Follow-up services for delirium after COVID-19—where now?

Abstract

Delirium is a common presentation in older inpatients with COVID-19, and a risk factor for cognitive decline at discharge. The glaring gaps in the service provision in delirium care, regardless of aetiology, after a hospital admission pre-existed the pandemic, but the pandemic arguably offers an opportunity now to address them. Whilst a delirium episode in itself is not a long-term condition, the context of it may well be, and therefore patients might benefit from personalised care and support planning. There is no reason to believe that the delirium following COVID-19 is fundamentally different from any other delirium. We propose that the needs of older patients who have experienced delirium including from COVID-19 could be addressed through a new model of post-acute delirium care that combines early supported discharge, including discharge-to-assess, with community-based follow-up to assess for persistent delirium and early new long-term cognitive impairment. Such a drive could be structurally integrated with existing memory clinic services. To succeed, such an ambition has to be both flexible, adaptable and person-centred. To understand the impact on resource and service utilisation, techniques of quality improvement should be implemented, and appropriate metrics reflecting both process and outcome will be essential to underpin robust and sustainable business cases to support implementation of delirium care as a long-term solution.

Pulmonary embolism or COVID‐19 pneumonia? A case report

“…6 Although delirium typically occurs during the acute phase of illness, it can be prolonged in vulnerable patients, such as those with advanced age, neurocognitive impairments, or limited mobility. 7 As with COVID-19, PE may manifest with fever and cardiorespiratory symptoms such as a drop in blood pressure, tachycardia, dyspnea, tachypnea, and hypoxia. 8 Furthermore, the ischemia-related lung changes of pulmonary embolism on chest CT can present as bilateral ground-glass opacities resembling infectious conditions, including COVID-19 and other viral or bacterial pneumonia.…”

“…According to prior research, delirium is the most prevalent neuropsychological symptom of COVID‐19 in older persons 6 . Although delirium typically occurs during the acute phase of illness, it can be prolonged in vulnerable patients, such as those with advanced age, neurocognitive impairments, or limited mobility 7 …”

Persistent delirium in older hospital patients: an updated systematic review and meta-analysis

“…These are almost non-existent, certainly out of proportion with the potential demand, though multicomponent interventions show promise. 39 Recognising the opportunities for the emerging field of interface acute geriatrics would be an important starting point, 40 and continued community-based management of delirium is likely to have an impact. 41 This systematic review emphasises the key importance of delirium as a persistent and extensive problem, particularly in the oldest-old.…”

The evidence for introducing case-finding for delirium and dementia in older medical inpatients in a New Zealand hospital

“…The question then becomes, if we can identify people with dementia and/or delirium, what services can we provide that will improve their outcomes? Enhanced case-finding should be linked with high quality care packages whilst in hospital, 12 but patients also require comprehensive follow-up to monitor recovery, identify persistent cognitive impairment and plan future care, 13 and integration with appropriate dementia services such as crisis services designed to prevent unnecessary admissions to hospital. 14 A model that combines intensive crisis services for dementia with high quality inpatient care for delirium and dementia, and assertive outpatient follow-up to support recovery, is worthy of consideration in our local hospital setting, although such services have yet to be tested in New Zealand.…”