Coronavirus Info: What to Expect Regarding Hospitalization (3.27.20)

Comments

1. Nicole Fisk says

   April 10, 2020 at 9:01 am

   Hi, Dr. Kernisan—

   I’ve been reading a lot of your posts today based on a current upset with my father … I’m hoping this is an appropriate comment thread to solicit advice, as it concerns two of your specialities/interests: dementia/delirium (which you discuss in prior posts) *during* the coronavirus crisis (the subject of this one).

   My 70-year-old father has moderate vascular dementia but is in stellar physical shape. This is problematic at the best of times but during a pandemic is downright frightening b/c he has the propensity to wander (e.g., he escaped from my house twice recently, once flagging down a cop and another time climbing a neighbor’s fence). Last Tuesday (4/31) we checked him into a memory care facility, thinking that he would be safer and happier in a more controlled environment with lots of people (he’s generally very friendly) and activities.

   This worked out beautifully during the day, when there was more staff and one-on-one attention, but not during the evenings, when he would get more disoriented and agitated. One week after his admission (4/7), the care facility sent him to the hospital for “behavior” issues, despite EMS asking them not to do so b/c of covid-19 exposure risks or us agreeing to the transfer (we would have rather picked him up ourselves than have him at a hospital treating covid-19 patients). I spoke to a case manager and two nurses at the hospital, and all of them were insistent that his behavior is in keeping with his prognosis and that he shouldn’t be in the hospital; the case manager went so far as to tell me that she believes he was dumped by memory care staff, who were refusing to readmit him after his hospital stay b/c of potential virus exposure.

   My mother picked up my father from the hospital yesterday afternoon and was shocked by how much he seems to have declined in a week — too sharply for even someone with a progressive disease like vascular dementia (think: not knowing how to sit; peeing and banging on walls). She describes him as seeming “vacant,” which she has never before experienced with him.

   From what you’ve written, this seems like delirium to me, no doubt exacerbated by the fact that he was sent to the hospital at a time when he was perfectly calm (sitting on a couch between two female residents and watching television); physically restrained on a stretcher; and thrown into the hospital environment for over 40 hours with nothing but the clothes on his back (e.g., as you’ve written, routine is very important, so being without pajamas, toothbrush, hairbrush, etc. no doubt compounded his distress).

   My question is: where in the world do we go from here? My mother has put in a call, of course, to Dad’s neorologist, but as it’s Good Friday, has only gotten voicemail. How does one get a diagnosis of and supportive care for delirium during a pandemic? Or, could this possibly not be delirium at all and reactions to lingering medication, like Hadol? Or could it be both, with one compounding the other?

   Thanks so much both for disseminating such important information on the web and for responding to comments. All the best, Nicole

   • Nicole Didyk, MD says

     April 10, 2020 at 12:10 pm

     Hi Nicole and I’m so sorry to hear about your situation. You have obviously been reading a lot on the site – your comments are very insightful.

     Transitions are hard for persons with dementia at the best of times, and this pandemic has compounded some of the challenges by limiting visiting hours, creating staffing shortages and making hospital trips much more anxiety-provoking. Delirium can certainly make a person appear much worse than usual and typically fluctuates as well. Medications like haldol (a major tranquilizer) are often used in delirium (to promote sleep and calm) but can have side effects that include sedation, increased risk of falls and more confusion.

     There is no definitive treatment for delirium and unfortunately, it can persist in a fluctuating pattern for days or weeks. The best way to promote delirium recovery is emphasizing routine, offering a familiar setting and familiar people (so it may be a good thing that he is at home), ensuring adequate hydration and avoiding sedating or anticholinergic medications if possible.

     I hope that the more time that passes since the hospital visit, the more your dad will feel and act like himself. Hope that is helpful and wishing you the best.

2. Leslie Kernisan, MD MPH says

   March 30, 2020 at 4:34 pm

   Thank you all for these comments, I’m so glad if the update was helpful.

   A reader emailed to ask for a reference for the household attack rate, in order to understand the risk of choosing to care for a family member at home. Let me say that I don’t think we know this yet, I haven’t come across a study for that. The question that I researched for the presentation was more this: If your household contact (e.g. a close family member) falls sick from COVID, how likely is it that you have already been exposed and caught the disease?

   Per the article below, among a Chinese sample, they found that household contacts tested positive for COVID 15% of the time.
   Epidemiology and Transmission of COVID-19 in Shenzhen China: Analysis of 391 cases and 1,286 of their close contacts
   Honestly, this was lower than I expected, given that people in households have a lot of contact with each other. I would also not assume this is the risk of getting COVID if you opt to care for a family member who falls ill from COVID and spend several days in the same house doing so, because in this study people who were symptomatic were removed from their homes and treated in hospitals (“Symptomatic cases were isolated and treated at designated hospitals regardless of test results. “)

   Another study estimated the “secondary attack rate” at 35%. Again, this was NOT a study of people caring for someone with symptomatic COVID.

   I hope this helps.

3. Kathy says

   March 28, 2020 at 3:28 pm

   Thank you for keeping us followers informed as information changes each day. My heart goes out to those families separated from each other because of this virus. It is time for each of us to have a plan just in case. Your talking points are spot on again about the best practices for our frail elderly parent should they contract Covid 19. I appreciate the detail in what medications might help in a hospice type setting to promote calmness.
   I have shared your website with other children of the elderly due to your candid and balanced advice.