Characteristics of COVID-associated versus Other Deliria: A Retrospective Chart Review of 152 Inpatient Psychiatric Consultations in 2020

Friday, November 12, 2021

2:45 PM – 3:45 PM US Eastern Time

Background/Significance
The Coronavirus Disease 2019 (COVID) is a significant driver of morbidity and mortality worldwide, and, despite the advent of several vaccines, genetic variants and the complexities of population health management threaten to maintain it as such. Data are emerging as to the scope of neuropsychiatric manifestations and sequelae of COVID infection; in terms of severe acute manifestations, delirium appears to be highly prevalent.¹ Previous work has suggested that COVID delirium may, by virtue of its etiopathogenesis, present with stereotyped syndromes (eg, with abulia, alogia, rigidity), which may distinguish it from delirium associated with other illnesses.² Our study aims to elucidate the clinical characteristics of COVID delirium, as compared to non-COVID delirium.

Methods
We conducted an exploratory retrospective chart review using electronic health record (EHR) data from all adults who were admitted to Massachusetts General Hospital and received in-person psychiatric consultation for delirium March – May 2020, grouped by whether or not a current diagnosis of COVID was given. In each group within the cohort, we assessed variables relating to demographics; medical and psychiatric history; medication use prior to admission and in-hospital; vital signs; laboratory and imaging findings; and features of neuropsychiatric examination. Between COVID-status groups, we made multiple comparisons, including of the rates between previously described unique features of COVID delirium to determine whether these features are more common in delirious patients with COVID.

Results
Seventy-three COVID-negative delirious patients and 36 COVID-positive delirious patients were ultimately included in analysis. These groups were not significantly different in sex distribution (~60% male), median age (mid-60s), or race (mostly white). Those with COVID-delirium were more likely to have come from a skilled nursing or rehabilitation facility (p = .001); to have had a history of psychosis (p = .043) but lower medical comorbidity burden (p = .003); and to have demonstrated myoclonus, hypertonia, withdrawal, akinesia, abulia, and alogia (p < 0.05). They were also more likely to be treated with ketamine (p = .005), PO/TD alpha-adrenergic agents (p = .014), and enteral antipsychotics (p = .007).

Discussion
Confirming prior work, abulic-spectrum features were more common in COVID-delirium than in other deliria.

Conclusions
Our results may facilitate safer and more efficacious management and rehabilitation, and greater understanding of the neuropsychiatry of COVID infection.

References
1. Kennedy, M., Helfand, B. K. I., Gou, R. Y., Gartaganis, S. L., Webb, et al. (2020). Delirium in Older Patients With COVID-19 Presenting to the Emergency Department. JAMA Network Open, 3(11), e2029540.

2. Beach, S. R., Praschan, N. C., Hogan, C., Dotson, S., Merideth, F., Kontos, N., Fricchione, G. L., & Smith, F. A. (2020). Delirium in COVID-19: A case series and exploration of potential mechanisms for central nervous system involvement. Gen Hosp Psych, 65, 47–53.

Learning Objectives:

Recognize manifestations specific to COVID delirium
Identify potential risk factors that may be specific to COVID delirium
Discern how symptomatic management of delirium may be informed by COVID status

Presenting Author(s)

Noor Beckwith, MD

Fellow in CL Psychiatry
Massachusetts General Hospital
Cambridge, Massachusetts, United States

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Co-Author(s)

Julia Probert, MD

Resident Physician
Massachusetts General Hospital McLean Psychiatry
Boston, Massachusetts, United States
BR

Blake Rosenbaum, MD

Resident Psychiatrist
Massachusetts General Hospital
Boston, Massachusetts, United States
AB

Ashika Bains, MD, MSc

Attending Psychiatrist
Massachusetts General Hospital
Boston, MA, United States
SL

Stephanie London, MD

Resident psychiatrist
Massachusetts General Hospital
CAMBRIDGE, Massachusetts, United States
VA

Victoria Angelucci

Physician
Massachusetts General Hospital
Boston, Massachusetts, United States
Joshua Zollman, MD

Resident Physician
Massachusetts General Hospital
Cambridge, Massachusetts, United States
AS

Andrea Soto Ordonez, MD

Resident
Massachusetts General Hospital
Boston, Massachusetts, United States
AM

Alejandra Morfin Rodriguez, MD

Resident Physician
Massachusetts General Hospital/Mclean Hospital
Cambridge, Massachusetts, United States
HO

Henry Onyeaka

Resident Psychiatry
Massachusetts General Hospital
boston, Massachusetts, United States
NK

Nicholas Kontos, MD

Director of Fellowship in Consultation-Liaison Psychiatry, Massachusetts General Hospital
Massachusetts General Hospital
Boston, Massachusetts, United States
Felicia Smith, MD

Associate Chief of Psychiatry, MGH
MGH
Boston, MA, United States
Christopher Celano, MD, FACLP

Associate Director, Cardiac Psychiatry Research Program
Massachusetts General Hospital
Boston, Massachusetts, United States
Scott Beach, MD, FACLP

Program Director
Massachusetts General Hospital
Boston, Massachusetts, United States