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As we get past the surge (fingers crossed) of COVID-19, the two most striking pathologies we are seeing are a much greater volume than usual of delirium as well as persistent encephalopathy.
“You guys must be twiddling your thumbs these days, huh?” This was the ill-informed question posed to me by one of our outpatient primary care doctors moonlighting now as a hospitalist in this “all-hands-on-deck” time of ours. I looked at him and only laughed.
Previously, at the early stages (for my state, Massachusetts) I had written briefly about the frequent emergency department cases of brief psychosis related to severe anxiety in the context of what was then COVID-19 anticipation.1 Now that we are in full-blown “surge,” or even past the surge (fingers crossed), the two most striking pathologies we are seeing on the medical side are a much greater volume than usual of refractory delirium, both in COVID-19 and non-COVID-19 patients, punctuated by less common, but puzzling, cases of persistent encephalopathy seemingly related to COVID-19 infection.
The biggest challenge we have faced thus far has been the requests for assistance in managing persistent delirium. These have increased about three-fold and continue to rise. These have been split roughly in half between COVID-19 and non-COVID-19 patients, mirroring where we are at this point with regard to inpatient populations, with actually only about a quarter having been intubated at some point in the ICU. Almost all are older than 75, and about three-quarters are male. About three-quarters have pre-existing cognitive decline. About a quarter are non-native English speakers. Many have required significantly higher doses of antipsychotic medications than are typically prescribed. Most have required augmenting agents such as anti-epilepsy drugs, benzodiazepines, barbiturates, dexmedetomidine, opiates, and/or ketamine.
The question of course is why are these cases so refractory? Never in my experience have we had to resort to such trial and error, and really for the safety of the patients and staff, as many patients have been unwittingly violent.
We have collected the following contributors to this phenomenon:
1. The hospital has not been allowing any visitors. There have been no family or other social supports at the bedside on a consistent basis to orient and re-orient patients appropriately.
2. Staff are required to wear masks at all times. And on the medical and surgical floors, most are wearing much more, including all manner of goggles, face shields, and surgical caps. In other words, every person these patients see looks like something out of a science fiction movie. There are no faces to read, no way to gain a sense of the situation.
3. There is no touch anymore. I never noticed how much I touch older patients until now. We all catch ourselves as we instinctively reach to touch a shoulder, to hold a hand, to press someone back down gently into bed.
4. The lack of technological experience in the older population has made communication between patients and their spouses, siblings, and peers difficult. Many family members with whom we have spoken do not have smartphones or computers. This has also made applications for Medicaid and other assistance exceedingly slow and difficult to arrange.
5. Cases of guardianship have been delayed, lengthening duration of hospital stay, due to the closure of the courts.
6. The language barrier is obviously that much more isolating in these particular cases.
7. Staff fatigue and burnout at this point is playing a role, as there seems to be little patience left for agitation and confusion. The immediate requests for assistance are invariably requests for sedating medications.
8. There has been and continues to be the problem of bottlenecking on the discharge end. With the COVID-19 crisis, although recently improving, there have generally been very few available skilled nursing facilities and long-term care facilities, also resulting in much longer hospital stays.
Much less common, but more difficult to explain, and thus far unresponsive to all attempted treatments, has been another form of persistent encephalopathy that in the two cases we have seen to this point were first aptly described by one ICU team as “different than the typical different we’ve been seeing.” In each case, one male and one female, the female in her late fifties, the male in his early sixties, both with significant psychiatric histories with psychotic symptoms in the past, both previously on longstanding chronic antipsychotic medications, the admission was for COVID-19 infection with subsequent complications. Both were intubated during their respective hospital courses, three days for our female patient, and three weeks for our male; both required tracheostomy due to complications. Both had type 2 diabetes and hypertension. Both had COPD and were smokers. Both had had previous strokes and had been living in skilled nursing facilities. Both had remote alcohol and cannabis histories. But at baseline, prior to their hospitalizations, both had been fully cognizant and conversant, both fully ambulatory with only minimal motor deficits.
The difference was noted soon after extubation. As their pulmonary function improved, and organs generally recovered, they remained mentally altered, mostly staring off and non-interactive. They appeared conscious and awake, but they would not eat or drink on their own. They would not respond to any commands. Their pupils were sluggish but reactive, but their eyes could not track. They had intermittent episodes of rigidity, mostly in their upper extremities and neck. The differential included stroke, status epilepticus, catatonia, hypoactive delirium, and neuroleptic malignant syndrome (their antipsychotic medications had been discontinued abruptly in the setting of treatment with hydroxychloroquine and azithromycin, due to risk of QTc prolongation). Inflammatory markers were persistently elevated, consistent with COVID-19 infection as well as neuroleptic malignant syndrome. Vital signs at this point were unremarkable.
Stroke and seizure were ruled out. Further infectious causes were ruled out. Metabolic causes were ruled out. Antipsychotics were held, and empiric treatment with lorazepam and bromocriptine were initiated. Some improvement was noted in rigidity, but nothing else. Gradual reintroduction of antipsychotics had no effect. Inflammatory markers have since stabilized, but with no improvement in mental status. Both patients are still with us, vegetative, on total parenteral nutrition, now total care, awaiting long-term care placement.
At this point the differential includes anoxic brain injury due to complicated intubation, chronic delirium, or to direct neurotoxic effect of the COVID-19 virus on the brain. There are similar case reports, but presently these cases remain a mystery.2,3
Other issues the psychiatry consultation-liaison service is contending with are the management of acute substance withdrawals in critically ill COVID-19 patients, often mimicking symptoms of the illness itself, collaborating with our palliative care colleagues in determining the futility of care, and the management and placement of psychiatrically decompensated COVID-19-positive but asymptomatic patients for whom there are very few placement options at this time.
Not exactly twiddling our thumbs, but I must say, all of our services, in my particular hospital, have been working inspiringly, tirelessly, and exceedingly well together throughout this crisis.
Dr Martin is Director of Medical Psychiatry, Newton-Wellesley Hospital, Newton, MA, and Clinical Assistant Professor of Psychiatry, Tufts University School of Medicine, Boston.
1. Martin Jr, EB. Brief psychotic disorder triggered by fear of coronavirus?Psychiatric Times. May 8, 2020; Epub ahead of print.
2. McNamara D. Neurologic symptoms and COVID-19: what’s known, what isn’t. The Hospitalist. April 6, 2020.
3. Wu Y, Xu X, Chen Z, et al. Nervous system involvement after infection with COVID-19 and other coronaviruses. Brain Behav Immun. March 30, 2020; Epub ahead of print.