Terrifying delirium plagues COVID patients
Kim Victory was paralyzed on a bed and being burned alive.
Just in time, someone rescued her, but suddenly, she was turned into an ice sculpture on a fancy cruise ship buffet. Next, she was a subject of an experiment in a lab in Japan. Then she was being attacked by cats.
Nightmarish visions like these plagued Victory during her hospitalization this spring for severe respiratory failure caused by the coronavirus. They made her so agitated that one night she pulled out her ventilator breathing tube; another time, she fell off a chair and landed on the floor of the intensive care unit.
“It was so real, and I was so scared,” said Victory, 31, now back home in Franklin, Tenn.
To a startling degree, many coronavirus patients are reporting similar experiences. Called hospital delirium, the phenomenon has previously been seen mostly in a subset of older patients, some of whom already had dementia, and in recent years, hospitals adopted measures to reduce it.
“All of that has been erased by COVID,” said Dr. E. Wesley Ely, a director of the Critical Illness, Brain Dysfunction and Survivorship Center at Vanderbilt University and the Nashville Veteran’s Administration Hospital, whose team developed guidelines for hospitals to minimize delirium.
Now, the condition is bedeviling coronavirus patients of all ages with no previous cognitive impairment. Reports from hospitals and researchers suggest that about two-thirds to three-fourths of coronavirus patients in ICUs have experienced it in various ways. Some have “hyperactive
delirium,” paranoid hallucinations and agitation; some have “hypoactive delirium,” internalized visions and confusion that cause patients to become withdrawn and incommunicative; and some have both.
The experiences are not just terrifying and disorienting. Delirium can have detrimental consequences long after it lifts, extending hospital stays, slowing recovery and increasing people’s risk of developing depression or post-traumatic stress disorder. Previously healthy older patients with delirium can develop dementia sooner than they otherwise would have and can die earlier, researchers have found.
“There’s increased risk for temporary or even permanent cognitive deficits,” said Dr. Lawrence Kaplan, director of consultation liaison psychiatry at the University of California, San Francisco Medical Center. “It is actually more devastating than people realize.”
‘The perfect storm’
The ingredients for delirium are pervasive during the pandemic. They include long stints on ventilators, heavy sedatives and poor sleep. Other factors: Patients are mostly immobile, occasionally restrained to keep them from accidentally disconnecting tubes, and receive minimal social interaction because families cannot visit and medical providers wear face-obscuring protective gear and spend limited time in patients’ rooms.
“It’s like the perfect storm to generate delirium; it really, really is,” said Dr. Sharon Inouye, a leading delirium expert who founded the Hospital Elder Life Program, guidelines that have helped to significantly decrease delirium among older patients. Both her program and Ely’s have devised recommendations for reducing delirium during the pandemic.
The virus itself or the body’s response to it may also generate neurological effects, “flipping people into more of a delirium state,” said Dr. Sajan Patel, an assistant professor at the University of California, San Francisco.
The oxygen depletion and inflammation that many seriously ill coronavirus patients experience can affect the brain and other organs besides the lungs. Kidney or liver failure can lead to buildup of delirium-promoting medications. Some patients develop small blood clots that do not cause strokes but spur subtle circulation disruption that might trigger cognitive problems and delirium, Inouye said.
Exacerbated by drugs
“AK-47,” Ron Temko wrote in shaky handwriting from his hospital bed.
Then he pointed at his neck to show where the assault rifle should aim.
Temko, a 69-year-old mortgage company executive, could not speak because of the breathing tube in his mouth — he had been on a ventilator at UCSF Medical Center for about three weeks by then. So, on a Zoom call nurses arranged with his family, he wrote on paper attached to a clipboard.
“He wants us to kill him,” his son gasped, according to Temko and his wife Linda.
“No, honey,” Linda implored, “you’re going to be OK.”
At home now in San Francisco
after a 60-day hospitalization, Temko said his suggestion that his family shoot him stemmed from a delirium-fueled delusion that he had been abducted.
“I was in a paranoiac phase where I thought there was some sort of conspiracy against me,” he said.
When he was first placed on the ventilator, doctors used a lighter sedative, propofol, and dialed it down for hours so he could be awake and know where he was — a “regimen to try to avoid delirium,” said Dr. Daniel Burkhardt, an anesthesiologist and intensivist who treated him.
But then Temko’s respiratory failure worsened. His blood pressure plummeted, a condition propofol intensifies. To allow the ventilator to completely breathe for him, doctors had him chemically paralyzed, which required heavier sedatives to prevent the trauma of being conscious while unable to move.
So Temko’s sedation was switched to midazolam, a benzodiazepine, and fentanyl, an opioid — drugs that exacerbate delirium.
His hallucinations included a rotating human head. “Every time it came around, someone put a nail in it, and I could see that the person was still alive,” he said.
He met with Kaplan, the psychiatrist, who recognized his symptoms as delirium, partly because Temko bungled tests like naming the months backward and counting down from 100 by sevens. “He could only get from 100 to 93,” Kaplan said, adding, “The cardinal sin of delirium is always impaired attention.”
Kaplan prescribed Seroquel, which he said helps with perceptual disturbances and anxiety.
Temko said another turning point came when
Bloomer said that with months of hard work, recovery was likely.
An optimistic cognitive sign, said Kaplan, is that Temko can now describe his delirium in much more detail than he could several weeks ago.
‘Down a rabbit hole’
Two months after returning home from her threeweek hospitalization, Victory said she has been experiencing troubling emotional and psychological symptoms, including depression and insomnia. She has been noticing the smell of cigarettes or wood burning, a figment of her imagination.
“I feel like I’m going down a rabbit hole, and I don’t know when I will be back to myself,” she said.
Dr. Kevin Hageman, one of her physicians at Vanderbilt University Medical Center, said she “was pretty profoundly delirious.”
Victory, a Vietnamese immigrant and previously healthy community college student majoring in biochemistry, said she did not remember yanking out her breathing tube, which was reinserted. But she recalled visions blending horror with absurdity.
One moment, scientists in Japan were testing chemicals on her; the next, she was telling them, “‘I am an American, and I have a right to eat a cheeseburger and drink Coca-Cola,’ ” she recalled, adding: “I don’t even like cheeseburgers.”
Now, to help overcome the fallout from the experience, she has started taking an antidepressant her doctor prescribed and recently saw a psychologist.
“People think when the patient got well and out of the hospital, it will be OK, it’s over,” Kim Victory said. “I worry if the virus didn’t kill me back then, would that have affected my body enough to kill me now?”