Altered mental status in COVID-19

Abstract

Background Altered mental status (AMS) is a common neurological manifestation of COVID-19 infection in hospitalized patients. The principal causes of AMS have yet to be determined. We aimed to identify the common causes of AMS in patients with COVID-19 presenting to the emergency department with AMS on arrival. Methods We conducted a retrospective observational study of patients presenting with AMS to three New York hospitals, from March 1 to April 16, 2020. Underlying causes of AMS on arrival to the emergency department (ED) were categorized as (1) neurological causes (stroke, seizure, encephalitis); (2) metabolic encephalopathy; (3) indeterminant. Multivariable analysis was used to assess independent predictors. Results Overall, 166 patients presented to the ED with AMS. Metabolic encephalopathy was diagnosed as the cause in 154 (92.8%), with 118 (71.1%) categorized as multifactorial ME and 36 (21.7%) with single-cause ME. Hypoxia 103 (62.0%) and renal failure 75 (45.2%) were the most common underlying mechanisms. Neurological causes of AMS occurred in a total 20 patients (12%) and as the sole factor in 5 (3.0%); 10 (6.0%) cases were seizure related and 10 (6.0%) were cerebrovascular events. Of the 7 patients with indeterminant causes, only 1 was suspicious for encephalitis (0.6%). Age, pre-existing dementia and cerebrovascular disease, and impaired renal function were independent predictors of AMS. Conclusion In patients with COVID-19, AMS on presentation to the ED is most frequently caused by metabolic encephalopathy (delirium). Seizures and cerebrovascular events contribute to a lesser degree; encephalitis appears rare.

The etiology and mortality of altered level of consciousness in the emergency room: before and after coronavirus disease

“…Intra-cranial etiologies account- ed for approximately a quarter of the total. This finding is compatible with previous studies on BC [2,8,21]. Although the proportion of systemic infections decreased by approximately 8%, it was still the most common etiology of ALC in the ER, followed by metabolic causes.…”

“…There have been studies on changes in medical or ER utilization after the COVID-19 outbreak; however, there needs to be a more coherent definition of AC, discordant inclusion criteria, consistency in the study period, and etiology classification. Several studies have investigated periods of only 2 to 4 months to find a significant reduction in ER visits [15,20,21]. A few studies adopted a contrived definition of AC, with the number 2020 representing the year in the calendar rather than any medical gauge [18].…”

“…In contrast, few studies have evaluated ALC in the ER and compared BC and AC. An American study evaluated ALC in the ER in AC [21]; however, the study included only 166 patients over approximately 40 days, and its etiology classification was crude with only three categories: neurologic, metabolic, and indeterminate. Our study showed that the main etiologies of ALC in the ER were extra-cranial in AC and BC, and the leading cause was systemic infection.…”

Etiology and mortality of patients with altered level of consciousness in the emergency room: a multicenter analysis before and after the coronavirus disease 2019 outbreak

“…The complexity of these terms has led to abstract and inconsistent characteristics in research, since the study population or etiology classi cation system was different for each study [4][5][6][7][8][9]. The period analyzed was only 14 days in one study in the early days [10], another study had a short study period of 4 months [3], and a recent study evaluated only 47 days [11]. Some studies set the analysis target for suspicious alcohol intoxication only [12], trauma only [13], or elderly patients only [10,14].…”