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Delirium may be an early warning sign of Covid-19 infection in older adults, a new study has found. In some cases, it was the only symptom in patients who tested positive for the virus.

More than one-fourth of older patients in the study arrived at hospital emergency rooms with delirium, and 37% of these patients had no typical Covid-19 signs, such as fever or shortness or breath.

Delirium — confusion, inattention, disorientation, and other cognitive change — is a common sign of any infection in older people, whose immune systems respond differently to viral or bacterial illnesses than younger adults’. Patients hospitalized for Covid-19, especially if they need ventilators to help them breathe in intensive care units, are known to be vulnerable to delirium, a risk that research has shown can be augmented by the isolation imposed to limit coronavirus spread. 


Identifying delirium as a Covid-19 symptom in patients before they are admitted to a hospital could be important to protect others from infection. It could also be critical for their care because in general, patients with delirium from any cause are more likely to fare worse than other patients. They suffer more severe disease, they stay in the hospital longer, and they are more likely to die. If they survive, they are more likely to need care in a rehabilitation facility or a nursing home after their hospitalization. 

“Delirium is a great barometer,” said Wes Ely, a pulmonologist and critical care physician at Vanderbilt University, who was not involved in the study. “The message to get to the lay public and to the medical personnel is, if people are confused, pay attention, because right now they could have Covid.”


For their study, published Thursday in JAMA Network Open, researchers analyzed the medical records of 817 patients seen at seven hospitals in five states as the pandemic first surged in March. Their mean age was 77 years old and all were at least 65; 62% were white, 27% were Black, and 7% were Hispanic or Latino. All tested positive for SARS-CoV-2, the virus that causes Covid-19.

More than a quarter, 28%, were diagnosed with delirium, the sixth most common symptom after fever, shortness of breath, low oxygen, cough, and weakness. But more than a third of patients with delirium had none of those more typical signs of Covid-19. Delirium was their sole symptom.

“One of our main messages, especially right now, is to really try to screen everyone, older adults especially,” said Benjamin Helfand, a study co-author and an M.D.-Ph.D. candidate at the University of Massachusetts Medical School. “People coming in with even these atypical symptoms still should be screened and tested for Covid.”

In the study, patients with delirium were more likely to be over 75, live in a nursing home or assisted living facility, have taken psychoactive drugs in the past, have Parkinson’s disease, and have vision or hearing problems. 

When they came to hospital emergency departments, less than half were screened and diagnosed using a test such as the Confusion Assessment Method, a tool developed by a team including Vanderbilt’s Ely and Sharon Inouye of Harvard Medical School, who is a co-author of the current study. The remaining patients’ symptoms were compared to checklists from the Centers for Disease Control and Prevention and the World Health Organization to confirm the delirium diagnosis.

Ely thinks if more patients were assessed with some version of a delirium tool, more cases would have been detected. “If you don’t use a delirium tool, you miss about 75% of delirium,” Ely said. “There’s no question that the number they put forth is lower than the actual delirium number. It’ll be bigger than that.”

The study authors acknowledge that limitation, recognizing that most emergency departments do not routinely screen patients for delirium.

Delirium is a serious problem that Ely compares to other conditions that can also occur in Covid-19 patients.

“If you’re not breathing well, you have low oxygen. If your heart is failing, you have low blood pressure,” Ely said. “If your brain is failing, you have delirium.”

The study authors hope their work will help delirium be spotted and treated earlier.

“Adding delirium as a common presenting symptom of Covid-19 will keep important cases from being missed and allow earlier identification and management of vulnerable patients at high risk for poor outcomes,” they wrote.

  • The virus that cause covid-19 can also infect brain cells. That would probably open a window to different neurologic symptoms. Hope violence and paralysis will not be one of them. Different part of the brain are responsible for different functions, so one can only hope that covid 19 does not open the pandorox box for brain dysfunctions.

  • My then 75 year old husband was in a local nursing home after a hip fracture. He was insulin dependent diabetic, and had Alzheimer’s. But he still knew family & friends. Still participated in visits & activities. The quarantine started mid March. I talked to him several times daily & we did video calls with staff’s help at least a couple times a week. It was on a call around April 19 that I noticed an abrupt change in his mental status. He appeared drugged but wasn’t on anything to cause that. I spoke to his nurse. She got orders from a doctor for blood work. They did a covid test because of a slight elevation in temp in the middle of the night. He had no cough or shortness of breath. But was positive on April 21. For about 10 days he was confused, had lower O2 sats, poor oral intake. He then seemed to rally. We could talk on the phone. His intake was better. He was up for short periods. He was still very fatigued & had terrible pain in his hands. A new complaint. After about 10-12 days of this rally period he ran a temp again, developed a cough & shortness of breath and a chest xray showed a left pneumonia. This was accompanied by an abrupt change in mental status again. He could not recover from the pneumonia and died on June 12. We were blessed in that the facility sacrificed some PPE and let us stay the last two & a half days. I’m an RN, retired after over 40 years in the profession. I have never witnessed such a death. The pain he experienced was worse than any I’ve seen in even terminal cancer patients. The local hospice got Frank’s pain under control. But the coughing & secretions never stopped. I still visit that bedside in my sleep.

    • If you are a retired nurse, why did put your husband in a nursing home knowing there is covid 19 going around and after seeing what happened in the nursing home in WA state.

      Had you nursed him at home, he probably won’t get a covid-19 and die. That is the saddest part of it, his dead is probably avoidable if his family did not put him in a nursing with covid-19 going around and with WA nursing home as a good example. In Feb – March, cover 19 was raging and killing many people in WA nursing home.

      As as nurse, I am not sure what you are thinking in putting him in a nursing home or local hospice. If his family take time to care for him instead of putting him in nursing, he would probably be still alive.

    • Okay, he had pneumonia and coma, but you guys never thought of bringing him to the hospital and keep him in the local hospice, at a time where cover is raging in nursing home.

      First, putting him in nursing home instead of caring for him at home at a time when covid19 is rampant among nursing home in several states.

      Second, keep him in local hospice when he probably need to be in ICU.

      What a way to rush his death. Why are you grieving when you push him to death ?

  • Hi
    My Name is Sandeeph Maharaj i am from a town Called Newcastle In the Kwa zulu Natal Region… i have a Concern regarding Covid 19 from Personal Exprience… on the 7th of September 2020 My Mum showed symtoms of covid 19 which we had not wasted time and got medical treatment on the 10th her results for covid 19 came back positive while taking care of her i then started to show symtoms on the 11th and on the 14th of September 2020 i was positive for Covid 19 but with mild sysmtoms which i had major headachs then followed with no taste and smell i den quarentined for 10days but my mum had to be admitted to hostipal for oxygen which she forght for her life for 1mouth but recovered from covid 19 on the 11th of October 2020 when her swab came back negative but on da same evening she went into a coma which doctors cant understand why or what coursed it. she recovered Covid 19 and was to be discharged the coming week but on the 15th of October 2020 my mum sadly passed on… So i have a concern of every year my mum in september used to fall sick with the comon flu which she over come but this year which in september the flu turned into covid 19 which she even tought its a normal flu which we didnt take lightly but then her breading became a major problem… we took all precautions we never left our home in a hurry so what is realy going on… coz i know alot of other friends and family and have also sat with there family memebers and we have noticed the same months they have always fell sick with normal flu and over come but surprisingly this year on the same months they have gotten the flu but it turned out to be covid 19 so what exactly is going on with like to know if there us any explanations or research with valid outcomes

    Kind regards
    Sandeeph maharaj

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