients can quickly lose hold of their normal rhythm. I frequently walk into a room to find a patient asleep in the middle of the day with the lights off. Other times, patients are awake and yet newly unable to communicate. Apparently simple interventions, such as opening the blinds, playing a favorite song, or asking about a patient’s childhood, can have dramatic effects on patients’ orientation and comfort. I remember one patient this past fall who, upon hearing a favorite song from his childhood, went in minutes from being non-verbal to singing along. The gratitude many patients express for returning to their normal selves has made volunteering in the Hospital Delirium Program one of my most meaningful clinical experiences.
As the number of COVID-19 cases continues to rise, shortages of beds, staff, and protective equipment have pushed hospitals to cancel elective procedures and restrict patient visitors. At many hospitals, this also understandably includes suspending volunteer programs like the Hospital Delirium Program at Mount Sinai Morningside. In combination, these steps promise to isolate vulnerable patients at a time of profound need.
The COVID-19 outbreak and the necessary response may undo much of the progress hospitals have made in recent years to reduce hospital delirium. In addition to limiting visitors, clinical best practices such as waking patients and mobilizing them for exercise have been abandoned in some cases for fear of promoting spread of the virus [10]. Drugs that are low-risk for delirium that are used for sedation for ventilation such as dexmedetomidine and propofol are in short supply, leading critical care physicians to switch to delirium-inducing drugs such as benzodiazepines [11]. A recent report from France detailed the neurological findings from 58 COVID-19 patients admitted to the ICU with acute respiratory distress syndrome (ARDS). More than 85% of the patients received a benzodiazepine (midazolam) as part of their ventilation and 65% of patients were positive on the Confusion Assessment Method-ICU (CAM-ICU) assessment, indicating delirium [12].
While the toll of the pandemic is currently measured on a daily or weekly basis, delirium, left untreated, could extend the tail of COVID-19 for several months. Those who develop delirium in the hospital often suffer from long-lasting cognitive deficits. Symptoms are often similar to mild Alzheimer’s disease or moderate traumatic brain injury. This will pose an additional strain on those tasked with caring for patients when they leave the hospital, such as skilled nursing facilities, inpatient rehabilitation facilities, long-term care hospitals, and home health agencies. These facilities normally operate with high occupancy rates, and already there are calls to build a surge capacity in postacute care facilities in anticipation of increased demand [13]. Once inundated with COVID-19 patients, postacute care facilities may then face the same pressure as hospitals to isolate patients from family and visitors for infection control. This may further limit the ability of patients with delirium to return to baseline.
Hospitals and postacute care facilities should consider how to develop new strategies to mitigate the delirium-related impact of COVID-19 in a way that is safe for health care workers, volunteers, families, and patients. Supply allowing, hospitals should prioritize the reduced use of delirium-inducing benzodiazepines for the elderly patients at highest risk for developing delirium such as those poor mobility, advanced age, and visual impairment. Elderly patients should be universally screened for delirium using validated tools such as the CAM, which can be performed by non-mental health professionals. Allowing limited family and caregivers to visit would be an important step to reduce patient isolation and manage delirium. However, required personal protective equipment may limit the quality of in-person interactions and will likely contribute to further sensory impairment and disorientation for patients.
When in-person visiting is not possible, facilities should also consider using digital technologies to connect patients to family members, who are relied upon in best practice to help diagnosis delirium by identifying cognitive changes from baseline. A similar protocol using phone calls was already standard practice at Mount Sinai Morningside pre-COVID-19 for patients who did not have caregivers present. At sites with established programs, volunteer patient visitors could also virtually continue to converse with patients, play music, and deliver other effective preventive interventions. While best practices are emerging for using telemedicine to reach elderly patients at home, this modality has not been studied for treating hospital delirium specifically [14]. Virtual visiting is likely to present an extra challenge for elderly patients with delirium who may be less adept at engaging with technology and may require additional supervision to use virtual devices. Not being in-person will also limit the ability of volunteers and family members to encourage mobility and make environmental adjustments. I have also found through my own experiences that simple physical touches, such as squeezing a hand, can be key to forming personal connection with patients and helping them return to their usual selves. For these reasons, virtual visiting should only be a temporary substitute.
The spread of COVID-19 and the challenges of treating patients during the pandemic mean there is almost certain to be a rise in the cases of delirium. Focusing on preventing and treating delirium, however, is essential to ensure the burden of COVID-19 does not extend unnecessarily long. At its core, delirium management is about treating the patient as person. While we may have to modify our approach, this ideal should remain at the center of health care, in times of crisis and not.
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