Residents with COVID-19 are at high risk for delirium, and sometimes delirium may be a presenting feature of infection even without respiratory symptoms. Anxiety and depressive symptoms are often common reactions for people with a COVID-19 diagnosis, especially for those who are hospitalized.
Stressors particular to COVID-19 include:
- Fear of falling ill and dying
- Fear of being socially excluded/placed in quarantine
- Loss of livelihood
- Loss of loved ones
- Feelings of helplessness, boredom and loneliness due to being isolated
These stressors may trigger new symptoms or exacerbate underlying mental or neurological conditions. Residents with pre-existing mental health conditions and substance abuse disorders may also be adversely impacted. Residents with COVID-19 are at higher risk for sleep problems owing to acute stress responses, as well as additional reasons for those who are hospitalized such as environmental factors, invasive medical procedures (e.g. mechanical ventilation) and the frequent combination of multiple medications possibly disrupting sleep patterns.
It is highly recommended that in residents with COVID-19, measures to prevent delirium be implemented and using standardized protocols, evaluate for the development of delirium. If the resident is suspected of having delirium, immediately evaluate, address underlying causes of delirium and seek treatment orders from the attending physician.
- Manage any underlying causes of delirium by:
- Monitoring oxygenation and fluid status
- Correcting metabolic or endocrine abnormalities
- Addressing co-infections
- Minimizing the use of medications that may cause or worsen delirium
- Treating withdrawal from substances
- Understanding and minimizing the effects of any harmful drug-drug interactions
- Maintaining normal sleep cycles as much as possible
- In residents experiencing agitation (defined as marked restlessness or excessive motor activity, often accompanied by anxiety), use calming communication strategies and attempt to reorient the resident.
- Acute pain due to physical illness or air hunger should be considered as triggers for agitation and need to be addressed immediately. If the resident continues to be agitated despite these interventions and is experiencing severe distress, it may be necessary to use psychotropic medications.
- When using antipsychotic medications for agitation, consider side-effects that may worsen symptoms including:
- Respiratory or cardiac function
- Risk of fever or other immunological abnormalities
- Coagulation abnormalities
- Potential drug-drug interactions between these and other medications.
Use minimum effective doses of antipsychotic medications at the lowest frequency and for the shortest duration possible, with doses adjusted according to age, medical co-morbidities and degree of distress.
Mental health and psychosocial support:
Provide basic mental health and psychosocial support for residents with suspected or confirmed COVID-19 by asking them about their needs and concerns, and address them.
- It is critical that prompt identification and assessment for anxiety and depressive symptoms in residents diagnosed with COVID-19 and that psychosocial support strategies be initiated to manage new anxiety and depressive symptoms.
- For residents who are experiencing symptoms of anxiety, psychosocial support strategies such as psychological first aid, stress management, and brief psychological interventions based on the principles of cognitive behavioral therapy should be considered.
- For residents who are experiencing symptoms of depression, brief psychological interventions based on the principles of cognitive behavioral therapy, problem-solving treatment and relaxation training can be considered.
- If the resident’s anxiety or depressive symptoms persist beyond recovery from COVID-19 and/or discharge from the hospital, then an underlying anxiety or depressive disorder may be suspected, and a mental health professional should be consulted.
- It is important to ask about thoughts or acts of self-harm, particularly during COVID-19, due to risk factors for self-harm and suicide such as sense of isolation, loss of a loved one, job, or financial loss and hopelessness. Remove possible means of self-harm, activate psychosocial support, follow up with the person, and consult a mental health professional as necessary.
- Sleep hygiene and stress management (including relaxation techniques and mindfulness practices) are effective in reducing sleep problems and may be offered. Psychological interventions based on the principles of cognitive behavioral therapy may also be considered.
- For residents who are hospitalized for COVID-19, additional causes of insomnia may include environmental factors (e.g. excessive light and noise at night), anxiety, delirium, agitation, pain or air hunger. Identifying and promptly addressing underlying causes should be prioritized before using any pharmacological sleep aids.