Department of Emergency Medicine, Massachusetts General Hospital, Boston.
Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts.
JAMA Netw Open. 2020 Nov 2;3(11):e2029540. doi: 10.1001/jamanetworkopen.2020.29540.
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.
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.
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).
The primary outcome was delirium as identified from the medical record according to a validated record review approach.
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).
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.
急诊科（ED）的老年患者中常见谵妄，与高发病率和死亡率相关，且常被忽视。有传闻证据描述了 COVID-19 中老年人的非典型表现；然而，感染 COVID-19 的老年 ED 患者谵妄的频率及其相关的住院结局尚未得到很好的描述。
确定患有 COVID-19 的老年患者出现谵妄到 ED 的频率及其相关的住院结局。
设计、地点和参与者：这是一项在美国 7 个地点进行的多中心队列研究。参与者包括 2020 年 3 月 13 日或之后因 COVID-19 到 ED 就诊的连续老年患者。
通过对严重急性呼吸综合征冠状病毒 2 的鼻拭子进行阳性检测（99%的病例）或经典影像学发现（1%的病例）来诊断 COVID-19。
主要结局是根据经验证的病历回顾方法从病历中确定的谵妄。
共纳入 817 例 COVID-19 老年患者，其中 386 例（47%）为男性，493 例（62%）为白人，215 例（27%）为黑人，54 例（7%）为西班牙裔或拉丁裔。患者的平均（SD）年龄为 77.7（8.2）岁。在纳入的患者中，226 例（28%）在就诊时存在谵妄，谵妄是所有就诊症状和体征中第六常见的症状。在有谵妄的患者中，37 例（16%）以谵妄为主要症状，84 例（37%）没有典型的 COVID-19 症状或体征，如发热或呼吸急促。谵妄的相关因素包括年龄大于 75 岁（调整后的相对风险 [aRR]，1.51；95%CI，1.17-1.95）、居住在疗养院或辅助生活设施（aRR，1.23；95%CI，0.98-1.55）、之前使用精神活性药物（aRR，1.42；95%CI，1.11-1.81）、视力障碍（aRR，1.98；95%CI，1.54-2.54）、听力障碍（aRR，1.10；95%CI 0.78-1.55）、中风（aRR，1.47；95%CI，1.15-1.88）和帕金森病（aRR，1.88；95%CI，1.30-2.58）。谵妄与入住重症监护病房（aRR，1.67；95%CI，1.30-2.15）和死亡（aRR，1.24；95%CI，1.00-1.55）相关。
在这项对 817 例因 COVID-19 到美国急诊科就诊的老年患者进行的队列研究中，谵妄很常见，且通常在没有其他典型症状或体征的情况下出现。此外，谵妄与不良的住院结局和死亡相关。这些发现表明，在指导筛查、检测和评估的 COVID-19 出现症状和体征的检查表中列入谵妄具有重要的临床意义。
