JAMA. 2021;325(17):1779-1780. doi:10.1001/jama.2021.2211
he SARS-CoV-2 outbreak was declared a pandemic on March 11, 2020. Although COVID-19 poses a risk at all ages, adults 65 years and older are at greatest risk of severe disease, hospitalization, intensive care use, and death. Globally, persons older than 65 years comprise 9% of the population, but account for 30% to 40% of COVID-19 cases. As of March 3, 2021, the Centers for Disease Control and Prevention reported that of the 494 235 total US deaths from COVID-19, 400 228 (81%) occurred in persons older than 65 years.1
Importance of Delirium in COVID-19
During the pandemic, delirium emerged as a well-recognized complication of COVID-19, with particular importance due to its high prevalence and mortality, significance as a presenting sign that is easily missed, and preventable nature. Delirium, also referred to as acute brain failure, is a common presenting symptom of any severe illness in older adults. Given this, it is not surprising that delirium is a common accompaniment of severe COVID-19 in older adults. Recent studies have described occurrence rates of 25% to 37% in hospitalized patients not in the intensive care unit (ICU) and greater than 65% in patients in the ICU.2-4 Development of delirium in patients with COVID-19 has been associated with a poor prognosis with increased mortality, even after controlling for comorbidity and illness severity.4-6
Delirium is an important presenting symptom of infection with COVID-19 in older adults. It can be a common, if atypical, presentation and can be the only presenting symptom. A 2020 study5 found that delirium was present in 28% of 817 older adults with COVID-19 who presented to the emergency department and was the sixth most common of all presenting symptoms. Of 226 patients with delirium, 16% had delirium as their primary symptom and, importantly, 37% had no typical COVID-19 symptoms (eg, fever, cough, shortness of breath).5 However, delirium is not included in the Centers for Disease Control and Prevention case report criteria for COVID-19 and is often unrecognized by health care professionals. The first and most important step in management of delirium is its recognition. Many brief screening instruments are available. The Ultra-Brief Confusion Assessment Method provides a brief cognitive assessment and observer rating that can be completed in less than 1 minute to screen for delirium in high-risk settings for older adults, such as an emergency department, hospital, ICU, or nursing home.7
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