Delirium and neuropsychological outcomes in critically Ill patients with COVID-19: a cohort study

  1. Jacqueline Ragheb
  2. Amy McKinney
  3. Mackenzie Zierau
  4. Joseph Brooks
  5. Maria Hill-Caruthers
  6. Mina Iskander
  7. Yusuf Ahmed
  8. Remy Lobo
  9. Graciela Mentz
  10. Phillip E Vlisides

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Abstract

To characterise the clinical course of delirium for patients with COVID-19 in the intensive care unit, including postdischarge neuropsychological outcomes.

Design

Retrospective chart review and prospective survey study.

Setting

Intensive care units, large academic tertiary-care centre (USA).

Participants

Patients (n=148) with COVID-19 admitted to an intensive care unit at Michigan Medicine between 1 March 2020 and 31 May 2020 were eligible for inclusion.

Primary and secondary outcome measures

Delirium was the primary outcome, assessed via validated chart review method. Secondary outcomes included measures related to delirium, such as delirium duration, antipsychotic use, length of hospital and intensive care unit stay, inflammatory markers and final disposition. Neuroimaging data were also collected. Finally, a telephone survey was conducted between 1 and 2 months after discharge to determine neuropsychological function via the following tests: Family Confusion Assessment Method, Short Blessed Test, Patient-Reported Outcomes Measurement Information System Cognitive Abilities 4a and Patient-Health Questionnaire-9.

Results

Delirium was identified in 108/148 (73%) patients, with median (IQR) duration lasting 10 (4–17) days. In the delirium cohort, 50% (54/108) of patients were African American and delirious patients were more likely to be female (76/108, 70%) (absolute standardised differences >0.30). Sedation regimens, inflammation, delirium prevention protocol deviations and hypoxic-ischaemic injury were likely contributing factors, and the most common disposition for delirious patients was a skilled care facility (41/108, 38%). Among patients who were delirious during hospitalisation, 4/17 (24%) later screened positive for delirium at home based on caretaker assessment, 5/22 (23%) demonstrated signs of questionable cognitive impairment or cognitive impairment consistent with dementia and 3/25 (12%) screened positive for depression within 2 months after discharge.

Conclusion

Patients with COVID-19 commonly experience a prolonged course of delirium in the intensive care unit, likely with multiple contributing factors. Furthermore, neuropsychological impairment may persist after discharge.

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  1. Version published to 10.1136/bmjopen-2021-050045
  2. Version published to 10.1101/2020.11.03.20225466v2 on medRxiv
  3. ScreenIT

    SciScore for 10.1101/2020.11.03.20225466: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: All study operations were conducted at Michigan Medicine, Ann Arbor MI USA, and approval was obtained from the University of Michigan Medical School Institutional Review Board (HUM00182646).
    Consent: A Health Insurance Portability and Accountability Act waiver was granted in order to retrospectively review patient medical records, and informed consent was not required for retrospective chart review.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Statistical Analysis: Analyses were performed using IBM SPSS version 27 (Armonk, NY USA) and SAS version 9.4 (SAS Institute, Cary, NC USA).
    SPSS
    suggested: (SPSS, RRID:SCR_002865)
    SAS Institute
    suggested: (Statistical Analysis System, RRID:SCR_008567)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    In terms of limitations, this is a this was a single center analysis, and the results are restricted to the institution studied. The study was not conducted with a matched control cohort, as this was a descriptive study. The post-discharge telephone-based assessments served as screening tools rather than thorough neuropsychological testing batteries. As such, these post-discharge results are preliminary and warrant rigorous, follow-up analysis. Additionally, neuropsychological impairment may have been present at baseline for some patients, particularly for those with previous neurological disorders. Baseline neuropsychological testing was not possible for this study. Lastly, data were limited for post-discharge cognitive outcomes, as more than half of patients called were unavailable to complete assessments. In summary, delirium is common complication of COVID-19 with multiple contributing factors. Furthermore, neuropsychological impairment may persist in some patients after discharge. Further research should aim to identify independent risk factors in this population and novel, effective prevention strategies.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  4. Version published to 10.1101/2020.11.03.20225466v1 on medRxiv