Please note that all session and slide content are the views of the Speakers, not the Dementia Academy. The content of the recording is the speaker’s personal opinion at the time of recording. Due to the everchanging situation, advice given at the time of recording is subject to change.

Speakers

Chair: Prof Iracema Leroi, Associate Professor in geriatric psychiatry, Trinity College Dublin

Dr Clara Domínguez Vivero, Atlantic Fellow, GBHI Trinity College Dublin

Dr Joseph Kane, Psychiatrist (SpR) and Academic Clinical Lecturer, Queen’s University Belfast

Dr Yaohua Chen, Neurogeriatrician, Lille, France

Summary

What proportion of people have been infected by COVID-19? (2:44)

Joe noted that we have more evidence than a few weeks ago but not as much as we would like. 

Estimates of mortality rate range from 0.1-15% – what proportion of COVID-19 deaths have been in those with dementia? (5:25)

Joe shared that the majority of data out of China so far has related mostly to younger patients and to in-patients which isn’t fully representative. We have now seen data regarding the community and care homes, which has been startling.

  • During March-April, nearly 4 times the number of people who died in hospitals died in care homes – with over 12,000 care home deaths. The most commonly recorded comorbidity is dementia, in 25% of cases.
  • To understand how many deaths are likely due to coronavirus, we need to look at the number of excess deaths.
  • We know that between 50-80% of people in care homes have dementia, meaning the number of those deaths affecting people with dementia must be higher than average. 
  • This representation is echoed in France as well. 

What is the degree of risk conferring with coronavirus? And of Alzheimer’s disease and ApoE 4 itself? (8:42)

Joe noted that initial data was related to hospital in-patients and seemed that dementia was a low comorbidity for COVID-19. However, data on this has developed considerably, with huge sample sizes. 

  • In a study of 16,000 people across the UK, the data indicates that dementia is the single biggest (3-fold) risk in COVID-19 and that women may have an even higher risk. 
  • We cannot know what direct and indirect factors are influencing this, but it is becoming a definite area of concern.
  • Regarding Alzheimer’s, in a study looking at 600 individuals with COVID-19, those with ApoE 4 were twice as likely to be admitted to hospital, and at higher risk of severity, than those with ApoE 3.

Why are mortality rates so high in care facilities and what measures are being put into place to reduce them? (13:11)

There are a large number of factors contributing to mortality in nursing home populations. There will need to be a multifactorial approach tailored to individuals. 

Some factors include:

  • In-patient population – older, frailer and have a higher number of comorbidities
  • In the early pandemic, we changed the way services were delivered, meaning a higher amount of advance care planning and palliative care delivered in the care homes themselves (some patients who would previously have been transferred to hospitals may not have been)
  • The way we have looked at the COVID-19 infection has evolved and we are more aware of other symptoms now
  • PPE has been a massive concern in UK as have the mechanism of discharge from hospitals into nursing homes
  • Care home workers may have been working in multiple homes (such as was the case in Washington State).

Measures in place might include:

  • Widespread adoption of video chats and consultations
  • Restriction of communal areas
  • Routine regular testing but the swab is not pleasant and repeated testing could pose problems

Is there a higher incidence of delirium with COVID-19? (18:35)

  • Clara shared that we would expect numbers to be higher:
    • The disease attacks the elderly who are more prone to delirium
    • Infections in general can lead to delirium symptoms
    • Delirium has been occurring in non-COVID-19 hospital in-patients during the pandemic
  • Papers pertaining to this demonstrate surprisingly low numbers, however. Under-reporting delirium is common, however, with a study citing that 75% of delirium cases will be missed if we are not screening for them.

Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China

Helms J, Kremer S, Merdji H, et al. Neurologic Features in Severe SARS-CoV-2 Infection

Clara’s extended answer

In a normal context, up to 50% to 70% of critically ill patients, and 10% to 15% of hospitalized general medical patients, develop delirium. We could expect the numbers to be higher in this situation, due to the drastic environmental modifications, extreme isolation during hospitalization and use of personal protective equipment (PPE).

Covid 19 characteristically causes respiratory disease and we know elderly are more vulnerable. Delirium incidence increases with age and is a common complication with pneumonia, so we could expect numbers to rise just due to COVID19 infection. However, there is also a surge in delirium incidence and duration in hospitalized patients regardless of COVID 19 status, due to the particular restrictions imposed by social isolation measures, that make it more difficult to implement delirium prevention strategies.

We have already several papers reporting incident delirium numbers. In an early retrospective report from Wuhan, Mao et al report of 214 COVID-19 patients, 36.4% were found to have neurologic manifestations at presentation, and from those only 7.5% had specifically any chart documentation of “impaired consciousness,” which was the only term approximating delirium. A report of 99 COVID-19 patients, 9% of patients presented with confusion on admission likely to be related to hypoxia or multiorgan damage instead of being a primary manifestation. Other early studies, like Helms et al. indicate that 20–30% of COVID-19 patients will present with or develop delirium or mental status changes during the course of their hospitalization, with rates of 60–70% in cases of severe illness at all ages.

We have to take under consideration that underreporting of delirium is extremely common in retrospective chart reviews, and the studies that show an incidence under 10% are likely a gross underestimation. The literature is very consistent that ~75% of occurrences of delirium are missed in patients unless objective delirium monitoring is being employed to detect it. Extreme circumstances are probably preventing screening from happening in many health settings.  

On top of the higher incidence of delirium during COVID 19 pandemic we need to consider that the typical behaviors observed in delirious patients pose now more than ever a high risk of disease exposure to health care personnel, such as self-removal of surgical masks during transport, grabbing the personal protective equipment (PPE) of bedside providers, and attempts to leave areas of containment that separate COVID-19 positive patients from uninfected individuals. The effective prevention and treatment of delirium in such patients has emerged as a significant challenge as the local health care system has been strained by the need to rapidly reallocate efforts and absorb the workload of health care providers who become sick or quarantined.

Why can we expect delirium rates to be higher at present? (23:32)

Clara explained that the virus can invade the central nervous system  but it seems to happen quite late in the virus. 

  • When a virus affects this, it will not only cause delirium but seizures and other symptoms. 
  • Environmental factors are also all having a role here, with isolation, a lack of personal interaction due to PPE, no family members and a confusing situation all of which could be delirium inducing.

Kotfis K, Williams Roberson S, Wilson JE, Dabrowski W, Pun BT, Ely EW. COVID-19: ICU delirium management during SARS-CoV-2 pandemic

Clara’s extended answer

In patients with COVID-19, delirium may be a manifestation of:

  1. Direct central nervous system (CNS) invasion:  Sars-COV2 may invade the CNS via ACE receptors but as it has happened with other closely related viruses from the coronaviridae family, direct CNS invasion appears to occur rarely and late. It can manifest as seizures, impairments in consciousness or signs of increased intracranial pressure. Such symptoms may require specialized neuro-intensivist management.
  2. Induction of CNS inflammatory mediators: Inflammatory response of the CNS to viral infection seems to be another important reason for occurrence of delirium. Immunologic responses to coronaviridae is mainly mediated by acute cytolytic T cell activation that if dysregulated, could cause an autoimmune encephalopathy. There is also a role for neutrophils and monocytes infiltration of the CNS, that disrupt BBB permeability and could lead to neuronal edema. This infiltration occurs in a matter of hours.
  3. A secondary effect of other organ system failure: Secondary effects include cerebral hypoxia or metabolic dysregulation in association with failure of pulmonary or other organ systems, such as can be seen in a variety of other types of delirium. Hyponatremia, for example, has been reported in many cases of COVID 19 and may be a leading cause of confusion and delirium.
  4. An effect of sedative strategies, prolonged mechanical ventilation time, or environmental factors, including social isolation:  Environmental and iatrogenic factors such as prolonged mechanical ventilation, sedatives (especially benzodiazepines), and immobility also contribute heavily to the risk of ICU delirium.  The use of personal protective equipment by hospital staff can be depersonalising and frightening to older adults, particularly those with underlying dementia or cognitive impairment. Visits are restricted and contact with health workers are very limited. This means that patients spend most of the time alone and communication is very limited. Normal preventive strategies as mobilization or engagement in activities does not happen anymore. Thus, the current approach has resulted in intense social isolation. The inability to prevent delirium in the normal way has increased use of both physical and chemical restraints for management of fear, agitation, and wandering, all of which may increase risk for development of delirium, exacerbate and prolong the duration of delirium, and lead to poor outcomes and accelerated mortality.

Good management approach to delirium at present (27:04)

Clara shared that delirium is avoidable; we can decrease incidence by 30-40%.

  • There is COVID-19-adapted NICE guidance and adapted guidance from the BGS for delirium during the COVID-19 pandemic. 
  • We should aim to address this during the COVID-19 pandemic. The more delirium we can avoid, the less time patients will spend in their beds, whether hospital, ICU or care home.
  • Ways to address this include:
    • Screening for delirium (WHO recommends this) especially with dementia patients
    • Many patients do not get fever and 40% of chest x-rays are normal yet delirium in the elderly is common so this should be a red flag.
    • Delirium prevention – tools such as the ABCDEF which assesses pain in patients in prone positions, and assesses neuropathy. 
    • Check daily for delirium, limit the use of CNS-active medications, 
    • Encourage early mobility and provide visual and hearing aids quickly, and a means of connecting with family members.
    • Pharmacological measures where necessary but use environmental measures as far as possible.
    • Avoid sleep deprivation and enable established sleep cycles, by managing lighting and such.

Kotfis K, Williams Roberson S, Wilson JE, Dabrowski W, Pun BT, Ely EW. COVID-19: ICU delirium management during SARS-CoV-2 pandemic

Clara’s extended answer

Delirium is not inevitable; rather, it is preventable in approximately 30% to 40% of cases. 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. Millions of people are at risk for delirium as a complementary and exacerbating factor of COVID-19. Even from a resource allocation point of view doubling down on established protocols and guidelines for delirium prevention and management will help with ventilator and hospital bed shortage.

First things first, even in an overwhelming environment, we should not stop screening for delirium. This will be essential to know its real incidence and also to tackle it from the first stages. The current assessment for COVID-19 does not routinely include delirium or mental status changes for older adults. While guidance on suspected COVID-19 cases from the World Health Organization cautions about ‘atypical symptoms’ in older people, and cites possible ‘altered mental status’, it does not explicitly mention delirium. Importantly, many national guidelines do not include mental status changes as part of their criteria. For instance, guidance from the US Centers for Disease Control and Prevention does not consider mental status or delirium at all, nor do the case definitions from Public Health England.

More importantly, delirium is considered the ‘barometer’ or ‘vital sign’ for severe illness in older adults. In the case of COVID-19, older adults often do not mount the typical febrile response, and many do not manifest dyspnoea even in the face of hypoxia. In total, 40% of all cases have no radiographic abnormalities on presentation. Thus, the risk of overlooking potential COVID-19 infections is high. Delirium may be regarded as an early symptom of infection and a red flag for COVID 19 in elderly patients. Therefore, delirium should be actively screened for using dedicated psychometric tools, i.e.,CAM-ICU  or ICDSC. It is also plausible that delirium severity, which could be measured with CAM-ICU-7 or DRS-R-98, may be associated with COVID-19 severity.

The rate of delirium in intubated patients is normally 75% but can be reduced dramatically to 50% using a lighter sedation and mobilization via the implementation of the safety bundle called the ABC-DEFs promoted by the Society of Critical Care Medicine (SCCM) in their ICU Liberation Collaborative.

There are 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.

  1. Assessment of pain: assess periodically, particularly in prone position and consider neuropathy as a possible complication of covid.
  2. Stop sedation and ventilation daily. Not possible in case of pronation, but in that case should reduce intensity of sedation.
  3. Adjust sedation to ventilation needs
  4. Delirium: check regularly, help with orientation, provide glasses and hearing aids, limit CNS active medications
  5. Early mobility: adapt rehabilitation
  6. Provide visual and hearing contact with family.

Implementation of policies that prevent visitors from coming into the hospital should be followed by additional efforts to support patient-family interaction. This must include dedicated time and effort for phone and video conversations during busy ICU time. Caregivers, even if family members or friends, are essential healthcare workers because they can prevent these poor clinical outcomes. Two of the most complete Works 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.

Moreover, hospital management should provide all possible novel technological options for communication, including teleconferences or portable speakerphones. Many hospitals are permitting a 1:1 caregiver or family member to be with the patient, particularly those with dementia or cognitive impairment. This can be critical to assist with management of fear and anxiety, and with instituting effective non-pharmacological approaches for delirium prevention and management.

The Hospital Elder Life Program has developed a Toolkit to provide delirium prevention strategies for patients in COVID-19 isolation. Both inside and outside the intensive care unit, in acute and long term care, slowing down for just a moment to provide comforting reassurance and to hold someone’s hand may provide the humanistic touch needed to prevent fear and agitation.

Regarding pharmacological interventions, the main message we need to convey is that the rule of avoiding overuse of potent psychoactive agents like sedatives and neuromuscular blockers (NMB) unless patients absolutely require such management still applies. We need to mention specifically the situation in which patients find themselves in a prone position to help with their breathing, which will be uncomfortable and require higher than usual amounts of sedation. It is also important to review previous medications to avoid withdrawal symptoms. On the other hand, the case report from Sanders et al. found that in many cases where medication is required to manage dangerous behaviors in patients with COVID-19, starting with the lowest common dose of a given antipsychotic has proven ineffective in rapidly controlling symptoms. The usual “low and slow” strategy of medication titration does not account for a pandemic scenario. When an antipsychotic medication is indicated, we suggest that providers consider foregoing the lowest common dose and instead start with the next incrementally higher dose (e.g. haloperidol 1mg instead of 0.5mg, olanzapine 5mg instead of 2.5mg, etc.). The authors insist, however, that due to the significant risk of harm associated with these medications, they do not recommend initiating early “prophylactic” dosing, nor do we endorse increasing antipsychotic doses indiscriminately if the first dose proves ineffective. The goal of this strategy is to more frequently ensure the safety of all parties on the initial attempt with a proportionality that matches the situation.

Finally, on sleep deprivation, we know it is a modifiable risk factor but also a consequence of delirium itself. There is a brief comment published regarding the use of Melatonin or Melatonin Receptor Agonists (MRA) that has been robustly associated with a shortened Intensive Care Unit (ICU) stay, reduced prevalence of delirium and improved sleep quality. Given its safety, Melatonin should be considered a firsteline agent to address sleepewake rhythm and consciousness disturbances to minimize administration of molecules that can worsen delirium in the elderly or central respiratory depression such as benzodiazepines or antipsychotics. It is noteworthy that, based on its anti-inflammatory, antioxidative and immune-enhancing features, a putative effect of melatonin in alleviating infection-induced acute respiratory distress has also been proposed.

What neuropsychiatric complications have been reported in relation to COVID-19? (35:00)

Yaohua highlighted that we should separate symptoms in acute and recovery phases.

  • Acute phases from data in Wuhan show that up to 36% of COVID-19 patients presented with neurological symptoms and this could be higher prevalence in higher severity patients, with a French study suggesting up to 80% of patients presented with neurological symptoms like confusion and delirium.
  • At the virtual EAN Congress, results from an online survey were presented looking at neurological symptoms observed in COVID-19 patients. Headache and impaired consciousness were both highly reported. 
  • These registries are occurring around the world. In the UK, the most common neurological manifestations reported were ischaemic stroke, then encephalitis and meningitis

Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China

Rogers et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic

What about specific cognitive impairment in dementia patients? (41:23)

Yaohua noted that there is less data regarding specific neurological presentations in dementia patients with COVID-19 – I only found 2 case reports!

  • Both cases exhibited diarrhea, dysphasia and agitation but no fever. The diagnosis was hard to make in these cases; one case was only diagnosed post-mortem.
  • In Italy, 13% of people with COVID-19 also had dementia and these patients had a higher hypoactive presentation and delirium, less commonly fever and cough.

Bianchetti, A., Rozzini, R., Guerini, F. et al. Clinical Presentation of COVID19 in Dementia Patients. (2020)

Is there any evidence that progression of dementia worsens following COVID-19? (44:07)

Yaohua highlighted that there are a lot of environmental factors which may be causing neuropsychiatric symptoms in the general population as well as those with dementia, including depression, anxiety and agitation. 

  • A small sample assessing neuropsychiatric symptoms before lockdown and 5 weeks afterwards, and they found that in patients with MCI or dementia, their symptoms worsened after lockdown, regarding agitation and apathy. Carers reported worsened health overall. 

Brooks et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence (Feb 2020)

Wang et al. Dementia care during COVID-19 (March 2020)

There is anecdotal evidence in care homes that BPSD has reduced in the long term care settings during lockdown. What are your thoughts? (46:30)

Joe shared that whilst there is little data, there has been anecdotal evidence from care home staff that this is the case. 

  • If I hear of a decrease in BPSD, you have to consider hypoactive delirium. Patients are in their beds more often, are less engaged in getting up and walking than they were – this has to suggest hypoactive delirium.
  • In the majority of cases where delirium is being detected (and we have heard from Clara how under-detected it is) it is hypoactive, rather than hyperactive.
  • It is not impossible that some side-effects of the lockdown could produce positive results. 
    • The volume of activity in care homes can be overwhelming, and for some, where it is quieter and there are less professionals coming and going, there has been an opportunity for more therapeutic time spent together, and more quieter care. 
    • Without having access to communal areas, we know staff are trying to spend one-to-one time with each resident and this could also be a positive thing.

We are hearing differing reports about antipsychotic drug use and COVID-19 (51:20)

Joe shared that propiomazine is an atypical antipsychotic, but that one care space found they had 14% COVID-19 rate in staff versus 4% in patients.

  • They wondered if this might be due to the patients being treated with propiomazine, prompting research into this. However, this has common, unpleasant and difficult to treat side-effects so we need to be mindful of that and watch for the evidence to emerge.
  • A recent study in China found that a third of patients treated with antipsychotics in ICUs are discharged with those dosages still in place, which is alarming and can be very harmful. 
  • Checking patient prescriptions to ensure they are not being prescribed harmful medications. They have their place, but they should be avoided unless absolutely necessary.

Care partners experiencing loneliness and isolation at home. This has an impact on physical and mental health, incidence of dementia and more. (56:16)

The launch of the global loneliness and isolation survey, a section of which will identify if respondents are carers of someone with dementia. Please do get in touch to pass on this survey if you would like to – just pop ‘survey’ in the chat box online.

Joe’s slides

Chen-slides-webinar-evidence-update-COVID-May-2020

Clara’s slides

Dominguez-Vivero-slides-webinar-evidence-update-COVID-May-2020_compressed

Yaohua’s slides

Kane-slides-webinar-evidence-update-COVID-May-2020

Resources

Our Dementia COVID-19 webinars are available on SoundCloud:
soundcloud.com/neurologyacademy

Neurology Academy · Alzheimer’s disease & dementia – An evidence update for COVID-19

→ More webinars

  

Posted in:

Subscribe
Notify of
guest
0 Comments
Inline Feedbacks
View all comments