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Altered mental status in COVID-19
Daniel Antoniello1, Mark J Milstein2, Joseph Dardick3
1Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Ave, 4th Floor, Bronx, NY, 10467, USA. dantonie@montefiore.org.
Insights
Altered mental status in COVID-19 patients is most often caused by metabolic encephalopathy, not primary neurological issues. Hypoxia and renal failure were key factors, with seizures and stroke less common.
Area of Science:
- Neurology
- Infectious Diseases
- Critical Care Medicine
Background:
- Altered mental status (AMS) is a frequent neurological symptom in hospitalized COVID-19 patients.
- The primary drivers of AMS in this population remain unclear.
- This study sought to identify common causes of AMS in emergency department (ED) patients with COVID-19.
Purpose of the Study:
- To determine the principal causes of altered mental status (AMS) in patients with COVID-19 presenting to the emergency department.
- To differentiate between neurological and metabolic etiologies of AMS in this cohort.
Main Methods:
- A retrospective observational study was conducted on 166 patients with AMS presenting to three New York hospitals (March 1 - April 16, 2020).
- Causes of AMS were classified as neurological, metabolic encephalopathy, or indeterminate.
- Multivariable analysis identified independent predictors of AMS.
Main Results:
- Metabolic encephalopathy (ME) was the predominant cause of AMS, diagnosed in 92.8% of patients.
- Hypoxia (62.0%) and renal failure (45.2%) were the most frequent underlying mechanisms contributing to ME.
- Neurological causes, including seizures and cerebrovascular events, accounted for 12% of cases; encephalitis was rare (0.6%).
Conclusions:
- Metabolic encephalopathy is the most common cause of altered mental status in COVID-19 patients presenting to the ED.
- Neurological events like seizures and cerebrovascular disease play a lesser role.
- Encephalitis is an infrequent cause of AMS in this patient group.
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.
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