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Case Report

Mild COVID-19 Disease Course With Protracted Delirium in a Cognitively Impaired Patient Over the Age of 85 Years

Case Report Header

Mild COVID-19 Disease Course With Protracted Delirium in a Cognitively Impaired Patient Over the Age of 85 Years

The coronavirus disease 2019 (COVID-19) pandemic has swept across the world, causing a staggering number of deaths, particularly among older individuals.1 The most common symptoms of COVID-19 are fever, dry cough, and shortness of breath, but delirium has been reported in older adults,2 including those with preexisting neurodegenerative disorders.3 Some researchers4 have suggested that the occurrence of delirium has been underreported and that such inattention may be costly for older adults. Indeed, given that changes in cognition and attention (eg, delirium) are not listed as a prominent COVID-19 symptom by the Centers for Disease Control and Prevention (CDC), older patients with COVID-19 who present with such symptoms but without fever and respiratory distress may experience delays in treatment and may unintentionally expose others. Here, we present the clinical course of a patient >85 years with moderate dementia, multiple comorbidities, and COVID-19 that is characterized by prolonged delirium.

Case Report

The patient presented at home with a low-grade temperature that was below the CDC definition for fever. The patient experienced cough, confusion, and functional decline but was not screened for severe acute respiratory syndrome coronavirus 2 until 1 week later when the patient’s primary care provider sought to rule out COVID-19. After testing positive for the virus, the patient was admitted to a COVID-19 unit for observation, primarily due to the patient’s advanced age and delirium-related functional decline at home. At admission, the patient’s vital signs were stable, and a laboratory panel was essentially normal except for abnormally elevated brain natriuretic peptide (Table 1). Four days later, the patient’s hyponatremia and monocytosis persisted and the C-reactive protein level was significantly elevated. Unfortunately, given that the patient presented in the early phase of the pandemic, the remaining COVID-19 laboratory panel tests were not obtained (eg, D-dimer and interleukin-6).

Table 1

Click figure to enlarge

The patient’s predominant and persistent symptom continued to be delirium, but the patient did not experience other COVID-19 signs or symptoms. Twenty-two days later, after testing COVID-19 negative, the patient continued to be delirious but was considered sufficiently stable to be discharged to a skilled nursing facility. During a follow-up telephone visit more than 3 months after the initial positive test, delirium persisted, and the patient had not returned to baseline cognitive or functional status. The majority of the clinical information provided here was obtained via chart review and telephone calls, given the restrictions placed on in-person clinical research visits during the COVID-19 pandemic.

Discussion

This case highlights the variability of symptom presentation in COVID-19 in patients of advanced age and offers additional evidence that altered mental status should be considered a cardinal symptom of COVID-19 in such individuals.5 Although delirium is known to be associated with respiratory viral infections in older individuals, the persistence of delirium over 3 months is unusual. Protracted delirium is typically associated with postcardiac operative states6 and not with viral infections. Additional prospective studies are necessary to better understand the range of symptoms and delirium in COVID-19 in older adults.

Received: June 19, 2020.

Published online: August 6, 2020.

Potential conflicts of interest: None

Funding/support: This report is based on work supported by a pilot project sponsored by the VA Puget Sound Research and Development Program, Seattle, Washington.

Role of the sponsor: The supporters had no role in the design, analysis, interpretation, or publication of this report.

Previous presentation: This case report is adapted from a poster presented at the virtual Alzheimer’s Association International Conference, July 29, 2020.

Patient consent: The patient and the patient’s legally authorized representative provided consent for information to appear in publication. Information has been de-identified to protect anonymity.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

REFERENCES

1.Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72,314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020;323(13):1239. PubMed CrossRef

2.Lovell N, Maddocks M, Etkind SN, et al. Characteristics, symptom management and outcomes of 101 patients with COVID-19 referred for hospital palliative care. J Pain Symptom Manage. 2020;60(1):e77-e81. PubMed CrossRef

3.Isaia G, Marinello R, Tibaldi V, et al. Atypical presentation of COVID-19 in an older adult with severe Alzheimer disease [published online ahead of print April 22, 2020]. Am J Geriatr Psychiatry. PubMed CrossRef

4.O’ Hanlon S, Inouye SK. Delirium: a missing piece in the COVID-19 pandemic puzzle [published online ahead of print May 6, 2020]. Age Ageing. PubMed CrossRef

5.Ward CF, Figiel GS, McDonald WM. Altered mental status as a novel initial clinical presentation for COVID-19 infection in the elderly [published online ahead of print May 15, 2020]. Am J Geriatr Psychiatry. PubMed CrossRef

6.Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367(1):30-39. PubMed CrossRef

aGeriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington

bMental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington

cDepartment of Medicine, Division of Geriatric Medicine, University of Washington, Seattle, Washington

dDepartment of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington

*Corresponding author: Debby W. Tsuang, MD, MSc, S182 GRECC, VA Puget Sound, 1660 S Columbian Way, Seattle, WA 98108 (dwt1@uw.edu).

Prim Care Companion CNS Disord 2020;22(4):20l02721

To cite: Payne S, Jankowski A, Shutes-David A, et al. Mild COVID-19 disease course with protracted delirium in a cognitively impaired patient over the age of 85 years. Prim Care Companion CNS Disord. 2020;22(4):20l02721.

To share: https://doi.org/10.4088/PCC.20l02721

© Copyright 2020 Physicians Postgraduate Press, Inc.

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