Neurocovid: Pharmacological recommendations for delirium associated with COVID-19

Baller, Erica B.; Hogan, Charlotte S.; Fusunyan, Mark A.; Ivkovic, Ana; Luccarelli, James W.; Madva, Elizabeth; Nisavic, Mladen; Praschan, Nathaniel; Quijije, Nadia V.; Beach, Scott R.; Smith, Felicia A.

BACKGROUND: The pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as one of the biggest health threats of our generation. A significant portion of patients are presenting with delirium and neuropsychiatric sequelae of the disease. Unique exam findings and responses to treatment have been identified. We seek to provide pharmacologic and treatment recommendations specific to delirium in patients with COVID-19. METHODS: We performed a literature search reviewing the neuropsychiatric complications and treatments in prior coronavirus epidemics including middle eastern respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS) coronaviruses as well as the emerging literature regarding COVID-19. We also convened a work group of consultation-liaison psychiatrists actively managing COVID-19 patients in our hospital. Finally, we synthesized these findings to provide preliminary pharmacologic recommendations for treating delirium in these patients. RESULTS: Delirium is frequently found in patients who test positive for COVID-19, even in the absence of respiratory symptoms. There appears to be a higher rate of agitation, myoclonus, abulia, and alogia. No data are currently available on the treatment of delirium in COVID-19 patients. Extrapolating from general delirium treatment, MERS/SARS case reports, and our experience, preliminary recommendations for pharmacologic management have been assembled. CONCLUSIONS: COVID-19 is associated with neuropsychiatric symptoms. Low potency neuroleptics and alpha-2 adrenergic agents may be especially useful in this setting. Further research into the pathophysiology of COVID-19 will be key in developing more targeted treatment guidelines.