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, co-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-quarters of coronavirus patients in I.C.U.’s 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and agitation; some have “hypoactive delirium,” internalized visions and confusion that cause patients to become withdrawn and incommunicative; and some have both.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 aren’t 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. 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 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 can’t visit and medical providers wear face-obscuring protective gear and spend limited time in patients’ room.
“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 Dr. 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 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 don’t cause strokes but spur subtle circulation disruption that might trigger cognitive problems and delirium, Dr. Inouye said.
Temko, a 69-year-old mortgage company executive, couldn’t speak because of the breathing tube in his mouth — he’d been on a ventilator at U.C.S.F. 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’d 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 dialled 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. “We had no choice,” Dr. Burkhardt said. “If you’re very sick and very unstable, basically what happens is we conclude you have bigger proble You know, I have to get you to live through it first.”
After about two weeks, the sedative-weaning process began, but other delirium-related quandaries emerged. Temko began experiencing pain and anxiety, compelling doctors to balance treating those conditions with using medications that can worsen delirium, they said.
The repeated nursing visits Temko needed interrupted his sleep-wake cycle, so he’d often take daytime naps and become sleepless and agitated at night, said Jason Bloomer, an ICU nurse.
At home, his wife kept her phone by her pillow so she could hear him via a nurse’s tablet. “He would wake up and was confused and anxious and he’d start getting all worked up to where the ventilator couldn’t work,” said Temko, who would reassure him, “It’s OK, breathe.” 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 Dr. 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,” Dr. Kaplan said, adding, “The cardinal sin of delirium is always impaired attention.”
Dr. 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.