Preventing and Managing Delirium in Older Emergency Department Patients During the COVID-19 Pandemic

Ula Hwang MD MPH, Aaron J Malsch RN MSN GCNS-BC, Kevin J Biese MD, Sharon K Inouye MD MPH
Supplement 1: Delirium Management COVID-19

March 2020
Volume 1
Issue 4
Supplement 1

The Journal of Geriatric Emergency Medicine has a mission to improve emergency health care for older adults by providing open access, peer-reviewed, quality education and dissemination platform giving providers in all disciplines the evidence they need to enhance emergency care of older adults.

  1. Delirium is an emergency! The mortality for persistent delirium is higher than 1-year mortality rates for acute conditions like heart disease.1  See the ADEPT tool for tips on delirium care: https://acep.org/patient-care/adept/
  2. In older adults, systemic illness (viral infection like COVID-19), fever, and hypoxemia may trigger delirium. Acute confusion may be a sign of COVID-19 in older adults (even before fever and cough).
  3. Although visitors in hospitals and EDs are now becoming restricted, and use of personal protective equipment (PPE) during the COVID-19 pandemic will protect and limit spread, it will be important to maintain calm, clear, and comforting communication whenever possible with our older patients.
  4. Confusion is NOT normal… it can be baseline, but it is not normal. Do not treat it as such.
    • Mom’s not usually like this” should be an alarm!
    • Assess baseline: Is the patient typically like this? Is this a change from their normal behavior? When did the change occur? Is there someone to provide information of what they are normally like?
  5. Delirium is an acute change from baseline, highlighted by altered level of awareness and inability to maintain attention. In older adults, hypoactive delirium (sleepy, withdrawn, “pleasantly confused”) is more common than hyperactive delirium (agitation and anxiety).
  6. Risk factors for delirium are:2
    • History of dementia
    • Sensory impairment (vision and hearing)
    • 65+ years in age
    • Nursing home patients
    • SERIOUS INFECTION
  7. Other exacerbating factors in the context of COVID-19:
    1. Decreased availability of caregivers to orient and provide meaningful interactions.
    2. Trouble hearing (sensory impairment) worsened by use of PPE. Older adults with sensory or cognitive limitations (dementia), will no longer be able to read lips or hear communication obscured by masks, and may become disoriented, frightened, and agitated by gowned and masked caregivers.
    3. Being placed into isolation. Closing of the exam room door, curtailing ambulation and mobility in the ED, and how the patient sees people in protective gear doing invasive tests (nasopharyngeal swabs, blood draws) is stressful for all.  For confused patients, it can only be worse.
    4. Polypharmacy and use of new anticholinergic or psychoactive medications.
  8. Identify and treat reversible causes of delirium – immobility, dehydration, fever, pain, hypoxia, nausea, constipation, psychoactive medications.
  9. Prevention is the best management for delirium. Stop it before it happens. Here are things that work: mobilize the patient, personal contact with orientation, ensure physiological needs are met (food, drink, warmth, bowel and bladder emptying). These may be hard with isolated older COVID-19 patients, but will be easier than managing agitated delirium once it develops.
  10. Use of antipsychotics for management of delirium is NOT supported as best practice.3 These medications may worsen delirium. If severe agitation develops, then use reduced doses of antipsychotics:  Risperidone ≤1mg PO, Olanzapine 2.5-5mg PO, Quetiapine 25-50mg PO, Olanzapine 2.5-5mg IM, Haloperidol 1-2.5mg IM/0.25-1mg IV.

References

  1. Kiely DK, Marcantonio ER, Inouye SK, et al. Persistent delirium predicts greater mortality. J Am Geriatr Soc. 2009;57(1):55-61.
  2. Lindroth H, Bratzke L, Purvis S, et al. Systematic Review of Prediction Models for Delirium in the Older Adult Inpatient. BMJ Open. 2018;8(4):e019223.
  3. Neufeld KJ, Yue J, Robinson TN, Inouye SK, Needham DM. Antipsychotic Medication for Prevention and Treamtent of Delirium in Hospitalized Adults: A Systematic Review and Meta-Analysis. J Am Geriatr Soc. 2016;64(4):705-714.

For author affiliations and disclaimers, please see: GEDC website: https://gedcollaborative.com/disclaimer-copyright/, HELP website: https://www.hospitalelderlifeprogram.org/

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