La confusion comme signe de COVID-19 chez la personne âgée ? Repère bibliographique.
Le présent article présente les publications en lien avec la recherche signalée dans le titre. Les repères bibliographiques comprennent :
- une phrase de recherche PubMed,
- les références intéressantes sélectionnées.
- Auteur principal : Dr MAEKER Eric
- Médecin gériatre et psychogériatre, France.
- Président de l'association Emp@thies, pour l'humanisation des soins. empathies.fr
- Premier co-auteur : MAEKER-POQUET Bérengère
- Infirmière diplômée d’État, France.
- Secrétaire de l'association Emp@thies, pour l'humanisation des soins. empathies.fr
- Correspondance : eric.maeker@gmail.com
- Les auteurs ne déclarent aucun conflit d’intérêts.
La confusion est un syndrome fréquent et sous-diagnostiqué en gériatrie. La COVID-19, maladie due au SARS-Cov-2, est apparue en fin d'année 2019. Sa présentation clinique était initialement respiratoire (toux, dyspnée), générale (hyperthermie, myalgies, frissons) et digestive (diarrhées). Depuis les études s'accordent sur un point : la confusion semble être un signe très fréquent chez les personnes âgées, et plus particulièrement si elles sont atteintes de troubles neurocognitifs. Les atteintes neurologiques centrales semblent être fréquentes.
Nous présentons ci-dessous des références qui permettent de se faire une idée plus exact de cette association entre la confusion et la COVID-19 afin d'inciter les cliniciens exerçant auprès de personnes âgées à intégrer cette présentation clinique dans le diagnostic de COVID-19.
Repères bibliographiques.
Nous présentons ci-dessous des références qui permettent de se faire une idée plus exact de cette association entre la confusion et la COVID-19 afin d'inciter les cliniciens exerçant auprès de personnes âgées à intégrer cette présentation clinique dans le diagnostic de COVID-19.
Repères bibliographiques.
Repère bibliographique
- Mots clés et recherche sur PubMed :
- “Delirium”[Mesh]
- “COVID-19”[Mesh]
- (“Aged”[Mesh] OR “Aged, 80 and over”[Mesh])
- Recherche de nouvelles publications (non incluses dans cette page)
- Recherche de toutes les publications
- . Neurologic Syndromes Predict Higher In-Hospital Mortality in COVID-19. Neurology. 2021 Mar 16;96(11):551. doi: 10.1212/WNL.0000000000011607.
[PMID: 33723028] [DOI: 10.1212/WNL.0000000000011607]
- . Acute confusional state as a prognostic sign of COVID-19 large-vessel occlusion (LVO). BMJ Case Rep. 2021 Feb 23;14(2):e240536. doi: 10.1136/bcr-2020-240536.
[PMID: 33622754] [PMCID: 7907863] [DOI: 10.1136/bcr-2020-240536]
COVID-19 is well known for its respiratory symptoms, but severe presentations can alter haemostasis, causing acute end-organ damage with poor outcomes. Among its various neurological presentations, cerebrovascular events often present as small-vessel strokes. Although uncommon, in predisposed individuals, large-vessel occlusions (LVOs) can occur as a possible consequence of direct viral action (viral burden or antigenic structure) or virus-induced cytokine storm. Subtle presentations and complicated stroke care pathways continue to exist, delaying timely care. We present a unique case of COVID-19 LVO manifesting as an acute confusional state in an elderly man in April 2020. CT angiography revealed 'de novo' occlusions of the left internal carotid artery and proximal right vertebral artery, effectively blocking anterior and posterior circulations. Delirium can lead to inaccurate stroke scale assessments and prolong initiation of COVID-19 stroke care pathways. Future studies are needed to look into the temporal relationship between confusion and neurological manifestations. - . Characteristics and outcomes of COVID-19 inpatients who underwent psychiatric consultations. Asian J Psychiatr. 2021 Mar;57:102563. doi: 10.1016/j.ajp.2021.102563. Epub 2021 Jan 28.
[PMID: 33556918] [PMCID: 7840407] [DOI: 10.1016/j.ajp.2021.102563]
Patients hospitalized with COVID-19 are at risk of developing many neuropsychiatric disorders, due to the effects of the disease on the brain and the psychosocial pressures of having the disease. The aim of the present study was to evaluate the characteristics and outcomes of patients who were hospitalized with a diagnosis of COVID-19, who underwent psychiatric consultations. The medical records of 892 patients hospitalized due to COVID-19 and the 89 among them who requested psychiatric consultations were analyzed retrospectively. After the psychiatric consultations, patients were most frequently diagnosed with delirium (38.2 %), adjustment disorder (27.0 %), depressive disorder (19.1 %) and anxiety disorder (11.2 %). Patients with delirium had longer hospital stays (p < 0.001), were transferred more frequently to intensive care units (p < 0.001), and had higher mortality rates during their hospital stays (p < 0.001), than all other patients. The need for oxygen (p < 0.001) and mechanical ventilation (p < 0.001) was also significantly higher in delirium patients, as well as in patients who received other psychiatric diagnoses. Neuropsychiatric disorders develop in patients receiving inpatient treatments in COVID-19 wards, and these disorders negatively affect the prognosis of COVID-19. Our findings suggest that the presence of neuropsychiatric disorders in in-patients with COVID-19 might be associated with the negative outcomes of the disease. - . Silent cognitive frailty at the interplay between delirium and COVID-19. Asian J Psychiatr. 2021 Mar;57:102565. doi: 10.1016/j.ajp.2021.102565. Epub 2021 Jan 23.
[PMID: 33516152] [DOI: 10.1016/j.ajp.2021.102565]
- . Correction to Lancet Respir Med 2021; published online Jan 8. https://doi.org/10.1016/S2213-2600(20)30552-X. Lancet Respir Med. 2021 Mar;9(3):e29. doi: 10.1016/S2213-2600(21)00047-3. Epub 2021 Jan 27.
[PMID: 33515501] [DOI: 10.1016/S2213-2600(21)00047-3]
- . [Delirium as the only symptom of COVID-19 pneumonia in the elderly]. Tijdschr Psychiatr. 2020;62(12):1014-1019.
[PMID: 33443753]
Early descriptions about the presentation of COVID-19 focused primarily on respiratory symptoms. However, we now know that COVID-19 can also present with one or more atypical symptom(s). With this case-report we want to draw attention to atypical presentations of COVID-19 that can occur in psychiatric practice, especially in the elderly. We report the case of an elderly woman with an atypical presentation of a COVID-19 pneumonia, namely without the often mentioned respiratory symptoms, gastrointestinal symptoms or fever, but with acute confusion. It is important to swiftly consider the possibility of a COVID-19 infection in (elderly) patients who present with delirium, as missing an infection can have important negative consequences, both for the treatment of the patient and for further spread within the (hospital) environment. - . Neurologic Syndromes Predict Higher In-Hospital Mortality in COVID-19. Neurology. 2021 Mar 16;96(11):e1527-e1538. doi: 10.1212/WNL.0000000000011356. Epub 2020 Dec 18.
[PMID: 33443111] [PMCID: 8032378] [DOI: 10.1212/WNL.0000000000011356]
Objective: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is protean in its manifestations, affecting nearly every organ system. However, nervous system involvement and its effect on disease outcome are poorly characterized. The objective of this study was to determine whether neurologic syndromes are associated with increased risk of inpatient mortality.
Methods: A total of 581 hospitalized patients with confirmed SARS-CoV-2 infection, neurologic involvement, and brain imaging were compared to hospitalized non-neurologic patients with coronavirus disease 2019 (COVID-19). Four patterns of neurologic manifestations were identified: acute stroke, new or recrudescent seizures, altered mentation with normal imaging, and neuro-COVID-19 complex. Factors present on admission were analyzed as potential predictors of in-hospital mortality, including sociodemographic variables, preexisting comorbidities, vital signs, laboratory values, and pattern of neurologic manifestations. Significant predictors were incorporated into a disease severity score. Patients with neurologic manifestations were matched with patients of the same age and disease severity to assess the risk of death.
Results: A total of 4,711 patients with confirmed SARS-CoV-2 infection were admitted to one medical system in New York City during a 6-week period. Of these, 581 (12%) had neurologic issues of sufficient concern to warrant neuroimaging. These patients were compared to 1,743 non-neurologic patients with COVID-19 matched for age and disease severity admitted during the same period. Patients with altered mentation (n = 258, p = 0.04, odds ratio [OR] 1.39, confidence interval [CI] 1.04-1.86) or radiologically confirmed stroke (n = 55, p = 0.001, OR 3.1, CI 1.65-5.92) had a higher risk of mortality than age- and severity-matched controls.
Conclusions: The incidence of altered mentation or stroke on admission predicts a modest but significantly higher risk of in-hospital mortality independent of disease severity. While other biomarker factors also predict mortality, measures to identify and treat such patients may be important in reducing overall mortality of COVID-19. - . Sedation in mechanically ventilated patients with COVID-19. Lancet Respir Med. 2021 Mar;9(3):218-219. doi: 10.1016/S2213-2600(20)30570-1. Epub 2021 Jan 8.
[PMID: 33428873] [PMCID: 7832546] [DOI: 10.1016/S2213-2600(20)30570-1]
- . Prevalence and risk factors for delirium in critically ill patients with COVID-19 (COVID-D): a multicentre cohort study. Lancet Respir Med. 2021 Mar;9(3):239-250. doi: 10.1016/S2213-2600(20)30552-X. Epub 2021 Jan 8.
[PMID: 33428871] [PMCID: 7832119] [DOI: 10.1016/S2213-2600(20)30552-X]
Background: To date, 750 000 patients with COVID-19 worldwide have required mechanical ventilation and thus are at high risk of acute brain dysfunction (coma and delirium). We aimed to investigate the prevalence of delirium and coma, and risk factors for delirium in critically ill patients with COVID-19, to aid the development of strategies to mitigate delirium and associated sequelae.
Methods: This multicentre cohort study included 69 adult intensive care units (ICUs), across 14 countries. We included all patients (aged ≥18 years) admitted to participating ICUs with severe acute respiratory syndrome coronavirus 2 infection before April 28, 2020. Patients who were moribund or had life-support measures withdrawn within 24 h of ICU admission, prisoners, patients with pre-existing mental illness, neurodegenerative disorders, congenital or acquired brain damage, hepatic coma, drug overdose, suicide attempt, or those who were blind or deaf were excluded. We collected de-identified data from electronic health records on patient demographics, delirium and coma assessments, and management strategies for a 21-day period. Additional data on ventilator support, ICU length of stay, and vital status was collected for a 28-day period. The primary outcome was to determine the prevalence of delirium and coma and to investigate any associated risk factors associated with development of delirium the next day. We also investigated predictors of number of days alive without delirium or coma. These outcomes were investigated using multivariable regression.
Findings: Between Jan 20 and April 28, 2020, 4530 patients with COVID-19 were admitted to 69 ICUs, of whom 2088 patients were included in the study cohort. The median age of patients was 64 years (IQR 54 to 71) with a median Simplified Acute Physiology Score (SAPS) II of 40·0 (30·0 to 53·0). 1397 (66·9%) of 2088 patients were invasively mechanically ventilated on the day of ICU admission and 1827 (87·5%) were invasively mechanical ventilated at some point during hospitalisation. Infusion with sedatives while on mechanical ventilation was common: 1337 (64·0%) of 2088 patients were given benzodiazepines for a median of 7·0 days (4·0 to 12·0) and 1481 (70·9%) were given propofol for a median of 7·0 days (4·0 to 11·0). Median Richmond Agitation-Sedation Scale score while on invasive mechanical ventilation was -4 (-5 to -3). 1704 (81·6%) of 2088 patients were comatose for a median of 10·0 days (6·0 to 15·0) and 1147 (54·9%) were delirious for a median of 3·0 days (2·0 to 6·0). Mechanical ventilation, use of restraints, and benzodiazepine, opioid, and vasopressor infusions, and antipsychotics were each associated with a higher risk of delirium the next day (all p≤0·04), whereas family visitation (in person or virtual) was associated with a lower risk of delirium (p<0·0001). During the 21-day study period, patients were alive without delirium or coma for a median of 5·0 days (0·0 to 14·0). At baseline, older age, higher SAPS II scores, male sex, smoking or alcohol abuse, use of vasopressors on day 1, and invasive mechanical ventilation on day 1 were independently associated with fewer days alive and free of delirium and coma (all p<0·01). 601 (28·8%) of 2088 patients died within 28 days of admission, with most of those deaths occurring in the ICU.
Interpretation: Acute brain dysfunction was highly prevalent and prolonged in critically ill patients with COVID-19. Benzodiazepine use and lack of family visitation were identified as modifiable risk factors for delirium, and thus these data present an opportunity to reduce acute brain dysfunction in patients with COVID-19.
Funding: None. TRANSLATIONS: For the French and Spanish translations of the abstract see Supplementary Materials section. - . Delirium in Patients with SARS-CoV-2 Infection: A Multicenter Study. J Am Geriatr Soc. 2020 Nov 27:10.1111/jgs.16969. doi: 10.1111/jgs.16969.
[PMID: 33411332] [PMCID: 7753490] [DOI: 10.1111/jgs.16969]
Objectives: The aims of this study are to report the prevalence of delirium on admission to the unit in patients hospitalized with SARS-CoV-2 infection, to identify the factors associated with delirium, and to evaluate the association between delirium and in-hospital mortality.
Design: Multicenter observational cohort study.
Settings: Acute medical units in four Italian hospitals.
Participants: A total of 516 patients (median age 78 years) admitted to the participating centers with SARS-CoV-2 infection from February 22 to May 17, 2020.
Measurements: Comprehensive medical assessment with detailed history, physical examinations, functional status, laboratory and imaging procedures. On admission, delirium was determined by the Diagnostic and Statistical Manual of Mental Disorders (5th edition) criteria, 4AT, m-Richmond Agitation Sedation Scale, or clinical impression depending on the site. The primary outcomes were delirium rates and in-hospital mortality.
Results: Overall, 73 (14.1%, 95% confidence interval (CI) = 11.0-17.3%) patients presented delirium on admission. Factors significantly associated with delirium were dementia (odds ratio, OR = 4.66, 95% CI = 2.03-10.69), the number of chronic diseases (OR = 1.20, 95% CI = 1.03; 1.40), and chest X-ray or CT opacity (OR = 3.29, 95% CI = 1.12-9.64 and 3.35, 95% CI = 1.07-10.47, for multiple or bilateral opacities and single opacity vs no opacity, respectively). There were 148 (33.4%) in-hospital deaths in the no-delirium group and 43 (58.9%) in the delirium group (P-value assessed using the Gray test <.001). As assessed by a multivariable Cox model, patients with delirium on admission showed an almost twofold increased hazard ratio for in-hospital mortality with respect to patients without delirium (hazard ratio = 1.88, 95% CI = 1.25-2.83).
Conclusion: Delirium is prevalent and associated with in-hospital mortality among older patients hospitalized with SARS-CoV-2 infection. - . A rapid review of the pathoetiology, presentation, and management of delirium in adults with COVID-19. J Psychosom Res. 2020 Dec 25;141:110350. doi: 10.1016/j.jpsychores.2020.110350.
[PMID: 33401078] [PMCID: 7762623] [DOI: 10.1016/j.jpsychores.2020.110350]
Background COVID-19 causes significant morbidity and mortality. Despite the high prevalence of delirium and delirium-related symptoms in COVID-19 patients, data and evidence-based recommendations on the pathophysiology and management of delirium are limited. Objective We conducted a rapid review of COVID-19-related delirium literature to provide a synthesis of literature on the prevalence, pathoetiology, and management of delirium in these patients. Methods Systematic searches of Medline, Embase, PsycInfo, LitCovid, WHO-COVID-19, and Web of Science electronic databases were conducted. Grey literature was also reviewed, including preprint servers, archives, and websites of relevant organizations. Search results were limited to the English language. We included literature focused on adults with COVID-19 and delirium. Papers were excluded if they did not mention signs or symptoms of delirium. Results 229 studies described prevalence, pathoetiology, and/or management of delirium in adults with COVID-19. Delirium was rarely assessed with validated tools. Delirium affected >50% of all patients with COVID-19 admitted to the ICU. The etiology of COVID-19 delirium is likely multifactorial, with some evidence of direct brain effect. Prevention remains the cornerstone of management in these patients. To date, there is no evidence to suggest specific pharmacological strategies. Discussion Delirium is common in COVID-19 and may manifest from both indirect and direct effects on the central nervous system. Further research is required to investigate contributing mechanisms. As there is limited empirical literature on delirium management in COVID-19, management with non-pharmacological measures and judicious use of pharmacotherapy is suggested. - . The frailty and mortality relationship in patients with COVID-19. Eur Geriatr Med. 2021 Jan 3:1-2. doi: 10.1007/s41999-020-00391-2.
[PMID: 33393061] [PMCID: 7779082] [DOI: 10.1007/s41999-020-00391-2]
- . Atypical presentations of COVID-19 in care home residents presenting to secondary care: A UK single centre study. Aging Med (Milton). 2020 Sep 17;3(4):237-244. doi: 10.1002/agm2.12126. eCollection 2020 Dec.
[PMID: 33392429] [PMCID: 7771562] [DOI: 10.1002/agm2.12126]
Background: Atypical presentations of COVID-19 pose difficulties for early isolation and treatment, particularly in institutional care settings. We aimed to characterize the presenting symptoms and associated mortality of COVID-19 in older adults, focusing on care home residents admitted to secondary care.
Methods: A retrospective cohort study of 134 consecutive inpatients over 80 years old hospitalized with PCR confirmed COVID-19 in the United Kingdom. Symptoms at presentation and frailty were analysed. Differences between community dwelling and care home residents, and associations with mortality, were assessed using between-group comparisons and logistic regression.
Results: Care home residents were less likely to experience cough (46.9% vs 72.9%, P = .002) but more likely to present with delirium (51.6% vs 31.4%, P = .018), particularly hypoactive delirium (40.6% vs 24.3%, P = .043). Mortality was more likely with increasing frailty (OR 1.25, 95% CI 1.00, 1.58, P = .049) and those presenting with anorexia (OR 3.20, 95% CI 1.21, 10.09, P = .028). There were no differences in mortality or length of stay based on residential status.
Conclusion: COVID-19 in older adults often presents with atypical symptoms, particularly in those admitted from institutional care. These individuals have a reduced incidence of cough and increased hypoactive delirium. Individuals presenting atypically, especially with anorexia, have higher mortality. - . Delirium: A Frequent Manifestation in COVID-19 Older Patients. Clin Interv Aging. 2020 Dec 1;15:2245-2247. doi: 10.2147/CIA.S280189. eCollection 2020.
[PMID: 33293801] [PMCID: 7718860] [DOI: 10.2147/CIA.S280189]
The authors report a high prevalence of delirium in COVID-19 old patients admitted in an academic hospital. During the recent COVID-19 period, delirium was present in 38% of old patients admitted with delirium at the COVID ward of the Erasmus MC University Medical Center of Rotterdam. We do not know in which patients COVID-19 can cause delirium; however, considering the high prevalence of delirium in COVID-19 old patients and the potential serious consequences, attention is needed in order to reduce disability and mortality in this vulnerable category of patients. - . Could COVID delirium bring on dementia?. Nature. 2020 Dec;588(7836):22-24. doi: 10.1038/d41586-020-03360-8.
[PMID: 33268868] [DOI: 10.1038/d41586-020-03360-8]
- . Delirium: Clinical Presentation and Outcomes in Older COVID-19 Patients. Front Psychiatry. 2020 Nov 12;11:586686. doi: 10.3389/fpsyt.2020.586686. eCollection 2020.
[PMID: 33262713] [PMCID: 7688465] [DOI: 10.3389/fpsyt.2020.586686]
The aim of the study is to describe the clinical characteristics and outcomes of a series of older patients consecutively admitted into a non-ICU ward due to SARS-CoV-2 infection (14, males 11), developing delirium. Hypokinetic delirium with lethargy and confusion was observed in 43% of cases (6/14 patients). A total of eight patients exhibited hyperkinetic delirium and 50% of these patients (4/8) died. The overall mortality rate was 71% (10/14 patients). Among the four survivors we observed two different clinical patterns: two patients exhibited dementia and no ARDS (acute respiratory distress syndrome), while the remaining two patients exhibited ARDS and no dementia. The observed different clinical patterns of delirium (hypokinetic delirium; hyperkinetic delirium with or without dementia; hyperkinetic delirium with or without ARDS) identified patients with different prognosis: we believe these observations may have an impact on the management of older subjects with delirium due to COVID-19. - . Comprensive Geriatric Assessment in hospitalized older patients with COVID-19. Geriatr Gerontol Int. 2021 Jan;21(1):118-119. doi: 10.1111/ggi.14103. Epub 2020 Dec 1.
[PMID: 33260256] [PMCID: 7753837] [DOI: 10.1111/ggi.14103]
- . Implementing Delirium Prevention in the Era of COVID-19. J Alzheimers Dis. 2021;79(1):31-36. doi: 10.3233/JAD-200696.
[PMID: 33252073] [DOI: 10.3233/JAD-200696]
Patients admitted with COVID-19 can develop delirium due to predisposing factors, isolation, and the illness itself. Standard delirium prevention methods focus on interaction and stimulation. It can be challenging to deliver these methods of care in COVID settings where it is necessary to increase patient isolation. This paper presents a typical clinical vignette of representative patients in a tertiary care hospital and how a medical team modified an evidence-based delirium prevention model to deliver high-quality care to COVID-19 patients. The implemented model focuses on four areas of delirium-prevention: Mobility, Sleep, Cognitive Stimulation, and Nutrition. Future studies will be needed to track quantitative outcome measures. - . The One-Two Punch of Delirium and Dementia During the COVID-19 Pandemic and Beyond. Front Neurol. 2020 Nov 5;11:596218. doi: 10.3389/fneur.2020.596218. eCollection 2020.
[PMID: 33224102] [PMCID: 7674550] [DOI: 10.3389/fneur.2020.596218]
- . Delirium in Older Patients With COVID-19 Presenting to the Emergency Department. JAMA Netw Open. 2020 Nov 2;3(11):e2029540. doi: 10.1001/jamanetworkopen.2020.29540.
[PMID: 33211114] [PMCID: 7677760] [DOI: 10.1001/jamanetworkopen.2020.29540]
Importance: Delirium is common among older emergency department (ED) patients, is associated with high morbidity and mortality, and frequently goes unrecognized. Anecdotal evidence has described atypical presentations of coronavirus disease 2019 (COVID-19) in older adults; however, the frequency of and outcomes associated with delirium in older ED patients with COVID-19 infection have not been well described.
Objective: To determine how frequently older adults with COVID-19 present to the ED with delirium and their associated hospital outcomes. DESIGN, SETTING, AND
Participants: This multicenter cohort study was conducted at 7 sites in the US. Participants included consecutive older adults with COVID-19 presenting to the ED on or after March 13, 2020. EXPOSURE: COVID-19 was diagnosed by positive nasal swab for severe acute respiratory syndrome coronavirus 2 (99% of cases) or classic radiological findings (1% of cases).
Main outcomes and measures: The primary outcome was delirium as identified from the medical record according to a validated record review approach.
Results: A total of 817 older patients with COVID-19 were included, of whom 386 (47%) were male, 493 (62%) were White, 215 (27%) were Black, and 54 (7%) were Hispanic or Latinx. The mean (SD) age of patients was 77.7 (8.2) years. Of included patients, 226 (28%) had delirium at presentation, and delirium was the sixth most common of all presenting symptoms and signs. Among the patients with delirium, 37 (16%) had delirium as a primary symptom and 84 (37%) had no typical COVID-19 symptoms or signs, such as fever or shortness of breath. Factors associated with delirium were age older than 75 years (adjusted relative risk [aRR], 1.51; 95% CI, 1.17-1.95), living in a nursing home or assisted living (aRR, 1.23; 95% CI, 0.98-1.55), prior use of psychoactive medication (aRR, 1.42; 95% CI, 1.11-1.81), vision impairment (aRR, 1.98; 95% CI, 1.54-2.54), hearing impairment (aRR, 1.10; 95% CI 0.78-1.55), stroke (aRR, 1.47; 95% CI, 1.15-1.88), and Parkinson disease (aRR, 1.88; 95% CI, 1.30-2.58). Delirium was associated with intensive care unit stay (aRR, 1.67; 95% CI, 1.30-2.15) and death (aRR, 1.24; 95% CI, 1.00-1.55).
Conclusions and relevance: In this cohort study of 817 older adults with COVID-19 presenting to US emergency departments, delirium was common and often was seen without other typical symptoms or signs. In addition, delirium was associated with poor hospital outcomes and death. These findings suggest the clinical importance of including delirium on checklists of presenting signs and symptoms of COVID-19 that guide screening, testing, and evaluation. - . Delirium Assessment in Critically Ill Older Adults: Considerations During the COVID-19 Pandemic. Crit Care Clin. 2021 Jan;37(1):175-190. doi: 10.1016/j.ccc.2020.08.009. Epub 2020 Aug 14.
[PMID: 33190768] [PMCID: 7427547] [DOI: 10.1016/j.ccc.2020.08.009]
Older adults are particularly vulnerable during the Coronavirus disease 2019 (COVID-19) pandemic, because higher age increases risk for both delirium and COVID-19-related death. Despite the health care system limitations and the clinical challenges of the pandemic, delirium screening and management remains an evidence-based cornerstone of critical care. This article discusses practical recommendations for delirium screening in the COVID-19 pandemic era, tips for training health care workers in delirium screening, validated tools for detecting delirium in critically ill older adults, and approaches to special populations of older adults (eg, sensory impairment, dementia, acute neurologic injury). - . The 'third wave': impending cognitive and functional decline in COVID-19 survivors. Br J Anaesth. 2020 Oct 21:S0007-0912(20)30849-7. doi: 10.1016/j.bja.2020.09.045.
[PMID: 33187638] [PMCID: 7577658] [DOI: 10.1016/j.bja.2020.09.045]
- . Low molecular weight heparin in COVID-19 patients prevents delirium and shortens hospitalization. Neurol Sci. 2021 Apr;42(4):1527-1530. doi: 10.1007/s10072-020-04887-4. Epub 2020 Nov 13.
[PMID: 33185785] [PMCID: 7664586] [DOI: 10.1007/s10072-020-04887-4]
Background: COVID-19 patients present with delirium during their hospitalization.
Aims: To assess the incidence of delirium in hospitalized COVID-19 patients and analyze the possible association with demographic, clinical, laboratory, and pharmacological factors.
Methods: COVID-19 patients were assessed for clinical signs of delirium and administered the assessment test for delirium and cognitive impairment (4AT) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scales.
Results: Out of the 56 patients of our cohort, 14 (25.0%) experienced delirium. The use of low molecular weight heparin (LMWH) (enoxaparin 1 mg/kg/daily) was less frequent in patients with delirium (p = 0.004) and was accompanied by lower C reactive protein (CRP) levels (p = 0.006).
Discussion: The use of LMWH was associated with absence of delirium, independently of comorbidities and age.
Conclusions: The use of LMWH may help preventing the occurrence of delirium in COVID-19 patients, with possible reduction of length of stay in the hospital and sequelae. - . Prevalence of delirium, depression, anxiety, and post-traumatic stress disorder among COVID-19 patients: protocol for a living systematic review. Syst Rev. 2020 Nov 6;9(1):258. doi: 10.1186/s13643-020-01507-2.
[PMID: 33158456] [PMCID: 7646715] [DOI: 10.1186/s13643-020-01507-2]
Background: Previous studies on the impact of corona virus disease 2019 (COVID-19) on the mental health of the patients has been limited by the lack of relevant data. With the rapid and sustained growth of the publications on COVID-19 research, we will perform a living systematic review (LSR) to provide comprehensive and continuously updated data to explore the prevalence of delirium, depression, anxiety, and post-traumatic stress disorder (PTSD) among COVID-19 patients.
Methods: We will perform a comprehensive search of the following databases: Cochrane Library, PubMed, Web of Science, EMBASE, and Chinese Biomedicine Literature to identify relevant studies. We will include peer-reviewed cross-sectional studies published in English and Chinese. Two reviewers will independently assess the methodological quality of included studies using the Joanna Briggs Institute Prevalence Critical Appraisal tool and perform data extraction. In the absence of clinical heterogeneity, the prevalence estimates with a 95% confidence interval (CI) of delirium, depression, anxiety, and post-traumatic stress disorder (PTSD) will be calculated by using random-effects model to minimize the effect of between-study heterogeneity separately. The literature searches will be updated every 3 months. We will perform meta-analysis if any new eligible studies or data are obtained. We will resubmit an updated review when there were relevant changes in the results, i.e., when outcomes became statistically significant (or not statistically significant anymore) or when heterogeneity became substantial (or not substantial anymore).
Discussion: This LSR will provide an in-depth and up-to-date summary of whether the common neuropsychiatric conditions observed in patients hospitalized for severe acute respiratory syndrome (SARS-CoV) and Middle East respiratory syndrome (MERS) are also prevalent in a different stage of COVID-19 patients. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020196610. - . Detecting Delirium: A Systematic Review of Identification Instruments for Non-ICU Settings. J Am Geriatr Soc. 2020 Nov 2. doi: 10.1111/jgs.16879.
[PMID: 33135780] [DOI: 10.1111/jgs.16879]
Background/objectives: Delirium manifests clinically in varying ways across settings. More than 40 instruments currently exist for characterizing the different manifestations of delirium. We evaluated all delirium identification instruments according to their psychometric properties and frequency of citation in published research.
Design: We conducted the systematic review by searching Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Excerpta Medica Database (Embase), PsycINFO, PubMed, and Web of Science from January 1, 1974, to January 31, 2020, with the keywords "delirium" and "instruments," along with their known synonyms. We selected only systematic reviews, meta-analyses, or narrative literature reviews including multiple delirium identification instruments.
Measurements: Two reviewers assessed the eligibility of articles and extracted data on all potential delirium identification instruments. Using the original publication on each instrument, the psychometric properties were examined using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) framework.
Results: Of 2,542 articles identified, 75 met eligibility criteria, yielding 30 different delirium identification instruments. A count of citations was determined using Scopus for the original publication for each instrument. Each instrument underwent methodological quality review of psychometric properties using COSMIN definitions. An expert panel categorized key domains for delirium identification based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III through DSM-5. Four instruments were notable for having at least two of three of the following: citation count of 200 or more, strong validation methodology in their original publication, and fulfillment of DSM-5 criteria. These were, alphabetically, Confusion Assessment Method, Delirium Observation Screening Scale, Delirium Rating Scale-Revised-98, and Memorial Delirium Assessment Scale.
Conclusion: Four commonly used and well-validated instruments can be recommended for clinical and research use. An important area for future investigation is to harmonize these measures to compare and combine studies on delirium. - . COVID-19 in Older Adults: A Series of 76 Patients Aged 85 Years and Older with COVID-19. J Am Geriatr Soc. 2020 Dec;68(12):2735-2743. doi: 10.1111/jgs.16894. Epub 2020 Oct 28.
[PMID: 33045106] [PMCID: 7675559] [DOI: 10.1111/jgs.16894]
Background: Clinical presentation and risk factors of death in COVID-19 in oldest adults have not been well characterized.
Objectives: To describe clinical features and outcome of COVID-19 in patients older than 85 years and study risk factors for mortality.
Design: Prospective cohort. PARTICIPANTS AND
Setting: Patients aged 85 years and older, admitted in noncritical care units at the University Hospital Lariboisière Fernand-Widal (Paris, France) for confirmed severe acute respiratory syndrome coronavirus 2 infection were included and followed up for 21 days.
Measurements: Clinical and laboratory findings were collected. Cox survival analysis was performed to explore factors associated with death.
Results: From March 14 to April 11, 2020, 76 patients (median age = 90 (86-92) years; women = 55.3%) were admitted for confirmed COVID-19. Of the patients, 64.5% presented with three or more comorbidities. Most common symptoms were asthenia (76.3%), fever (75.0%) and confusion and delirium (71.1%). An initial fall was reported in 25.0% of cases, and digestive symptoms were reported in 22.4% of cases. COVID-19 was severe in 51.3% of cases, moderate in 32.9%, and mild in 15.8%. Complications included acute respiratory syndrome (28.9%), cardiac decompensation (14.5%), and hypotensive shock (9.0%). Fatality at 21 days was 28.9%, after a median course of disease of 13 (8-17) days. Males were overrepresented in nonsurvivors (68.2%). In survivors, median length of stay was 12 (9-19.5) days. Independent predictive factors of death were C-reactive protein level at admission and lymphocyte count at nadir.
Conclusion: Specific clinical features, multiorgan injury, and high case fatality rate are observed in older adults with COVID-19. However, rapid diagnosis, appropriate care, and monitoring seem to improve prognosis. - . Acute Care of Older Patients with COVID-19: Clinical Characteristics and Outcomes. Geriatrics (Basel). 2020 Sep 27;5(4):65. doi: 10.3390/geriatrics5040065.
[PMID: 32992602] [PMCID: 7709587] [DOI: 10.3390/geriatrics5040065]
(1)
Background: COVID-19 has become a global pandemic and older patients present higher mortality rates. However, studies on the characteristics of this population set are limited. The objective of this study is to describe clinical characteristics and outcomes of older patients hospitalized with COVID-19. (2)
Methods: This retrospective cohort study was conducted from March to May 2020 and took place in three acute geriatric wards in France. Older patients hospitalized for COVID-19 infections were included. We collected clinical, radiological, and laboratory outcomes. (3)
Results: Ninety-four patients were hospitalized and included in the final analysis. Mean age was 85.5 years and 55% were female. Sixty-four (68%) patients were confirmed COVID-19 cases and 30 (32%) were probable. A majority of patients were dependent (77%), 45% were malnourished, and the mean number of comorbidities was high in accordance with the CIRS-G score (12.3 ± 25.6). The leading causes of hospitalization were fever (30%), dyspnea (28%), and geriatric syndromes (falls, delirium, malaise) (18%). Upon follow-up, 32% presented acute respiratory failure and 30% a geriatric complication. Frailty and geriatric characteristics were not correlated with mortality. Acute respiratory failure (p = 0.03) and lymphopenia (p = 0.02) were significantly associated with mortality. (4)
Conclusions: Among older patients hospitalized with COVID-19, clinical presentations were frequently atypical and complications occurred frequently. Frailty and geriatric characteristics were not correlated with mortality. - . Probable delirium is a presenting symptom of COVID-19 in frail, older adults: a cohort study of 322 hospitalised and 535 community-based older adults. Age Ageing. 2021 Jan 8;50(1):40-48. doi: 10.1093/ageing/afaa223.
[PMID: 32986799] [PMCID: 7543251] [DOI: 10.1093/ageing/afaa223]
Background: Frailty, increased vulnerability to physiological stressors, is associated with adverse outcomes. COVID-19 exhibits a more severe disease course in older, comorbid adults. Awareness of atypical presentations is critical to facilitate early identification.
Objective: To assess how frailty affects presenting COVID-19 symptoms in older adults.
Design: Observational cohort study of hospitalised older patients and self-report data for community-based older adults.
Setting: Admissions to St Thomas' Hospital, London with laboratory-confirmed COVID-19. Community-based data for older adults using the COVID Symptom Study mobile application.
Subjects: Hospital cohort: patients aged 65 and over (n = 322); unscheduled hospital admission between 1 March 2020 and 5 May 2020; COVID-19 confirmed by RT-PCR of nasopharyngeal swab. Community-based cohort: participants aged 65 and over enrolled in the COVID Symptom Study (n = 535); reported test-positive for COVID-19 from 24 March (application launch) to 8 May 2020.
Methods: Multivariable logistic regression analysis performed on age-matched samples from hospital and community-based cohorts to ascertain association of frailty with symptoms of confirmed COVID-19.
Results: Hospital cohort: significantly higher prevalence of probable delirium in the frail sample, with no difference in fever or cough. Community-based cohort: significantly higher prevalence of possible delirium in frailer, older adults and fatigue and shortness of breath.
Conclusions: This is the first study demonstrating higher prevalence of probable delirium as a COVID-19 symptom in older adults with frailty compared to other older adults. This emphasises need for systematic frailty assessment and screening for delirium in acutely ill older patients in hospital and community settings. Clinicians should suspect COVID-19 in frail adults with delirium. - . Delirium in COVID-19: epidemiology and clinical correlations in a large group of patients admitted to an academic hospital. Aging Clin Exp Res. 2020 Oct;32(10):2159-2166. doi: 10.1007/s40520-020-01699-6. Epub 2020 Sep 18.
[PMID: 32946031] [PMCID: 7498987] [DOI: 10.1007/s40520-020-01699-6]
Background: Delirium incidence and clinical correlates in coronavirus disease-19 (COVID-19) pneumonia are still poorly investigated.
Aim: To describe the epidemiology of delirium in patients hospitalized for suspect COVID-19 pneumonia during the pandemic peak in an academic hospital of Northern Italy, identify its clinical correlations and evaluate the association with mortality.
Methods: The clinical records of 852 patients admitted for suspect COVID-19 pneumonia, defined as respiratory symptoms or fever or certain history of contact with COVID-19 patients, plus chest CT imaging compatible with alveolar-interstitial pneumonia, were retrospectively analyzed. Delirium was defined after careful revision of daily clinical reports in accordance with the Confusion Assessment Method criteria. Data on age, clinical presentation, comorbidities, drugs, baseline lab tests and outcome were collected. The factors associated with delirium, and the association of delirium with mortality, were evaluated through binary logistic regression models.
Results: Ninety-four patients (11%) developed delirium during stay. They were older (median age 82, interquartile range, IQR 78-89, vs 75, IQR 63-84, p < 0.001), had more neuropsychiatric comorbidities and worse respiratory exchanges at baseline. At multivariate models, delirium was independently and positively associated with age [odds ratio (OR) 1.093, 95% confidence interval (CI) 1.046-1.143, p < 0.001], use of antipsychotic drugs (OR 4.529, 95% CI 1.204-17.027, p = 0.025), serum urea and lactate-dehydrogenase at admission. Despite a higher mortality in patients with delirium (57% vs 30%), this association was not independent of age and respiratory parameters.
Conclusions: Delirium represents a common complication of COVID-19 and a marker of severe disease course, especially in older patients with neuropsychiatric comorbidity. - . Delirium in Older People with COVID-19: Clinical Scenario and Literature Review. SN Compr Clin Med. 2020 Aug 29:1-8. doi: 10.1007/s42399-020-00474-y.
[PMID: 32904497] [PMCID: 7455775] [DOI: 10.1007/s42399-020-00474-y]
Delirium is a potentially fatal acute brain dysfunction that is characterised by inattention and fluctuating mental changes. It is indicative of an acute serious organ failure or acute infection. Delirium is also associated with undesirable health outcomes that include prolonged hospital stay, long-term cognitive decline and increased mortality. The new SARS-CoV-2 shows, not only pulmonary tropism but also, neurotropism which results in delirium in the acute phase illness particularly in the older age groups. The current assessment for COVID-19 in older people does not routinely include screening for delirium. Implementation of a rapid delirium screening tool is necessary because, without screening, up to 75% of cases can be missed. Delirium can also be exaggerated by health care policies that recommend social isolation and wearing personal protective equipment in addition to less interaction with patients. Non-pharmacological intervention for delirium prevention and management may be helpful if implemented as early and as often as possible in hospitalised older people with COVID-19. A holistic approach that includes psychological support in addition to medical care is needed for older people admitted to hospital with COVID-19. - . Frailty and outcomes from pneumonia in critical illness: a population-based cohort study. Br J Anaesth. 2020 Nov;125(5):730-738. doi: 10.1016/j.bja.2020.07.049. Epub 2020 Sep 3.
[PMID: 32891413] [PMCID: 7467940] [DOI: 10.1016/j.bja.2020.07.049]
Background: A threshold Clinical Frailty Scale (CFS) of 5 (indicating mild frailty) has been proposed to guide ICU admission for UK patients with coronavirus disease 2019 (COVID-19) pneumonia. However, the impact of frailty on mortality with (non-COVID-19) pneumonia in critical illness is unknown. We examined the triage utility of the CFS in patients with pneumonia requiring ICU.
Methods: We conducted a retrospective cohort study of adult patients admitted with pneumonia to 170 ICUs in Australia and New Zealand from January 1, 2018 to September 31, 2019. We classified patients as: non-frail (CFS 1-4) frail (CFS 5-8), mild/moderately frail (CFS 5-6),and severe/very severely frail (CFS 7-8). We evaluated mortality (primary outcome) adjusting for site, age, sex, mechanical ventilation, pneumonia type and illness severity. We also compared the proportion of ICU bed-days occupied between frailty categories.
Results: 1852/5607 (33%) patients were classified as frail, including1291/3056 (42%) of patients aged >65 yr, who would potentially be excluded from ICU admission under UK-based COVID-19 triage guidelines. Only severe/very severe frailty scores were associated with mortality (adjusted odds ratio [aOR] for CFS=7: 3.2; 95% confidence interval [CI]: 1.3-7.8; CFS=8 [aOR: 7.2; 95% CI: 2.6-20.0]). These patients accounted for 7% of ICU bed days. Vulnerability (CFS=4) and mild frailty (CFS=5) were associated with a similar mortality risk (CFS=4 [OR: 1.6; 95% CI: 0.7-3.8]; CFS=5 [OR: 1.6; 95% CI: 0.7-3.9]).
Conclusions: Patients with severe and very severe frailty account for relatively few ICU bed days as a result of pneumonia, whilst adjusted mortality analysis indicated little difference in risk between patients in vulnerable, mild, and moderate frailty categories. These data do not support CFS ≥5 to guide ICU admission for pneumonia. - . Delirium: A suggestive sign of COVID-19 in dementia. EClinicalMedicine. 2020 Sep;26:100524. doi: 10.1016/j.eclinm.2020.100524. Epub 2020 Aug 24.
[PMID: 32864594] [PMCID: 7444936] [DOI: 10.1016/j.eclinm.2020.100524]
- . Prevalence and prognostic value of Delirium as the initial presentation of COVID-19 in the elderly with dementia: An Italian retrospective study. EClinicalMedicine. 2020 Sep;26:100490. doi: 10.1016/j.eclinm.2020.100490. Epub 2020 Jul 30.
[PMID: 32838241] [PMCID: 7392565] [DOI: 10.1016/j.eclinm.2020.100490]
Background: Delirium may be one of the presenting symptoms of COVID-19, complicating diagnosis and care of elderly patients with dementia. We aim to identify the prevalence and prognostic significance of delirium as the sole onset manifestation of COVID-19.
Methods: This is a retrospective single-centre study based on review of medical charts, conducted during the outbreak peak (March 27-April 18, 2020) in a Lombard dementia facility, including 59 elderly subjects with dementia and laboratory-confirmed COVID-19.
Findings: Of the 59 residents, 57 (96⋅6%) tested positive (mean age: 82⋅8; women: 66⋅7%). Comorbidities were present in all participants, with 18/57 (31⋅6%) having three or more concomitant diseases. Delirium-Onset COVID-19 (DOC) was observed in 21/57 (36⋅8%) subjects who were chiefly older (mean age: 85⋅4 y/o) and with multiple comorbidities. Eleven/21 DOC patients (52⋅4%) had hypoactive delirium, while hyperactive delirium occurred in ten/21 (47⋅6%). Lymphopenia was present in almost all subjects (median: 1⋅3 × 10(9)/L). Overall mortality rate was 24⋅6% (14/57) and dementia severity per se had no impact on short-term mortality due to COVID-19. DOC was strongly associated with higher mortality (p<0⋅001). Also, DOC and male gender were independently associated with increased risk of mortality (OR: 17⋅0, 95% CI: 2⋅8-102⋅7, p = 0⋅002 and 13⋅6, 95% CI: 2⋅3-79⋅2, p = 0⋅001 respectively).
Interpretation: Delirium occurrence in the elderly with dementia may represent a prodromal phase of COVID-19, and thus deserves special attention, especially in the presence of lymphopenia. Hypoxia and a severe inflammatory state may develop subsequently. DOC cases have higher short-term mortality rate.
Funding: None. - . Delirium and Adverse Outcomes in Hospitalized Patients with COVID-19. J Am Geriatr Soc. 2020 Nov;68(11):2440-2446. doi: 10.1111/jgs.16803. Epub 2020 Sep 5.
[PMID: 32835425] [PMCID: 7460960] [DOI: 10.1111/jgs.16803]
Background: Little is known about the association between acute mental changes and adverse outcomes in hospitalized adults with COVID-19.
Objectives: To investigate the occurrence of delirium in hospitalized patients with COVID-19 and explore its association with adverse outcomes.
Design: Longitudinal observational study.
Setting: Tertiary university hospital dedicated to the care of severe cases of COVID-19 in São Paulo, Brazil.
Participants: A total of 707 patients, aged 50 years or older, consecutively admitted to the hospital between March and May 2020.
Measurements: We completed detailed reviews of electronic medical records to collect our data. We identified delirium occurrence using the Chart-Based Delirium Identification Instrument (CHART-DEL). Trained physicians with a background in geriatric medicine completed all CHART-DEL assessments. We complemented our baseline clinical information using telephone interviews with participants or their proxy. Our outcomes of interest were in-hospital death, length of stay, admission to intensive care, and ventilator utilization. We adjusted all multivariable analyses for age, sex, clinical history, vital signs, and relevant laboratory biomarkers (lymphocyte count, C-reactive protein, glomerular filtration rate, D-dimer, and albumin).
Results: Overall, we identified delirium in 234 participants (33%). On admission, 86 (12%) were delirious. We observed 273 deaths (39%) in our sample, and in-hospital mortality reached 55% in patients who experienced delirium. Delirium was associated with in-hospital death, with an adjusted odds ratio of 1.75 (95% confidence interval = 1.15-2.66); the association held both in middle-aged and older adults. Delirium was also associated with increased length of stay, admission to intensive care, and ventilator utilization.
Conclusion: Delirium was independently associated with in-hospital death in adults aged 50 years and older with COVID-19. Despite the difficulties for patient care during the pandemic, clinicians should routinely monitor delirium when assessing severity and prognosis of COVID-19 patients. - . The impact of delirium on outcomes for older adults hospitalised with COVID-19. Age Ageing. 2020 Oct 23;49(6):923-926. doi: 10.1093/ageing/afaa189.
[PMID: 32821901] [PMCID: 7499475] [DOI: 10.1093/ageing/afaa189]
Introduction: Delirium is a frequent condition in hospitalized older patients and it usually has a negative prognostic value. A direct effect of SARS-COV-2 on the central nervous system (CNS) has been hypothesized.
Objective: To evaluate the presence of delirium in older patients admitted for a suspected diagnosis of COVID-19 and its impact on in-hospital mortality. SETTING AND
Subjects: 91 patients, aged 70-years and older, admitted to an acute geriatric ward in Northern Italy from March 8th to April 17th, 2020.
Methods: COVID-19 cases were confirmed by reverse transcriptase-polymerase chain reaction assay for SARS-Cov-2 RNA from nasal and pharyngeal swabs. Delirium was diagnosed by two geriatricians according to the Diagnostic and Statistical Manual of Mental Disorders V (DMS V) criteria. The number of chronic diseases was calculated among a pre-defined list of 60. The pre-disease Clinical Frailty Scale (CFS) was assessed at hospital admission.
Results: Of the total sample, 39 patients died, 49 were discharged and 3 were transferred to ICU. Twenty-five patients (27.5%) had delirium. Seventy-two percent of patients with delirium died during hospitalization compared to 31.8% of those without delirium. In a multivariate logistic regression model adjusted for potential confounders, patients with delirium were four times more likely to die during hospital stay compared to those without delirium (OR = 3.98;95%CI = 1.05-17.28; p = 0.047).
Conclusions: Delirium is common in older patients with COVID-19 and strongly associated with in-hospital mortality. Regardless of causation, either due to a direct effect of SARS-COV-2 on the CNS or to a multifactorial cause, delirium should be interpreted as an alarming prognostic indicator in older people. - . Association of frailty with mortality in older inpatients with Covid-19: a cohort study. Age Ageing. 2020 Oct 23;49(6):915-922. doi: 10.1093/ageing/afaa184.
[PMID: 32778870] [PMCID: 7454254] [DOI: 10.1093/ageing/afaa184]
Background: COVID-19 has disproportionately affected older people.
Objective: The objective of this paper to investigate whether frailty is associated with all-cause mortality in older hospital inpatients, with COVID-19.
Design: Cohort study.
Setting: Secondary care acute hospital.
Participants: Participants included are 677 consecutive inpatients aged 65 years and over.
Methods: Cox proportional hazards models were used to examine the association of frailty with mortality. Frailty was assessed at baseline, according to the Clinical Frailty Scale (CFS), where higher categories indicate worse frailty. Analyses were adjusted for age, sex, deprivation, ethnicity, previous admissions and acute illness severity.
Results: Six hundred and sixty-four patients were classified according to CFS. Two hundred and seventy-one died, during a mean follow-up of 34.3 days. Worse frailty at baseline was associated with increased mortality risk, even after full adjustment (P = 0.004). Patients with CFS 4 and CFS 5 had non-significant increased mortality risks, compared to those with CFS 1-3. Patients with CFS 6 had a 2.13-fold (95% CI 1.34-3.38) and those with CFS 7-9 had a 1.79-fold (95% CI 1.12-2.88) increased mortality risk, compared to those with CFS 1-3 (P = 0.001 and 0.016, respectively). Older age, male sex and acute illness severity were also associated with increased mortality risk.
Conclusions: Frailty is associated with all-cause mortality risk in older inpatients with COVID-19. - . Delirium and encephalopathy in severe COVID-19: a cohort analysis of ICU patients. Crit Care. 2020 Aug 8;24(1):491. doi: 10.1186/s13054-020-03200-1.
[PMID: 32771053] [PMCID: 7414289] [DOI: 10.1186/s13054-020-03200-1]
Background: Neurotropism of SARS-CoV-2 and its neurological manifestations have now been confirmed. We aimed at describing delirium and neurological symptoms of COVID-19 in ICU patients.
Methods: We conducted a bicentric cohort study in two French ICUs of Strasbourg University Hospital. All the 150 patients referred for acute respiratory distress syndrome due to SARS-CoV-2 between March 3 and May 5, 2020, were included at their admission. Ten patients (6.7%) were excluded because they remained under neuromuscular blockers during their entire ICU stay. Neurological examination, including CAM-ICU, and cerebrospinal fluid analysis, electroencephalography, and magnetic resonance imaging (MRI) were performed in some of the patients with delirium and/or abnormal neurological examination. The primary endpoint was to describe the incidence of delirium and/or abnormal neurological examination. The secondary endpoints were to describe the characteristics of delirium, to compare the duration of invasive mechanical ventilation and ICU length of stay in patients with and without delirium and/or abnormal neurological symptoms.
Results: The 140 patients were aged in median of 62 [IQR 52; 70] years old, with a median SAPSII of 49 [IQR 37; 64] points. Neurological examination was normal in 22 patients (15.7%). One hundred eighteen patients (84.3%) developed a delirium with a combination of acute attention, awareness, and cognition disturbances. Eighty-eight patients (69.3%) presented an unexpected state of agitation despite high infusion rates of sedative treatments and neuroleptics, and 89 (63.6%) patients had corticospinal tract signs. Brain MRI performed in 28 patients demonstrated enhancement of subarachnoid spaces in 17/28 patients (60.7%), intraparenchymal, predominantly white matter abnormalities in 8 patients, and perfusion abnormalities in 17/26 patients (65.4%). The 42 electroencephalograms mostly revealed unspecific abnormalities or diffuse, especially bifrontal, slow activity. Cerebrospinal fluid examination revealed inflammatory disturbances in 18/28 patients, including oligoclonal bands with mirror pattern and elevated IL-6. The CSF RT-PCR SARS-CoV-2 was positive in one patient. The delirium/neurological symptoms in COVID-19 patients were responsible for longer mechanical ventilation compared to the patients without delirium/neurological symptoms. Delirium/neurological symptoms could be secondary to systemic inflammatory reaction to SARS-CoV-2.
Conclusions and relevance: Delirium/neurological symptoms in COVID-19 patients are a major issue in ICUs, especially in the context of insufficient human and material resources.
Trial registration: NA. - . 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 Aug 6;22(4):20l02721. doi: 10.4088/PCC.20l02721.
[PMID: 32767871] [DOI: 10.4088/PCC.20l02721]
- . An audit of end-of-life symptom control in patients with corona virus disease 2019 (COVID-19) dying in a hospital in the United Kingdom. Palliat Med. 2020 Oct;34(9):1249-1255. doi: 10.1177/0269216320947312. Epub 2020 Jul 31.
[PMID: 32736493] [DOI: 10.1177/0269216320947312]
Background: The literature contains limited information on the problems faced by dying patients with COVID-19 and the effectiveness of interventions to manage these.
Aim: The aim of this audit was to assess the utility of our end-of-life care plan, and specifically the effectiveness of our standardised end-of-life care treatment algorithms, in dying patients with COVID-19.
Design: The audit primarily involved data extraction from the end-of-life care plan, which includes four hourly nursing (ward nurses) assessments of specific problems: patients with problems were managed according to standardised treatment algorithms, and the intervention was deemed to be effective if the problem was not present at subsequent assessments. SETTING/
Participants: This audit was undertaken at a general hospital in England, covered the 8 weeks from 16 March to 11 May 2020 and included all inpatients with COVID-19 who had an end-of-life care plan (and died).
Results: Sixty-one patients met the audit criteria: the commonest problem was shortness of breath (57.5%), which was generally controlled with conservative doses of morphine (10-20 mg/24 h via a syringe pump). Cough and audible respiratory secretions were relatively uncommon. The second most common problem was agitation/delirium (55.5%), which was generally controlled with standard pharmacological interventions. The cumulative number of patients with shortness of breath, agitation and audible respiratory secretions increased over the last 72 h of life, but most patients were symptom controlled at the point of death.
Conclusion: Patients dying of COVID-19 experience similar end-of-life problems to other groups of patients. Moreover, they generally respond to standard interventions for these end-of-life problems. - . Presenting features of COVID-19 in older people: relationships with frailty, inflammation and mortality. Eur Geriatr Med. 2020 Dec;11(6):1089-1094. doi: 10.1007/s41999-020-00373-4. Epub 2020 Jul 30.
[PMID: 32734464] [PMCID: 7391232] [DOI: 10.1007/s41999-020-00373-4]
Purpose: To describe the clinical features of COVID-19 in older adults, and relate these to outcomes.
Methods: A cohort study of 217 individuals (median age 80, IQR 74-85 years; 62% men) hospitalised with COVID-19, followed up for all-cause mortality, was conducted. Secondary outcomes included cognitive and physical function at discharge. C-reactive protein and neutrophil:lymphocyte ratio were used as measures of immune activity.
Results: Cardinal COVID-19 symptoms (fever, dyspnoea, cough) were common but not universal. Inflammation on hospitalisation was lower in frail older adults. Fever, dyspnoea, delirium and inflammation were associated with mortality. Delirium at presentation was an independent risk factor for cognitive decline at discharge.
Conclusions: COVID-19 may present without cardinal symptoms as well as implicate a possible role for age-related changes in immunity in mediating the relationship between frailty and mortality. - . Immune-mediated neurological syndromes in SARS-CoV-2-infected patients. J Neurol. 2021 Mar;268(3):751-757. doi: 10.1007/s00415-020-10108-x. Epub 2020 Jul 30.
[PMID: 32734353] [PMCID: 7391231] [DOI: 10.1007/s00415-020-10108-x]
Background: Evidence of immune-mediated neurological syndromes associated with the severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection is limited. We therefore investigated clinical, serological and CSF features of coronavirus disease 2019 (COVID-19) patients with neurological manifestations.
Methods: Consecutive COVID-19 patients with neurological manifestations other than isolated anosmia and/or non-severe headache, and with no previous neurological or psychiatric disorders were prospectively included. Neurological examination was performed in all patients and lumbar puncture with CSF examination was performed when not contraindicated. Serum anti-gangliosides antibodies were tested when clinically indicated.
Results: Of the 349 COVID-19 admitted to our center between March 23rd and April 24th 2020, 15 patients (4.3%) had neurological manifestations and fulfilled the study inclusion/exclusion criteria. CSF examination was available in 13 patients and showed lymphocytic pleocytosis in 2 patients: 1 with anti-contactin-associated protein 2 (anti-Caspr2) antibody encephalitis and 1 with meningo-polyradiculitis. Increased serum titer of anti-GD1b antibodies was found in three patients and was associated with variable clinical presentations, including cranial neuropathy with meningo-polyradiculitis, brainstem encephalitis and delirium. CSF PCR for SARS-CoV-2 was negative in all patients.
Conclusions: In SARS-Cov-2 infected patients with neurological manifestations, CSF pleocytosis is associated with para- or post-infectious encephalitis and polyradiculitis. Anti-GD1b and anti-Caspr2 autoantibodies can be identified in certain cases, raising the question of SARS-CoV-2-induced secondary autoimmunity. - . Outcomes from COVID-19 across the range of frailty: excess mortality in fitter older people. Eur Geriatr Med. 2020 Oct;11(5):851-855. doi: 10.1007/s41999-020-00354-7. Epub 2020 Jul 18.
[PMID: 32683576] [PMCID: 7368630] [DOI: 10.1007/s41999-020-00354-7]
Purpose: Our aim was to quantify the mortality from COVID-19 and identify any interactions with frailty and other demographic factors.
Methods: Hospitalised patients aged ≥ 70 were included, comparing COVID-19 cases with non-COVID-19 controls admitted over the same period. Frailty was prospectively measured and mortality ascertained through linkage with national and local statutory reports.
Results: In 217 COVID-19 cases and 160 controls, older age and South Asian ethnicity, though not socioeconomic position, were associated with higher mortality. For frailty, differences in effect size were evident between cases (HR 1.02, 95% CI 0.93-1.12) and controls (HR 1.99, 95% CI 1.46-2.72), with an interaction term (HR 0.51, 95% CI 0.37-0.71) in multivariable models.
Conclusions: Our findings suggest that (1) frailty is not a good discriminator of prognosis in COVID-19 and (2) pathways to mortality may differ in fitter compared with frailer older patients. - . Frailty and Mortality in Hospitalized Older Adults With COVID-19: Retrospective Observational Study. J Am Med Dir Assoc. 2020 Jul;21(7):928-932.e1. doi: 10.1016/j.jamda.2020.06.008. Epub 2020 Jun 9.
[PMID: 32674821] [PMCID: 7280137] [DOI: 10.1016/j.jamda.2020.06.008]
Objectives: To determine the association between frailty and short-term mortality in older adults hospitalized for coronavirus disease 2019 (COVID-19).
Design: Retrospective single-center observational study.
Setting and participants: Eighty-one patients with COVID-19 confirmed by reverse-transcriptase polymerase chain reaction (RT-PCR), at the Geriatrics department of a general hospital in Belgium.
Measurements: Frailty was graded according to the Rockwood Clinical Frailty Scale (CFS). Demographic, biochemical, and radiologic variables, comorbidities, symptoms, and treatment were extracted from electronic medical records.
Results: Participants (N = 48 women, 59%) had a median age of 85 years (range 65-97 years) and a median CFS score of 7 (range 2-9); 42 (52%) were long-term care residents. Within 6 weeks, 18 patients died. Mortality was significantly but weakly associated with age (Spearman r = 0.241, P = .03) and CFS score (r = 0.282, P = .011), baseline lactate dehydrogenase (LDH; r = 0.301, P = .009), lymphocyte count (r = -0.262, P = .02), and RT-PCR cycle threshold (Ct, r = -0.285, P = .015). Mortality was not associated with long-term care residence, dementia, delirium, or polypharmacy. In multivariable logistic regression analyses, CFS, LDH, and RT-PCR Ct (but not age) remained independently associated with mortality. Both age and frailty had poor specificity to predict survival. A multivariable model combining age, CFS, LDH, and viral load significantly predicted survival.
Conclusions and implications: Although their prognosis is worse, even the oldest and most severely frail patients may benefit from hospitalization for COVID-19, if sufficient resources are available. - . Delirium as the first clinical presentation of the coronavirus disease 2019 in an older adult. Psychogeriatrics. 2020 Sep;20(5):763-765. doi: 10.1111/psyg.12587. Epub 2020 Jul 14.
[PMID: 32666597] [PMCID: 7405320] [DOI: 10.1111/psyg.12587]
- . Functional and cognitive outcomes after COVID-19 delirium. Eur Geriatr Med. 2020 Oct;11(5):857-862. doi: 10.1007/s41999-020-00353-8. Epub 2020 Jul 14.
[PMID: 32666303] [PMCID: 7358317] [DOI: 10.1007/s41999-020-00353-8]
Purpose: To ascertain delirium prevalence and outcomes in COVID-19.
Methods: We conducted a point-prevalence study in a cohort of COVID-19 inpatients at University College Hospital. Delirium was defined by DSM-IV criteria. The primary outcome was all-cause mortality at 4 weeks; secondary outcomes were physical and cognitive function.
Results: In 71 patients (mean age 61, 75% men), 31 (42%) had delirium, of which only 12 (39%) had been recognised by the clinical team. At 4 weeks, 20 (28%) had died, 26 (36%) were interviewed by telephone and 21 (30%) remained as inpatients. Physical function was substantially worse in people after delirium - 50 out of 166 points (95% CI - 83 to - 17, p = 0.01). Mean cognitive scores at follow-up were similar and delirium was not associated with mortality in this sample.
Conclusions: Our findings indicate that delirium is common, yet under-recognised. Delirium is associated with functional impairments in the medium term. - . Frailty and COVID-19: A Systematic Scoping Review. J Clin Med. 2020 Jul 4;9(7):2106. doi: 10.3390/jcm9072106.
[PMID: 32635468] [PMCID: 7408623] [DOI: 10.3390/jcm9072106]
Older people have paid a huge toll in terms of mortality during the coronavirus disease-19 (COVID-19) pandemic. Frailty may have contributed to the vulnerability of older people to more severe clinical presentation. We aimed at reviewing available evidence about frailty and COVID-19. We searched PUBMED, Web of Science, and EMBASE from 1 December 2019 to 29 May 2020. Study selection and data extraction were performed by three independent reviewers. Qualitative synthesis was conducted and quantitative data extracted when available. Forty papers were included: 13 editorials, 15 recommendations/guidelines, 3 reviews, 1 clinical trial, 6 observational studies, 2 case reports. Editorials and reviews underlined the potential clinical relevance of assessing frailty among older patients with COVID-19. However, frailty was only investigated in regards to its association with overall mortality, hospital contagion, intensive care unit admission rates, and disease phenotypes in the few observational studies retrieved. Specific interventions in relation to frailty or its impact on COVID-19 treatments have not been evaluated yet. Even with such limited evidence, clinical recommendations on the use of frailty tools have been proposed to support decision making about escalation plan. Ongoing initiatives are expected to improve knowledge of COVID-19 interaction with frailty and to promote patient-centered approaches. - . Clozapine Toxicity in the Setting of COVID-19. Psychosomatics. 2020 Sep-Oct;61(5):577-578. doi: 10.1016/j.psym.2020.05.025. Epub 2020 May 30.
[PMID: 32593477] [PMCID: 7260496] [DOI: 10.1016/j.psym.2020.05.025]
- . COVID-19-Associated Hyperactive Intensive Care Unit Delirium With Proposed Pathophysiology and Treatment: A Case Report. Psychosomatics. 2020 Sep-Oct;61(5):544-550. doi: 10.1016/j.psym.2020.05.007. Epub 2020 May 19.
[PMID: 32591212] [PMCID: 7236743] [DOI: 10.1016/j.psym.2020.05.007]
- . End-of-life care in COVID-19: An audit of pharmacological management in hospital inpatients. Palliat Med. 2020 Oct;34(9):1235-1240. doi: 10.1177/0269216320935361. Epub 2020 Jun 26.
[PMID: 32588748] [DOI: 10.1177/0269216320935361]
Background: Hospital clinicians have had to rapidly develop expertise in managing the clinical manifestations of COVID-19 including symptoms common at the end of life, such as breathlessness and agitation. There is limited evidence exploring whether end-of-life symptom control in this group requires new or adapted guidance.
Aim: To review whether prescribing for symptom control in patients dying with COVID-19 adhered to existing local guidance or whether there was deviation which may represent a need for revised guidance or specialist support in particular patient groups. DESIGN/
Setting: A retrospective review of the electronic patient record of 61 hospital inpatients referred to the specialist palliative care team with swab-confirmed COVID-19 who subsequently died over a 1-month period. Intubated patients were excluded.
Results: In all, 83% (40/48) of patients were prescribed opioids at a starting dose consistent with existing local guidelines. In seven of eight patients where higher doses were prescribed, this was on specialist palliative care team advice. Mean total opioid dose required in the last 24 h of life was 14 mg morphine subcutaneous equivalent, and mean total midazolam dose was 9.5 mg. For three patients in whom non-invasive ventilation was in place higher doses were used.
Conclusion: Prescription of end-of-life symptom control drugs for COVID-19 fell within the existing guidance when supported by specialist palliative care advice. While some patients may require increased doses, routine prescription of higher starting opioid and benzodiazepine doses beyond existing local guidance was not observed. - . Neurological, Cognitive, and Behavioral Disorders during COVID-19: The Nitric Oxide Track. J Am Geriatr Soc. 2020 Sep;68(9):1922-1923. doi: 10.1111/jgs.16671. Epub 2020 Jun 24.
[PMID: 32583434] [PMCID: 7361837] [DOI: 10.1111/jgs.16671]
See the Reply by Alkeridy et al. - . Delirium as a presenting feature in COVID-19: Neuroinvasive infection or autoimmune encephalopathy?. Brain Behav Immun. 2020 Aug;88:68-70. doi: 10.1016/j.bbi.2020.06.012. Epub 2020 Jun 9.
[PMID: 32531427] [PMCID: 7282789] [DOI: 10.1016/j.bbi.2020.06.012]
- . Schizophrenia and COVID-19 delirium. Psychiatry Res. 2020 Aug;290:113137. doi: 10.1016/j.psychres.2020.113137. Epub 2020 May 27.
[PMID: 32485483] [PMCID: 7251413] [DOI: 10.1016/j.psychres.2020.113137]
Since its outbreak, coronavirus disease 2019 has been producing atypical manifestations aside from fever, coughing and dysnea. One of the most common is delirium, which, however, is highly overlooked. This has consequences in the treatment of patients and also may lead to underdiagnosing the infection. In this work, we present the case of a man diagnosed with schizophrenia, who had been stable for more than 20 years and that presented with an atypical picture of psychotic and confusional symptoms related to COVID-19 infection. - . Delirium in COVID-19: A case series and exploration of potential mechanisms for central nervous system involvement. Gen Hosp Psychiatry. 2020 Jul-Aug;65:47-53. doi: 10.1016/j.genhosppsych.2020.05.008. Epub 2020 May 22.
[PMID: 32470824] [PMCID: 7242189] [DOI: 10.1016/j.genhosppsych.2020.05.008]
Introduction: Neuropsychiatric manifestations of the coronavirus disease 2019 (COVID-19) have been described, including anosmia, ageusia, headache, paresthesia, encephalitis and encephalopathy. Little is known about the mechanisms by which the virus causes central nervous system (CNS) symptoms, and therefore little guidance is available regarding potential workup or management options. CASES: We present a series of four consecutive cases, seen by our psychiatry consultation service over a one-week period, each of which manifested delirium as a result of infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).
Discussion: The four cases highlighted here all occurred in older patients with premorbid evidence of cognitive decline. Unique features seen in multiple cases included rigidity, alogia, abulia, and elevated inflammatory markers. In all four cases, a change in mental status was the presenting symptom, and three of the four cases lacked significant respiratory symptoms. In addition to discussing unique features of the cases, we discuss possible pathophysiologic explanations for COVID-19 delirium.
Conclusions: Delirium should be recognized as a potential feature of infection with SARS-CoV-2 and may be the only presenting symptom. Based on the high rates of delirium demonstrated in prior studies, hospitals should consider adding mental status changes to the list of testing criteria. Further research is needed to determine if delirium in COVID-19 represents a primary encephalopathy heralding invasion of the CNS by the virus, or a secondary encephalopathy related to systemic inflammatory response or other factors. - . Clinical characteristics and outcomes of inpatients with neurologic disease and COVID-19 in Brescia, Lombardy, Italy. Neurology. 2020 Aug 18;95(7):e910-e920. doi: 10.1212/WNL.0000000000009848. Epub 2020 May 22.
[PMID: 32444493] [DOI: 10.1212/WNL.0000000000009848]
Objective: To report clinical and laboratory characteristics, treatment, and clinical outcomes of patients admitted for neurologic diseases with and without coronavirus disease 2019 (COVID-19).
Methods: In this retrospective, single-center cohort study, we included all adult inpatients with confirmed COVID-19 admitted to a neuro-COVID unit beginning February 21, 2020, who had been discharged or died by April 5, 2020. Demographic, clinical, treatment, and laboratory data were extracted from medical records and compared (false discovery rate corrected) to those of neurologic patients without COVID-19 admitted in the same period.
Results: One hundred seventy-three patients were included in this study, of whom 56 were positive and 117 were negative for COVID-19. Patients with COVID-19 were older (77.0 years, interquartile range [IQR] 67.0-83.8 years vs 70.1 years, IQR 52.9-78.6 years, p = 0.006), had a different distribution regarding admission diagnoses, including cerebrovascular disorders (n = 43, 76.8% vs n = 68, 58.1%), and had a higher quick Sequential Organ Failure Assessment (qSOFA) score on admission (0.9, IQR 0.7-1.1 vs 0.5, IQR 0.4-0.6, p = 0.006). In-hospital mortality rates (n = 21, 37.5% vs n = 5, 4.3%, p < 0.001) and incident delirium (n = 15, 26.8% vs n = 9, 7.7%, p = 0.003) were significantly higher in the COVID-19 group. Patients with COVID-19 and without COVID with stroke had similar baseline characteristics, but patients with COVID-19 had higher modified Rankin Scale scores at discharge (5.0, IQR 2.0-6.0 vs 2.0, IQR 1.0-3.0, p < 0.001), with a significantly lower number of patients with a good outcome (n = 11, 25.6% vs n = 48, 70.6%, p < 0.001). In patients with COVID-19, multivariable regressions showed increasing odds of in-hospital death associated with higher qSOFA scores (odds ratio [OR] 4.47, 95% confidence interval [CI] 1.21-16.5, p = 0.025), lower platelet count (OR 0.98, 95% CI 0.97-0.99, p = 0.005), and higher lactate dehydrogenase (OR 1.01, 95% CI 1.00-1.03, p = 0.009) on admission.
Conclusions: Patients with COVID-19 admitted with neurologic disease, including stroke, have a significantly higher in-hospital mortality and incident delirium and higher disability than patients without COVID-19. - . Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry. 2020 Jul;7(7):611-627. doi: 10.1016/S2215-0366(20)30203-0. Epub 2020 May 18.
[PMID: 32437679] [PMCID: 7234781] [DOI: 10.1016/S2215-0366(20)30203-0]
Background: Before the COVID-19 pandemic, coronaviruses caused two noteworthy outbreaks: severe acute respiratory syndrome (SARS), starting in 2002, and Middle East respiratory syndrome (MERS), starting in 2012. We aimed to assess the psychiatric and neuropsychiatric presentations of SARS, MERS, and COVID-19.
Methods: In this systematic review and meta-analysis, MEDLINE, Embase, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature databases (from their inception until March 18, 2020), and medRxiv, bioRxiv, and PsyArXiv (between Jan 1, 2020, and April 10, 2020) were searched by two independent researchers for all English-language studies or preprints reporting data on the psychiatric and neuropsychiatric presentations of individuals with suspected or laboratory-confirmed coronavirus infection (SARS coronavirus, MERS coronavirus, or SARS coronavirus 2). We excluded studies limited to neurological complications without specified neuropsychiatric presentations and those investigating the indirect effects of coronavirus infections on the mental health of people who are not infected, such as those mediated through physical distancing measures such as self-isolation or quarantine. Outcomes were psychiatric signs or symptoms; symptom severity; diagnoses based on ICD-10, DSM-IV, or the Chinese Classification of Mental Disorders (third edition) or psychometric scales; quality of life; and employment. Both the systematic review and the meta-analysis stratified outcomes across illness stages (acute vs post-illness) for SARS and MERS. We used a random-effects model for the meta-analysis, and the meta-analytical effect size was prevalence for relevant outcomes, I(2) statistics, and assessment of study quality.
Findings: 1963 studies and 87 preprints were identified by the systematic search, of which 65 peer-reviewed studies and seven preprints met inclusion criteria. The number of coronavirus cases of the included studies was 3559, ranging from 1 to 997, and the mean age of participants in studies ranged from 12·2 years (SD 4·1) to 68·0 years (single case report). Studies were from China, Hong Kong, South Korea, Canada, Saudi Arabia, France, Japan, Singapore, the UK, and the USA. Follow-up time for the post-illness studies varied between 60 days and 12 years. The systematic review revealed that during the acute illness, common symptoms among patients admitted to hospital for SARS or MERS included confusion (36 [27·9%; 95% CI 20·5-36·0] of 129 patients), depressed mood (42 [32·6%; 24·7-40·9] of 129), anxiety (46 [35·7%; 27·6-44·2] of 129), impaired memory (44 [34·1%; 26·2-42·5] of 129), and insomnia (54 [41·9%; 22·5-50·5] of 129). Steroid-induced mania and psychosis were reported in 13 (0·7%) of 1744 patients with SARS in the acute stage in one study. In the post-illness stage, depressed mood (35 [10·5%; 95% CI 7·5-14·1] of 332 patients), insomnia (34 [12·1%; 8·6-16·3] of 280), anxiety (21 [12·3%; 7·7-17·7] of 171), irritability (28 [12·8%; 8·7-17·6] of 218), memory impairment (44 [18·9%; 14·1-24·2] of 233), fatigue (61 [19·3%; 15·1-23·9] of 316), and in one study traumatic memories (55 [30·4%; 23·9-37·3] of 181) and sleep disorder (14 [100·0%; 88·0-100·0] of 14) were frequently reported. The meta-analysis indicated that in the post-illness stage the point prevalence of post-traumatic stress disorder was 32·2% (95% CI 23·7-42·0; 121 of 402 cases from four studies), that of depression was 14·9% (12·1-18·2; 77 of 517 cases from five studies), and that of anxiety disorders was 14·8% (11·1-19·4; 42 of 284 cases from three studies). 446 (76·9%; 95% CI 68·1-84·6) of 580 patients from six studies had returned to work at a mean follow-up time of 35·3 months (SD 40·1). When data for patients with COVID-19 were examined (including preprint data), there was evidence for delirium (confusion in 26 [65%] of 40 intensive care unit patients and agitation in 40 [69%] of 58 intensive care unit patients in one study, and altered consciousness in 17 [21%] of 82 patients who subsequently died in another study). At discharge, 15 (33%) of 45 patients with COVID-19 who were assessed had a dysexecutive syndrome in one study. At the time of writing, there were two reports of hypoxic encephalopathy and one report of encephalitis. 68 (94%) of the 72 studies were of either low or medium quality.
Interpretation: If infection with SARS-CoV-2 follows a similar course to that with SARS-CoV or MERS-CoV, most patients should recover without experiencing mental illness. SARS-CoV-2 might cause delirium in a significant proportion of patients in the acute stage. Clinicians should be aware of the possibility of depression, anxiety, fatigue, post-traumatic stress disorder, and rarer neuropsychiatric syndromes in the longer term.
Funding: Wellcome Trust, UK National Institute for Health Research (NIHR), UK Medical Research Council, NIHR Biomedical Research Centre at University College London Hospitals NHS Foundation Trust and University College London. - . Prolonged confusional state as first manifestation of COVID-19. Ann Clin Transl Neurol. 2020 Aug;7(8):1450-1452. doi: 10.1002/acn3.51067. Epub 2020 Jul 6.
[PMID: 32433817] [PMCID: 7276856] [DOI: 10.1002/acn3.51067]
A 77-year-old gentleman, normally fit and well, was admitted with acute confusion. On admission, Glasgow Coma Scale (GCS) was 14/15, vital signs were within the normal limits and bilateral crepitation at the lung base. Head CT scan was normal. CXR showed some air space opacification. Investigations revealed hyponatraemia, raised CRP, and positive for COVID-19. Treated with antibiotics and intravenous saline, sodium returned to normal. Delirium remained unchanged 4 weeks post-incidence. Neurological manifestations were documented in patients with COVID-19; however no report has shown delirium as a primary manifestation. This case illustrates acute confusion may be the only presenting symptom of COVID-19 without overt lung disease. - . [Atypical clinical picture of COVID-19 in older patients]. Ned Tijdschr Geneeskd. 2020 Apr 8;164:D5004.
[PMID: 32395966]
Clinical characteristics and outcomes among older patients with a SARS-CoV-2 infection differ greatly from those seen in younger patients. Here we highlight atypical presentations of this fulminant infectious disease COVID-19, based on a clinical case and a cohort of 19 patients admitted to a geriatric ward. The degree of frailty, resilience and number of co-morbidities caused COVID-19 to present as acute geriatric syndrome events such as falls, delirium and dehydration in these patients. Clinical laboratory results considered typical for COVID-19 were present less often in this frail older population. As in other countries, morbidity and mortality is most severe among frail male patients; therefore, assessment of changes suggestive of typical acute geriatric syndromes in frail older patients with chronic diseases should lead to a careful clinical examination for a SARS-CoV-2 infection. Protocols for diagnosis, and contact isolation measures, should take these atypical presentations into account. - . A Unique Presentation of Delirium in a Patient with Otherwise Asymptomatic COVID-19. J Am Geriatr Soc. 2020 Jul;68(7):1382-1384. doi: 10.1111/jgs.16536. Epub 2020 May 16.
[PMID: 32383778] [PMCID: 7272789] [DOI: 10.1111/jgs.16536]
Objective: Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), manifests with a wide spectrum of presentations. Most reports of COVID-19 highlight fever and upper respiratory symptoms as the dominant initial presentations, consistent with the World Health Organization guidelines regarding suspected SARS-CoV-2 infection. However, atypical presentations of this disease have been evolving since the initial outbreak of the pandemic in December 2019. We report a case of an older male patient who presented at our hospital with an unusual manifestation of COVID-19.
Design: Brief report.
Setting: A university hospital in Saudi Arabia. PARTICIPANT: A 73-year-old man who presented with confusion in the absence of any respiratory symptoms or fever.
Intervention: The patient was initially admitted with delirium and underwent a further work-up.
Measurements: Given his recent history of domestic travel and the declaration of a global COVID-19 pandemic status, the patient was administered a swab test for SARS-CoV-2.
Results: The patient's positive test led to a diagnosis of COVID-19. Although he began to experience a spiking fever and mild upper respiratory symptoms, he recovered rapidly with no residual sequela.
Conclusion: The recognition of atypical presentations of COVID-19 infection, such as delirium, is critical to the timely diagnosis, provision of appropriate care, and avoidance of outbreaks within healthcare facilities during this pandemic. J Am Geriatr Soc 68:1382-1384, 2020. - . Delirium: a missing piece in the COVID-19 pandemic puzzle. Age Ageing. 2020 Jul 1;49(4):497-498. doi: 10.1093/ageing/afaa094.
[PMID: 32374367] [PMCID: 7239228] [DOI: 10.1093/ageing/afaa094]
- . COVID-19: ICU delirium management during SARS-CoV-2 pandemic. Crit Care. 2020 Apr 28;24(1):176. doi: 10.1186/s13054-020-02882-x.
[PMID: 32345343] [PMCID: 7186945] [DOI: 10.1186/s13054-020-02882-x]
The novel coronavirus, SARS-CoV-2-causing Coronavirus Disease 19 (COVID-19), emerged as a public health threat in December 2019 and was declared a pandemic by the World Health Organization in March 2020. Delirium, a dangerous untoward prognostic development, serves as a barometer of systemic injury in critical illness. The early reports of 25% encephalopathy from China are likely a gross underestimation, which we know occurs whenever delirium is not monitored with a valid tool. Indeed, patients with COVID-19 are at accelerated risk for delirium due to at least seven factors including (1) direct central nervous system (CNS) invasion, (2) induction of CNS inflammatory mediators, (3) secondary effect of other organ system failure, (4) effect of sedative strategies, (5) prolonged mechanical ventilation time, (6) immobilization, and (7) other needed but unfortunate environmental factors including social isolation and quarantine without family. Given early insights into the pathobiology of the virus, as well as the emerging interventions utilized to treat the critically ill patients, delirium prevention and management will prove exceedingly challenging, especially in the intensive care unit (ICU). The main focus during the COVID-19 pandemic lies within organizational issues, i.e., lack of ventilators, shortage of personal protection equipment, resource allocation, prioritization of limited mechanical ventilation options, and end-of-life care. However, the standard of care for ICU patients, including delirium management, must remain the highest quality possible with an eye towards long-term survival and minimization of issues related to post-intensive care syndrome (PICS). This article discusses how ICU professionals (e.g., physicians, nurses, physiotherapists, pharmacologists) can use our knowledge and resources to limit the burden of delirium on patients by reducing modifiable risk factors despite the imposed heavy workload and difficult clinical challenges posed by the pandemic. - . Preliminary therapeutic drug monitoring data of β-lactams in critically ill patients with SARS-CoV-2 infection. Anaesth Crit Care Pain Med. 2020 Jun;39(3):387-388. doi: 10.1016/j.accpm.2020.04.005. Epub 2020 Apr 18.
[PMID: 32315803] [PMCID: 7166006] [DOI: 10.1016/j.accpm.2020.04.005]
- . A model for a ventilator-weaning and early rehabilitation unit to deal with post-ICU impairments following severe COVID-19. Ann Phys Rehabil Med. 2020 Jul;63(4):376-378. doi: 10.1016/j.rehab.2020.04.002. Epub 2020 Apr 18.
[PMID: 32315800] [PMCID: 7165266] [DOI: 10.1016/j.rehab.2020.04.002]
- . Atypical presentation of COVID-19 in a frail older person. Age Ageing. 2020 Jul 1;49(4):523-524. doi: 10.1093/ageing/afaa068.
[PMID: 32315386] [PMCID: 7188159] [DOI: 10.1093/ageing/afaa068]
Common symptoms of pandemic coronavirus disease (COVID-19) include fever and cough. We describe a 94-year-old man with well-controlled schizoaffective disorder, who presented with non-specific and atypical symptoms: delirium, low-grade pyrexia and abdominal pain. He was given antibiotics for infection of unknown source, subsequently refined to treatment for community-acquired pneumonia. Despite active treatment, he deteriorated with oxygen desaturation and tachypnoea. A repeat chest X-ray showed widespread opacification. A postmortem throat swab identified COVID-19 infection. He was treated in three wards over 5 days with no infection control precautions. This has implications for the screening, assessment and isolation of frail older people to COVID-specific clinical facilities and highlights the potential for spread among healthcare professionals and other patients. - . Collaborative Delirium Prevention in the Age of COVID-19. J Am Geriatr Soc. 2020 May;68(5):947-949. doi: 10.1111/jgs.16480.
[PMID: 32277467] [PMCID: 7262233] [DOI: 10.1111/jgs.16480]
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Empathie Humanisme Mythes et réalités Revue de la littérature
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2020
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[PMID: 33167822] [PMCID: 7655056] [DOI: 10.1080/10872981.2020.1844394]
Humanisme Enseignement Empathie Compassion
Lire
[PMID: 33167822] [PMCID: 7655056] [DOI: 10.1080/10872981.2020.1844394]
Humanisme Enseignement Empathie Compassion
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2020
. Prognostic factors for severity and mortality in patients infected with COVID-19: A systematic review. PLoS One. 2020 Nov 17;15(11):e0241955. doi: 10.1371/journal.pone.0241955. eCollection 2020.
[PMID: 33201896] [PMCID: 7671522] [DOI: 10.1371/journal.pone.0241955]
COVID19 Facteurs de risque Gravité Mortalité
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[PMID: 33201896] [PMCID: 7671522] [DOI: 10.1371/journal.pone.0241955]
COVID19 Facteurs de risque Gravité Mortalité
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2020
. Pharmacological interventions for the treatment of delirium in critically ill adults. Cochrane Database Syst Rev. 2019 Sep 3;9(9):CD011749. doi: 10.1002/14651858.CD011749.pub2.
[PMID: 31479532] [PMCID: 6719921] [DOI: 10.1002/14651858.CD011749.pub2]
Confusion Prévention Traitement Cochrane
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[PMID: 31479532] [PMCID: 6719921] [DOI: 10.1002/14651858.CD011749.pub2]
Confusion Prévention Traitement Cochrane
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2018
. Antipsychotics for treatment of delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2018 Jun 18;6(6):CD005594. doi: 10.1002/14651858.CD005594.pub3.
[PMID: 29920656] [PMCID: 6513380] [DOI: 10.1002/14651858.CD005594.pub3]
Neuroleptique Confusion Prévention Traitement
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[PMID: 29920656] [PMCID: 6513380] [DOI: 10.1002/14651858.CD005594.pub3]
Neuroleptique Confusion Prévention Traitement
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2016
. Antipsychotic Medication for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta-Analysis. J Am Geriatr Soc. 2016 Apr;64(4):705-14. doi: 10.1111/jgs.14076. Epub 2016 Mar 23.
[PMID: 27004732] [PMCID: 4840067] [DOI: 10.1111/jgs.14076]
Neuroleptique Confusion Prévention Traitement
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[PMID: 27004732] [PMCID: 4840067] [DOI: 10.1111/jgs.14076]
Neuroleptique Confusion Prévention Traitement
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2020
. Antipsychotics and the Risk of Mortality or Cardiopulmonary Arrest in Hospitalized Adults. J Am Geriatr Soc. 2020 Mar;68(3):544-550. doi: 10.1111/jgs.16246. Epub 2019 Nov 19.
[PMID: 31743435] [PMCID: 7155937] [DOI: 10.1111/jgs.16246]
Neuroleptique Mortalité Lire
[PMID: 31743435] [PMCID: 7155937] [DOI: 10.1111/jgs.16246]
Neuroleptique Mortalité Lire
2020
Confusion, COVID-19, troubles neurocognitifs chez la personne âgée : Repère bibliographique
Confusion COVID-19 Alzheimer Repère bibliographique
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Confusion COVID-19 Alzheimer Repère bibliographique
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2020
. Effects of dance on cognitive function in older adults: a systematic review and meta-analysis. Age Ageing. 2020 Dec 19:afaa270. doi: 10.1093/ageing/afaa270.
[PMID: 33338209] [DOI: 10.1093/ageing/afaa270]
Danse Prévention Alzheimer Revue systématique
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[PMID: 33338209] [DOI: 10.1093/ageing/afaa270]
Danse Prévention Alzheimer Revue systématique
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2020
. Alcohol and Dementia - What is the Link? A Systematic Review. Neuropsychiatr Dis Treat. 2020 Jan 9;16:87-99. doi: 10.2147/NDT.S198772. eCollection 2020.
[PMID: 32021202] [PMCID: 6957093] [DOI: 10.2147/NDT.S198772]
Alcool Prévention Alzheimer Revue systématique
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[PMID: 32021202] [PMCID: 6957093] [DOI: 10.2147/NDT.S198772]
Alcool Prévention Alzheimer Revue systématique
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2021
. The effect of plant-based dietary patterns on blood pressure: a systematic review and meta-analysis of controlled intervention trials. J Hypertens. 2021 Jan;39(1):23-37. doi: 10.1097/HJH.0000000000002604.
[PMID: 33275398] [DOI: 10.1097/HJH.0000000000002604]
Prévention Tension artérielle Régime alimentaire Végétarien
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[PMID: 33275398] [DOI: 10.1097/HJH.0000000000002604]
Prévention Tension artérielle Régime alimentaire Végétarien
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2020
. Efficacy of different dietary patterns on lowering of blood pressure level: an umbrella review. Am J Clin Nutr. 2020 Oct 6:nqaa252. doi: 10.1093/ajcn/nqaa252.
[PMID: 33022695] [DOI: 10.1093/ajcn/nqaa252]
Prévention Tension artérielle Régime alimentaire Végétarien
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[PMID: 33022695] [DOI: 10.1093/ajcn/nqaa252]
Prévention Tension artérielle Régime alimentaire Végétarien
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2020
. Approximating dementia prevalence in population-based surveys of aging worldwide: An unsupervised machine learning approach. Alzheimers Dement (N Y). 2020 Aug 27;6(1):e12074. doi: 10.1002/trc2.12074. eCollection 2020.
[PMID: 32885026] [PMCID: 7453145] [DOI: 10.1002/trc2.12074]
Alzheimer Prévalence Mondiale Machine learning
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[PMID: 32885026] [PMCID: 7453145] [DOI: 10.1002/trc2.12074]
Alzheimer Prévalence Mondiale Machine learning
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2014
. American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. J Am Geriatr Soc. 2015 Jan;63(1):142-50. doi: 10.1111/jgs.13281. Epub 2014 Dec 12.
[PMID: 25495432] [PMCID: 5901697] [DOI: 10.1111/jgs.13281]
Confusion Postopératoire Prévention Prise en charge
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[PMID: 25495432] [PMCID: 5901697] [DOI: 10.1111/jgs.13281]
Confusion Postopératoire Prévention Prise en charge
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2020
. Multicomponent Interventions for the Prevention of Delirium in Hospitalized Older People: A Meta-Analysis. J Am Geriatr Soc. 2020 Sep 9. doi: 10.1111/jgs.16768.
[PMID: 32902909] [DOI: 10.1111/jgs.16768]
Confusion Prévention Hôpital Meta-Analyse
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[PMID: 32902909] [DOI: 10.1111/jgs.16768]
Confusion Prévention Hôpital Meta-Analyse
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2020
. National French survey of COVID-19 symptoms in people aged 70 and over. Clin Infect Dis. 2020 Jun 18:ciaa792. doi: 10.1093/cid/ciaa792.
[PMID: 32556328] [PMCID: 7337693] [DOI: 10.1093/cid/ciaa792]
COVID-19 Symptômes Confusion France
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[PMID: 32556328] [PMCID: 7337693] [DOI: 10.1093/cid/ciaa792]
COVID-19 Symptômes Confusion France
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2020
. Blood phosphorylated tau 181 as a biomarker for Alzheimer's disease: a diagnostic performance and prediction modelling study using data from four prospective cohorts. Lancet Neurol. 2020 May;19(5):422-433. doi: 10.1016/S1474-4422(20)30071-5.
[PMID: 32333900] [DOI: 10.1016/S1474-4422(20)30071-5]
Alzheimer Diagnostic Biomarqueurs Sanguins
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[PMID: 32333900] [DOI: 10.1016/S1474-4422(20)30071-5]
Alzheimer Diagnostic Biomarqueurs Sanguins
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2009
. The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial. Lancet Neurol. 2009 Feb;8(2):151-7. doi: 10.1016/S1474-4422(08)70295-3. Epub 2009 Jan 8.
[PMID: 19138567] [DOI: 10.1016/S1474-4422(08)70295-3]
Alzheimer Neuroleptique Risque Iatrogénie
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[PMID: 19138567] [DOI: 10.1016/S1474-4422(08)70295-3]
Alzheimer Neuroleptique Risque Iatrogénie
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2013
. The desired moral attitude of the physician: (I) empathy. Med Health Care Philos. 2012 May;15(2):103-13. doi: 10.1007/s11019-011-9366-4.
[PMID: 22167298] [DOI: 10.1007/s11019-011-9366-4]
. The desired moral attitude of the physician: (II) compassion. Med Health Care Philos. 2012 Nov;15(4):397-410. doi: 10.1007/s11019-011-9368-2.
[PMID: 22160990] [DOI: 10.1007/s11019-011-9368-2]
. The desired moral attitude of the physician: (III) care. Med Health Care Philos. 2013 May;16(2):125-39. doi: 10.1007/s11019-012-9380-1.
[PMID: 22270800] [DOI: 10.1007/s11019-012-9380-1]
Empathie Care Compassion Humanisme
Lire la traduction partielle de l'article
[PMID: 22167298] [DOI: 10.1007/s11019-011-9366-4]
. The desired moral attitude of the physician: (II) compassion. Med Health Care Philos. 2012 Nov;15(4):397-410. doi: 10.1007/s11019-011-9368-2.
[PMID: 22160990] [DOI: 10.1007/s11019-011-9368-2]
. The desired moral attitude of the physician: (III) care. Med Health Care Philos. 2013 May;16(2):125-39. doi: 10.1007/s11019-012-9380-1.
[PMID: 22270800] [DOI: 10.1007/s11019-012-9380-1]
Empathie Care Compassion Humanisme
Lire la traduction partielle de l'article
2017
. CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol. 2017 Sep;89:218-235. doi: 10.1016/j.jclinepi.2017.04.026. Epub 2017 May 18.
[PMID: 28529185] [DOI: 10.1016/j.jclinepi.2017.04.026]
Recommandations Publication Cas clinique Checklist
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[PMID: 28529185] [DOI: 10.1016/j.jclinepi.2017.04.026]
Recommandations Publication Cas clinique Checklist
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2019
. The New Science of Practical Wisdom. Perspect Biol Med. 2019;62(2):216-236. doi: 10.1353/pbm.2019.0011.
[PMID: 31281119] [PMCID: 7138215] [DOI: 10.1353/pbm.2019.0011]
Empathie Sagesse Neurophysiologie Humanisme
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[PMID: 31281119] [PMCID: 7138215] [DOI: 10.1353/pbm.2019.0011]
Empathie Sagesse Neurophysiologie Humanisme
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2019
. Effect of Clinical Geriatric Assessments and Collaborative Medication Reviews by Geriatrician and Family Physician for Improving Health-Related Quality of Life in Home-Dwelling Older Patients Receiving Polypharmacy: A Cluster Randomized Clinical Trial. JAMA Intern Med. 2019 Oct 16;180(2):181-9. doi: 10.1001/jamainternmed.2019.5096.
[PMID: 31617562] [PMCID: 6802420] [DOI: 10.1001/jamainternmed.2019.5096]
Iatrogénie Conciliation médicamenteuse Médecin traitant Qualité de vie
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[PMID: 31617562] [PMCID: 6802420] [DOI: 10.1001/jamainternmed.2019.5096]
Iatrogénie Conciliation médicamenteuse Médecin traitant Qualité de vie
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2019
. Clinical Predictors of Intracranial Bleeding in Older Adults Who Have Fallen: A Cohort Study. J Am Geriatr Soc. 2020 May;68(5):970-976. doi: 10.1111/jgs.16338. Epub 2020 Feb 3.
[PMID: 32010977] [DOI: 10.1111/jgs.16338]
Chute Hémorragie cérébrale Facteurs prédictifs Étude de cohorte
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[PMID: 32010977] [DOI: 10.1111/jgs.16338]
Chute Hémorragie cérébrale Facteurs prédictifs Étude de cohorte
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2020
. Prevention of Falls in Community-Dwelling Older Adults. N Engl J Med. 2020 Feb 20;382(8):734-743. doi: 10.1056/NEJMcp1903252.
[PMID: 32074420] [DOI: 10.1056/NEJMcp1903252]
Chute Prévention Recommandations Médecine ambulatoire
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[PMID: 32074420] [DOI: 10.1056/NEJMcp1903252]
Chute Prévention Recommandations Médecine ambulatoire
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2020
. Boosting the signal in scientific talks. Nature. 2020 Mar;579(7800):621-622. doi: 10.1038/d41586-020-00838-3.
[PMID: 32210382] [DOI: 10.1038/d41586-020-00838-3]
Recommandations Présentation scientifique Communication orale Congrés
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[PMID: 32210382] [DOI: 10.1038/d41586-020-00838-3]
Recommandations Présentation scientifique Communication orale Congrés
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2020
. Effect of Aspirin vs Placebo on the Prevention of Depression in Older People: A Randomized Clinical Trial. JAMA Psychiatry. 2020 Jun 3. doi: 10.1001/jamapsychiatry.2020.1214.
[PMID: 32492080] [DOI: 10.1001/jamapsychiatry.2020.1214]
Dépression Prévention Traitement médicamenteux Aspirine
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[PMID: 32492080] [DOI: 10.1001/jamapsychiatry.2020.1214]
Dépression Prévention Traitement médicamenteux Aspirine
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2020
. American Cancer Society Guideline for Diet and Physical Activity for cancer prevention. CA Cancer J Clin. 2020 Jun 9. doi: 10.3322/caac.21591.
[PMID: 32515498] [DOI: 10.3322/caac.21591]
Prévention Cancer Régime alimentaire Activité physique
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[PMID: 32515498] [DOI: 10.3322/caac.21591]
Prévention Cancer Régime alimentaire Activité physique
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2020
Traductions partielles d'articles récemment publiés sur le thème de la prévention de la maladie d'Alzheimer, 2020
Alzheimer Prévention Recommandations Actualités
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Alzheimer Prévention Recommandations Actualités
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2020
L'élévation des troponines dans les rhabdomyolyse du sujet âgé, repère bibliographique.
Rhabdomyolyse Biomarqueurs Troponine Repères bibliographiques
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Rhabdomyolyse Biomarqueurs Troponine Repères bibliographiques
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2020
Résumé de livre : Noami Feil. La Validation© mode d'emploi. 2e édition, 2014, Éditions Pradel.
Alzheimer Empathie Communication Validation
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Alzheimer Empathie Communication Validation
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2019
Recension d'un article : Confusion en psychogériatrie : savoir-faire et savoir-être, Revue de Gériatrie Avril 2019.
Confusion Clinique Relation soignant-soigné Humanisme
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Confusion Clinique Relation soignant-soigné Humanisme
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2020
Traduction d'extraits de l'article : L'écoute active, de Carl Rogers et Richard Farson, excerpt from ACTIVE LISTENING, Communicating in Business Today, R.G. Newman, M.A. Danzinger, M. Cohen (eds), D.C. Heath & Company, 1987
Écoute active Communication Empathie Authenticité
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Écoute active Communication Empathie Authenticité
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