Collaborative Delirium Prevention in the Age of COVID-19.

To the Editor:

The coronavirus disease 2019 (COVID‐19) pandemic is an unprecedented threat to all of us, regardless of age, nationality, or socioeconomic status. However, older patients are especially at risk for life‐threatening respiratory, cardiovascular, and cerebral complications.1 As the COVID‐19 pandemic continues to consume available global hospital resources, including in the United States, delirium prevention strategies may become an unintended casualty of scarce resource and personnel allocation.2 A significant consequence of these realities is an anticipated surge of delirium incidence and duration in hospitalized patients, regardless of COVID‐19 status, due to increased risk factors and barriers to implementation of evidence‐based delirium prevention guidelines.3, 4 An increase in delirium will result in both inadvertent harm to individuals and also exacerbation of hospital resource shortages.3, 4 Our goals are to highlight this insidious complication and pose pragmatic recommendations for minimizing the risk and duration of delirium in all patients during the COVID‐19 pandemic.

Even in the absence of drastic environmental modifications resulting from isolation and personal protective equipment (PPE) shortages, up to 50% to 70% of critically ill patients, and 10% to 15% of hospitalized general medical patients, develop delirium.3, 5 Compared with non‐delirious patients, delirious patients are more likely to consume more hospital staff time and precious life‐support resources, stay longer, and develop in‐hospital complications. Higher rates of delirium will also likely result in more patients discharged to a facility and readmitted to the hospital.6 Such complications would greatly stress an already chaotic healthcare system during the COVID‐19 pandemic.

Delirium is not inevitable; rather, it is preventable in approximately 30% to 40% of cases.3 Unfortunately, the COVID‐19 management issues outlined in Table 1 bring to light potential barriers to our typical nonpharmacologic prevention strategies such as the Assess, Prevent, and Manage Pain, Both Spontaneous Awakening Trials and Spontaneous Breathing Trials, Choice of analgesia and sedation, Delirium: Assess, Prevent, and Manage, Early mobility and Exercise, and Family engagement and empowerment (ABCDEF) bundle in the intensive care unit (ICU)7 or the Hospital Elder Life Program.8 These interventions target risk factors for delirium including inadequate pain management, overuse of sedation and time on mechanical ventilation, restraints, social isolation from loved ones, immobility, and sleep disruption.7, 8

Table 1

Reducing Delirium Burden in COVID‐19 Patients

Usual delirium care pathways to reduce delirium incidence and duration

Systematic, routine delirium screeninga

Assess and adjust medications with deleriogenic potentialb

Avoid antipsychotics unless patient is a danger to self or others

Fundamental physical needs

Assess and treat pain, nausea, constipation, and cough

Treat dehydration with oral fluids

Ensure call button and telephone are within reach after every encounter

Cognitive stimulation and caregiver support

Reorient patient with each interaction

Visitor pass for caregivers of COVID‐19–negative patients with dementia or delirium

Facilitating telephone/video chat with family

Normalize sleep/wake cycles

Provide ambient light/sunlight during day (eg, open blinds and turn on lights)

Keep the room dark and quiet at night (eg, close blinds, turn off lights and TV)

Schedule melatonin for sleep if needed

Limit room changes or tests that take place outside the room during night hours

Mobilization

Prioritize assisted mobility during meals and medication administration

Keep chair and assistive devices in room

Encourage independent safe mobility at each encounter

Minimize tethers

Remove lines, catheters, pulse oximetry, and telemetry when appropriate

Discontinue bladder and rectal catheters as soon as possible

Minimize use of physical restraints

Minimize sensory deprivation

Keep eyeglasses within reach

Provide portable amplifying devices and/or personal hearing aids

Enhanced delirium care pathways for COVID‐19–affected patients

Usual care pathways as outlined

Enhanced communication

Provide card with name/photograph (eg, “baseball card”) for patient to keep

Orient the patient to roles of each individual involved in care daily

Daily family/caregiver teleconferencing with “patient update” (tablets, iPads)

Speak slowly, in low tones with assessment for understanding

Enhanced mobilization

Instructional handouts for room and bed exercises/stretches

Physical/occupational therapists instruct physicians/nurses on patient exercises

Instruct patient on safe transferring

Enhanced considerations in intubated patientsc

Perform daily spontaneous awakening trials (SATs)

Perform daily spontaneous breathing trials (SBTs)

Avoid prolonged administration of deliriogenic medications, such as benzodiazepines

Routine delirium screening, a cornerstone of delirium care pathways, can be challenging at this time, even for non‐COVID patients, due to limited resources. We still encourage asking patients orientation questions or offering daily attention tasks, such as reciting the days of the week backwards, during patient encounters.

A medication of particular importance now is hydroxychloroquine, which can cause hallucinations.

In the Intensive Care Unit (ICU) patients are frequently intubated on mechanical ventilation and in shock on vasopressors. These patients experience profound isolation and barriers to mobility and so special attention should be given to any attempt at mitigating delirium. This is further exacerbated by the frequent need for high doses of sedation to suppress the severe COVID‐19 cough, which acts to displace the endotracheal tube and exacerbate droplet spread of the virus. In turn, the sedation greatly enhances the likelihood of a prolonged delirium and so performing SATs and SBTs are of utmost importance.

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. Visitors are now prohibited for all hospitalized patients, with rare exceptions.9 Because we know that caregivers play pivotal roles in delirium prevention by reducing isolation, providing daytime stimulation to maintain sleep‐wake cycles, and advocating for patient needs,10 excluding them is likely to exacerbate rates of delirium, posttraumatic stress disorder, and depression. For this reason, we posit that caregivers, even if family members or friends, are essential healthcare workers because they can prevent these poor clinical outcomes.11 We 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.

Patients hospitalized with COVID‐19 face additional challenges (outlined in Table 1). Those who are critically ill, requiring ICU‐level care, are most at risk of developing delirium. Those who improve may be transferred out of the ICU still delirious. Tests often occur late at night to ensure adequate time for equipment sterilization, disrupting sleep and causing disorientation for vulnerable patients. In addition to being isolated from visitors, these patients also have minimal contact with staff, including nursing and rehabilitation services, largely to preserve PPE and reduce exposure. Although created with the intention of minimizing contagion, policies that increase isolation and immobility for hospitalized patients, combined with acute illness, produce a high‐risk environment for delirium.3

We propose 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 (Table 1). We highlight meaningful steps that can occur outside patient rooms, as well as low‐tech ways for improving communication that is hindered by PPE. We also propose ways to integrate technology into the workflow to reduce the isolation felt between patients and family members. Mitigating delirium during this chaotic time is possible with interdisciplinary teamwork and flexibility of roles.

Some might think that infection with the SARS‐CoV‐2 virus has created a new reality in the field of healthcare that would allow us to triage delirium “off the table” as a priority. We believe the opposite is true. A focus on delirium during the COVID‐19 pandemic is more important than ever. Millions of people are at risk for delirium as a complementary and exacerbating factor of COVID‐19. Doubling down on established protocols and guidelines for delirium prevention and management will help with our ventilator and hospital bed shortage. Delirium prevention tenets are not antithetical to the precautions needed to care for patients in a pandemic. Rather, these principles center on the humanistic qualities that inspired many of us to enter medicine in the first place. While faced with unprecedented social isolation, preventing delirium in our patients is something we must all embrace.