JAMA 2020.11.19


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.”