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Hospitalized COVID-19 patients who presented with altered mental state had significantly higher risk of in-hospital death, even when pulmonary problems were not severe, a retrospective study showed.

Patients admitted to the hospital with confirmed SARS-Cov2 infection and altered mentation had a higher mortality risk than age- and severity-matched controls (OR 1.39, 95% CI 1.04-1.86, P=0.04), reported David Altschul, MD, of Montefiore Health Care System and Albert Einstein College of Medicine in New York City, and colleagues, in .

"Patients presenting with COVID-19 and altered mental status have a different hospital course than other patients with COVID-19. They are more likely to have abnormal presenting lab biomarker values and less likely to have classic COVID signs such as fever and oxygen desaturation," Altschul said.

"The important thing to understand here is that patients presenting to hospital emergency rooms with altered mental status and COVID-19 infection warrant hospital admission because they have a higher likelihood of a severe course, and a higher risk of death," he told 麻豆传媒. "These symptoms could be a harbinger for severe illness prior to other abnormal findings."

COVID patients with radiologically-confirmed stroke in the study, while fewer in number, also had higher mortality risk than controls (OR 3.1, 95% CI 1.65-5.92, P=0.001).

"Stroke, which can present with or without pulmonary COVID symptoms in COVID-19 patients, was the most severe neurologic manifestation presentation, but very rare, occurring in only 1% of all inpatient COVID-19 infections," Altschul noted. "COVID-19 patients who also had stroke were much more likely to have a severe illness."

The study looked at data from 4,711 COVID-19 patients admitted to Montefiore from March 1 to April 16, 2020. Of these, 581 (12%) had neurological problems serious enough to warrant neuroimaging. These patients were compared with 1,743 COVID-19 patients without neurologic symptoms, matched for age and disease severity, who were admitted in the same period.

Of the 581 patients, 258 had altered mental status and 55 were diagnosed with stroke. More than half of patients with altered mental status (56%) were men and 74% were older than 60. Some patients with altered mentation had dementia, but 23.6% had no history of cognitive impairment or any clear toxic, metabolic disturbances.

"We defined altered mental status as impaired cognition -- defined as disorientation, confusion, agitation, or delirium -- or impaired arousal, defined as drowsiness, somnolence, lethargy, or obtundation," Altschul said.

"The patients in this category were more likely to have abnormal biomarkers secondary to severe COVID-19 infection, which in many cases was the cause of their altered mental status," he added. "Regardless of the underlying cause of their altered mental state, these patients had worse outcomes."

It's likely many of these patients had delirium, "which has been confirmed in multiple previous studies to occur with increased frequency in older adults with COVID-19," noted Sharon Inouye, MD, MPH, of Hebrew SeniorLife in Boston and Harvard Medical School, who wasn't involved with the study.

"Delirium is a frequent presenting symptom and can be the main or only presenting symptom of COVID-19 infection," Inouye told 麻豆传媒. "Many older adults do not present with the typical symptoms of fever, cough, or shortness of breath. Heightening the awareness of delirium will help to improve the detection and management of COVID-19 infection in older adults."

More than half of stroke patients (56.4%) in the study did not have hypertension or other underlying risk factors for stroke, which "agrees with other studies of people with COVID-19 in suggesting that infection with the novel coronavirus is itself a risk factor for stroke," Altschul said.

The study is perhaps the largest to look at neurologic manifestations of COVID-19 and inpatient mortality, the researchers noted. It had several limitations: most patients were Black or Latino and all were admitted during a major surge period. Deaths that occurred outside the Montefiore health system were not captured and minor stroke cases may have been missed.

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