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Older COVID-19 Patients Often Present to Emergency Departments with Delirium

Key findings

  • This seven-center, retrospective cohort study examined records on 817 patients age 65 or older who presented to an emergency department (ED) and tested positive for COVID-19
  • 28% of patients had delirium on arrival to the ED, and delirium was the sixth most common presenting symptom or sign of COVID-19 overall
  • Among these patients with delirium, delirium was a primary symptom in 16%, and 37% did not have any typical COVID-19 symptoms
  • Factors associated with risk of delirium included age older than 75, living in a nursing home or assisted living facility, vision impairment, hearing impairment, Parkinson's disease, stroke and prior use of psychoactive medication
  • Delirium on arrival was significantly associated with increased risk of poor hospital outcomes, including ICU stay, discharge to a rehabilitation facility and death

It's now clear that delirium is one of the potential neuropsychiatric manifestations of COVID-19. Delirium is estimated to affect 25%–33% of hospitalized COVID-19 patients and 65% of COVID-19 patients in ICUs.

Maura Kennedy, MD, MPH, division chief of Geriatric Emergency Medicine within the Department of Emergency Medicine at Massachusetts General Hospital, and colleagues recently became the first to gather similar data from emergency departments (EDs). In JAMA Network Open, they say 28% of older patients with COVID-19 presenting to EDs had delirium on arrival.

Study Methods

Researchers at seven hospitals reviewed the records of 817 older adults (65 years or older) who presented to an ED on or after March 13, 2020 (the study end date varied at each hospital), and were diagnosed with COVID-19. Diagnosis codes for delirium were noted, but the evaluation also included a detailed review of all physician, nursing and other notes for keywords related to delirium and evidence of acute change from baseline.

Scope of the Problem

  • 226 patients (28%) had delirium on arrival—as context, typical rates of delirium in ED studies pre–COVID-19 were 7%–20%
  • Delirium was the sixth most common symptom overall (judged from the CDC list of 25 COVID-19 signs and symptoms)
  • Of patients with delirium, 16% had delirium as a primary symptom, 37% had no typical COVID-19 symptoms and 94% had to be hospitalized

Risk Factors

On multivariable analysis, risk factors for delirium in older patients with COVID-19 were:

  • Vision impairment (adjusted RR, 1.98)
  • Parkinson's disease (aRR, 1.88)
  • Age older than 75 (adjusted RR, 1.51)
  • Stroke (aRR, 1.47)
  • Prior use of psychoactive medication (aRR, 1.42)
  • Living in a nursing home or assisted living facility (aRR, 1.23)
  • Hearing impairment (aRR, 1.10)

Pre-existing cognitive impairment was also predictive of delirium but removed from the multivariable model due to collinearity with living in a nursing home or assisted living facility.


Outcomes significantly associated with delirium in the multivariable analysis were:

  • Hospital admission (aRR, 1.06)
  • Any ICU stay (aRR, 1.67)
  • Discharge to a rehabilitation facility (aRR, 1.55)
  • Death (aRR, 1.24)

Guidance for Frontline Clinicians

When evaluating older adults, clinicians must include COVID-19 in the differential diagnosis of delirium, whether or not they have other symptoms of COVID-19. This is important to avoid missing diagnoses and to better identify patients who are at high risk of severe COVID-19.

The CDC currently lists "new confusion" only as an emergency warning sign for patients with COVID-19. Centers that use the CDC list for screening, testing and evaluation of patients with suspected COVID-19 should add delirium as a presenting symptom.

of older patients with COVID-19 had delirium on arrival in the ED

of older patients with COVID-19 who had delirium on arrival in the ED had delirium as a primary symptom

of older patients with COVID-19 who had delirium on arrival in the ED had no typical symptoms of COVID-19

greater risk of delirium on arrival in the ED among patients with COVID-19 who were older than 75

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Refer a patient to the Geriatric Medicine Unit

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