Analysis: research has found that many frail older Covid-19 patients had delirium as the only presenting symptom of the virus
By Mary Ní Lochlainn, St Thomas' Hospital London
The Covid-19 pandemic has been raging now for nine months, and we are learning more about how this virus affects our bodies. It has been well publicised that older people and those with existing medical conditions are at a higher risk of dying from the disease, and of having a more severe illness. In Ireland, care homes were particularly hard hit, which typically have a population made up of frail older adults.
Those of us who work in Geriatric Medicine know that older people can often present in more atypical ways when they are sick. For example, they may have a pneumonia, but not have any fever or cough. Older people with an infection can sometimes present with new or worsening confusion, known as delirium. People who have dementia can also develop delirium, with a worsening in their confusion, or change in their behaviour. Sometimes, they may just become more sleepy than usual.
When the pandemic started, we were on high alert for unusual presentations of the virus in our older population. In order to research this, we used two different approaches. We looked at people hospitalised with Covid, and we also looked at people in the community who used the Covid Symptom Study mobile app and reported testing positive. Crucially, we found that the frail older adults were more likely to develop delirium with Covid than those who were fit and non-frail.
From RTÉ Radio 1's Drivetime, a 2019 study in Cork University Hospital found that no less than 20% of patients were presenting signs of delirium
Importantly, in the hospitalised group, almost 1 in 5 had delirium as the only presenting symptom of Covid. Our research led to the UK government changing their guidance to include delirium/confusion as an important symptom of COVID, advising that anyone experiencing this is tested as soon as possible. The Irish government advice does not list confusion, which may lead to this being missed in Ireland.
Previous studies carried out before the pandemic have shown that delirium is often under-recognised in older hospital patients. Now, with less patient contact and masks and other PPE being worn at all times, it is worrying that we may well be missing delirium in older patients even more than before. While we found delirium in 38% of frail older adults, it might have been even higher.
Populations worldwide are ageing, including in Ireland. Many older adults are fit and well, and we certainly do not want to contribute to some of the ageist attitudes that have become prevalent during this pandemic. However, we do know from the Irish Longitudinal Study on Ageing (TILDA) that 45% of people over 65 are either frail or pre-frail. It is important that these people and their loved ones, as well as staff who are working in care homes around the country, are aware that new confusion may be an early warning sign of Covid infection.
From RTÉ Radio 1's Morning Ireland, Dr Mark Ward from the Irish Longitudinal Study on how loneliness has increased in older people and how it can impact on mental and physical wellbeing.
When looking in more detail at the symptoms reported by older, frailer individuals, we found that they were more likely to have such symptoms as severe fatigue, skipped meals, low temperature, diarrhoea and abdominal pain. Many did not have the typical reported symptoms of fever, cough and/or shortness of breath. The key message here is to consider Covid testing in frail older adults, who become confused or unwell, even if they don't have any of the typical symptoms.
So how does COVID cause delirium? We don’t know for sure as we are only beginning to learn how Covid can affect the brain in many ways. Many researchers, myself included, believe delirium is a complex process, with many factors contributing. Examples include low oxygen levels, deranged electrolytes, low blood sugar, inflammation, and the body’s 'stress response’ when unwell. More research is needed to work out the details and look at ways of preventing and treating this condition.
Is there anything we can do to prevent this happening? Exercise and high-quality nutrition are crucial for preventing frailty. 'Training your brain' and reducing stress can be helpful for attention and memory function, which may be protective. Maintaining hydration, keeping bowels moving regularly, and a good social network are also ways in which you can potentially reduce the risk of delirium. Unfortunately loneliness is an issue for older people, and this has been heighted by the restrictions in this pandemic. There is hope to found in the many initiatives around the country trying to tackle this, including a new An Post campaign with free postage to and from all nursing and care homes in Ireland.
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From RTÉ News, RTÉ Midlands Correspondent Ciaran Mullooly hears from 107 year old Nancy Stewart
Nancy Stewart is Ireland's oldest citizen and sent a message of hope and resilience to the country on her 107th birthday which occured during the pademic. While this research may seem like a lot of doom and gloom, it is important to note that many frail older adults have fully recovered from Covid-19. Our understanding of the virus is ever increasing, and our treatments are improving. Knowledge is power, and being aware of these atypical symptoms of Covid may be the important difference for you or your loved one in this pandemic.
Dr Mary Ní Lochlainn is a Doctoral Fellow and Specialist Registrar in Geriatric Medicine at St Thomas' Hospital, London
The views expressed here are those of the author and do not represent or reflect the views of RTÉ
