Department of Emergency Medicine
Emergency Medicine | Epidemiology | Geriatrics | Health Services Administration | Infectious Disease | Nervous System Diseases | Pathological Conditions, Signs and Symptoms | Psychiatry and Psychology | Virus Diseases
Importance: Delirium is common among older emergency department (ED) patients, is associated with high morbidity and mortality, and frequently goes unrecognized. Anecdotal evidence has described atypical presentations of coronavirus disease 2019 (COVID-19) in older adults; however, the frequency of and outcomes associated with delirium in older ED patients with COVID-19 infection have not been well described.
Objective: To determine how frequently older adults with COVID-19 present to the ED with delirium and their associated hospital outcomes.
Design, setting, and participants: This multicenter cohort study was conducted at 7 sites in the US. Participants included consecutive older adults with COVID-19 presenting to the ED on or after March 13, 2020.
Exposure: COVID-19 was diagnosed by positive nasal swab for severe acute respiratory syndrome coronavirus 2 (99% of cases) or classic radiological findings (1% of cases).
Main outcomes and measures: The primary outcome was delirium as identified from the medical record according to a validated record review approach.
Results: A total of 817 older patients with COVID-19 were included, of whom 386 (47%) were male, 493 (62%) were White, 215 (27%) were Black, and 54 (7%) were Hispanic or Latinx. The mean (SD) age of patients was 77.7 (8.2) years. Of included patients, 226 (28%) had delirium at presentation, and delirium was the sixth most common of all presenting symptoms and signs. Among the patients with delirium, 37 (16%) had delirium as a primary symptom and 84 (37%) had no typical COVID-19 symptoms or signs, such as fever or shortness of breath. Factors associated with delirium were age older than 75 years (adjusted relative risk [aRR], 1.51; 95% CI, 1.17-1.95), living in a nursing home or assisted living (aRR, 1.23; 95% CI, 0.98-1.55), prior use of psychoactive medication (aRR, 1.42; 95% CI, 1.11-1.81), vision impairment (aRR, 1.98; 95% CI, 1.54-2.54), hearing impairment (aRR, 1.10; 95% CI 0.78-1.55), stroke (aRR, 1.47; 95% CI, 1.15-1.88), and Parkinson disease (aRR, 1.88; 95% CI, 1.30-2.58). Delirium was associated with intensive care unit stay (aRR, 1.67; 95% CI, 1.30-2.15) and death (aRR, 1.24; 95% CI, 1.00-1.55).
Conclusions and relevance: In this cohort study of 817 older adults with COVID-19 presenting to US emergency departments, delirium was common and often was seen without other typical symptoms or signs. In addition, delirium was associated with poor hospital outcomes and death. These findings suggest the clinical importance of including delirium on checklists of presenting signs and symptoms of COVID-19 that guide screening, testing, and evaluation.
older adults, COVID-19, emergency departments, delirium, hospital outcomes
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Copyright 2020 Kennedy M et al. JAMA Network Open. This is an open access article distributed under the terms of the CC-BY License.
DOI of Published Version
Kennedy M, Helfand BKI, Gou RY, Gartaganis SL, Webb M, Moccia JM, Bruursema SN, Dokic B, McCulloch B, Ring H, Margolin JD, Zhang E, Anderson R, Babine RL, Hshieh T, Wong AH, Taylor RA, Davenport K, Teresi B, Fong TG, Inouye SK. Delirium in Older Patients With COVID-19 Presenting to the Emergency Department. JAMA Netw Open. 2020 Nov 2;3(11):e2029540. doi: 10.1001/jamanetworkopen.2020.29540. PMID: 33211114; PMCID: PMC7677760. Link to article on publisher's site
JAMA network open
Kennedy M, Helfand BK. (2020). Delirium in Older Patients With COVID-19 Presenting to the Emergency Department. COVID-19 Publications by UMMS Authors. https://doi.org/10.1001/jamanetworkopen.2020.29540. Retrieved from https://escholarship.umassmed.edu/covid19/151
Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.
Emergency Medicine Commons, Epidemiology Commons, Geriatrics Commons, Health Services Administration Commons, Infectious Disease Commons, Nervous System Diseases Commons, Pathological Conditions, Signs and Symptoms Commons, Psychiatry and Psychology Commons, Virus Diseases Commons