To the Editor:
The coronavirus disease 2019 (COVID‐19) pandemic is an unprecedented threat to all
of us, regardless of age, nationality, or socioeconomic status. However, older patients
are especially at risk for life‐threatening respiratory, cardiovascular, and cerebral
complications.1 As the COVID‐19 pandemic continues to consume available global hospital
resources, including in the United States, delirium prevention strategies may become
an unintended casualty of scarce resource and personnel allocation.2 A significant
consequence of these realities is an anticipated surge of delirium incidence and duration
in hospitalized patients, regardless of COVID‐19 status, due to increased risk factors
and barriers to implementation of evidence‐based delirium prevention guidelines.3,
4 An increase in delirium will result in both inadvertent harm to individuals and
also exacerbation of hospital resource shortages.3, 4 Our goals are to highlight this
insidious complication and pose pragmatic recommendations for minimizing the risk
and duration of delirium in all patients during the COVID‐19 pandemic.
Even in the absence of drastic environmental modifications resulting from isolation
and personal protective equipment (PPE) shortages, up to 50% to 70% of critically
ill patients, and 10% to 15% of hospitalized general medical patients, develop delirium.3,
5 Compared with non‐delirious patients, delirious patients are more likely to consume
more hospital staff time and precious life‐support resources, stay longer, and develop
in‐hospital complications. Higher rates of delirium will also likely result in more
patients discharged to a facility and readmitted to the hospital.6 Such complications
would greatly stress an already chaotic healthcare system during the COVID‐19 pandemic.
Delirium is not inevitable; rather, it is preventable in approximately 30% to 40%
of cases.3 Unfortunately, the COVID‐19 management issues outlined in Table 1 bring
to light potential barriers to our typical nonpharmacologic prevention strategies
such as the Assess, Prevent, and Manage Pain, Both Spontaneous Awakening Trials and
Spontaneous Breathing Trials, Choice of analgesia and sedation, Delirium: Assess,
Prevent, and Manage, Early mobility and Exercise, and Family engagement and empowerment
(ABCDEF) bundle in the intensive care unit (ICU)7 or the Hospital Elder Life Program.8
These interventions target risk factors for delirium including inadequate pain management,
overuse of sedation and time on mechanical ventilation, restraints, social isolation
from loved ones, immobility, and sleep disruption.7, 8
Table 1
Reducing Delirium Burden in COVID‐19 Patients
Usual delirium care pathways to reduce delirium incidence and duration
Systematic, routine delirium screeninga
Assess and adjust medications with deleriogenic potentialb
Avoid antipsychotics unless patient is a danger to self or others
Fundamental physical needs
Assess and treat pain, nausea, constipation, and cough
Treat dehydration with oral fluids
Ensure call button and telephone are within reach after every encounter
Cognitive stimulation and caregiver support
Reorient patient with each interaction
Visitor pass for caregivers of COVID‐19–negative patients with dementia or delirium
Facilitating telephone/video chat with family
Normalize sleep/wake cycles
Provide ambient light/sunlight during day (eg, open blinds and turn on lights)
Keep the room dark and quiet at night (eg, close blinds, turn off lights and TV)
Schedule melatonin for sleep if needed
Limit room changes or tests that take place outside the room during night hours
Mobilization
Prioritize assisted mobility during meals and medication administration
Keep chair and assistive devices in room
Encourage independent safe mobility at each encounter
Minimize tethers
Remove lines, catheters, pulse oximetry, and telemetry when appropriate
Discontinue bladder and rectal catheters as soon as possible
Minimize use of physical restraints
Minimize sensory deprivation
Keep eyeglasses within reach
Provide portable amplifying devices and/or personal hearing aids
Enhanced delirium care pathways for COVID‐19–affected patients
Usual care pathways as outlined
Enhanced communication
Provide card with name/photograph (eg, “baseball card”) for patient to keep
Orient the patient to roles of each individual involved in care daily
Daily family/caregiver teleconferencing with “patient update” (tablets, iPads)
Speak slowly, in low tones with assessment for understanding
Enhanced mobilization
Instructional handouts for room and bed exercises/stretches
Physical/occupational therapists instruct physicians/nurses on patient exercises
Instruct patient on safe transferring
Enhanced considerations in intubated patientsc
Perform daily spontaneous awakening trials (SATs)
Perform daily spontaneous breathing trials (SBTs)
Avoid prolonged administration of deliriogenic medications, such as benzodiazepines
a
Routine delirium screening, a cornerstone of delirium care pathways, can be challenging
at this time, even for non‐COVID patients, due to limited resources. We still encourage
asking patients orientation questions or offering daily attention tasks, such as reciting
the days of the week backwards, during patient encounters.
b
A medication of particular importance now is hydroxychloroquine, which can cause hallucinations.
c
In the Intensive Care Unit (ICU) patients are frequently intubated on mechanical ventilation
and in shock on vasopressors. These patients experience profound isolation and barriers
to mobility and so special attention should be given to any attempt at mitigating
delirium. This is further exacerbated by the frequent need for high doses of sedation
to suppress the severe COVID‐19 cough, which acts to displace the endotracheal tube
and exacerbate droplet spread of the virus. In turn, the sedation greatly enhances
the likelihood of a prolonged delirium and so performing SATs and SBTs are of utmost
importance.
Delirium prevention programs are even more crucial in the era of COVID‐19 and cannot
be allowed to wither despite the challenges of integrating delirium prevention with
COVID‐19 care. Visitors are now prohibited for all hospitalized patients, with rare
exceptions.9 Because we know that caregivers play pivotal roles in delirium prevention
by reducing isolation, providing daytime stimulation to maintain sleep‐wake cycles,
and advocating for patient needs,10 excluding them is likely to exacerbate rates of
delirium, posttraumatic stress disorder, and depression. For this reason, we posit
that caregivers, even if family members or friends, are essential healthcare workers
because they can prevent these poor clinical outcomes.11 We believe that a designated
caregiver should be allowed to accompany a non‐COVID patient with cognitive impairment
or delirium during hospitalization, provided the caregiver passes the hospital health
screen and wears a mask.
Patients hospitalized with COVID‐19 face additional challenges (outlined in Table
1). Those who are critically ill, requiring ICU‐level care, are most at risk of developing
delirium. Those who improve may be transferred out of the ICU still delirious. Tests
often occur late at night to ensure adequate time for equipment sterilization, disrupting
sleep and causing disorientation for vulnerable patients. In addition to being isolated
from visitors, these patients also have minimal contact with staff, including nursing
and rehabilitation services, largely to preserve PPE and reduce exposure. Although
created with the intention of minimizing contagion, policies that increase isolation
and immobility for hospitalized patients, combined with acute illness, produce a high‐risk
environment for delirium.3
We propose several strategies for delirium prevention adapted during this critical
time that require minimal effort to implement and do not increase risk of exposure
to healthcare workers (Table 1). We highlight meaningful steps that can occur outside
patient rooms, as well as low‐tech ways for improving communication that is hindered
by PPE. We also propose ways to integrate technology into the workflow to reduce the
isolation felt between patients and family members. Mitigating delirium during this
chaotic time is possible with interdisciplinary teamwork and flexibility of roles.
Some might think that infection with the SARS‐CoV‐2 virus has created a new reality
in the field of healthcare that would allow us to triage delirium “off the table”
as a priority. We believe the opposite is true. A focus on delirium during the COVID‐19
pandemic is more important than ever. Millions of people are at risk for delirium
as a complementary and exacerbating factor of COVID‐19. Doubling down on established
protocols and guidelines for delirium prevention and management will help with our
ventilator and hospital bed shortage. Delirium prevention tenets are not antithetical
to the precautions needed to care for patients in a pandemic. Rather, these principles
center on the humanistic qualities that inspired many of us to enter medicine in the
first place. While faced with unprecedented social isolation, preventing delirium
in our patients is something we must all embrace.