Delirium is characterized by fluctuating disturbance of consciousness, inattention, reduced awareness, hallucinations or delusions, occurring in 20% of hospital admissions. Central nervous system symptoms are the main form of neurologic injury in patients with COVID-19 and a significant portion of these patients presents with delirium. COVID-19 infection’s course and symptoms, as well as patient comorbidities can facilitate its onset, which is exacerbated by the frequent need for higher doses of sedation to suppress severe cough.

To summarize the most recent practices for management of delirium in COVID-19 infected patients, with emphasis on the psychopharmacology approach.

Selective literature review via PubMed search, using the terms “delirium, neurological disorders, psychopharmacology and COVID-19”.

COVID-19 associated delirium can be presented in its hyperactive type with exuberant agitation, but also with additional clinical features such as rigidity, akinetic mutism, abulia and alogia. Psychopharmacological approaches may be needed for patients with agitation when there’s intractable stress or risk to self or others. In this group of patients, melatonin, alfa-2 agonists and low potency antipsychotics have been used as first line treatment. Trazodone, valproate, dopamine agonists, amantadine can be used. Other approaches such as correction of vitamin deficiencies and remdesivir can also play a role.

Delirium remains frequently unrecognized. In the pandemic context of COVID-19 it is important to consider this infection as a cause of delirium and mind the misdiagnosis as a psychiatric condition. One should look for atypical features and be more thoughtful about the psychopharmacological approach.

Psychopathy is a personality disorder characterized by lack of empathy, grandiosity, an impulsive lifestyle and antisociality. Anti-social personality disorder (ASPD) and psychopathy are distinct concepts presenting different criteria. Most people with a diagnosis of psychopathy also meet criteria for ASPD while the reverse is not true. Along the years there has been an increasing interest in investigating genetic and neurobiological factors.

To analyze the neurobiological factors involved in psychopathy and anti-social personality disorder according to the scientific knowledge available.

Review of scientific literature via PubMed search, using the terms “anti-social personality disorder”, “biology or etiology or pathophysiology and psychopathy”.

The strongest evidence base for a genetic pathway is associated with the low-expression variant of the Monoamine Oxidase-A (MAO-A) which is linked to the X chromosome. Other genetic factors involve the 5-HTT gene, dopamine receptor genes (DRD4 and DRD2) and genetic polimorfisms at SNAP25 t-snare protein, OXT gene and the CNR1 and FAAH cannabinoid receptor gene. Structural differences in the brain have been noticed such as reduced gray matter volume in the orbitofrontal cortex, gray matter volume reductions in the mid-anterior insula and left anterior temporal cortex, subtle reductions in gray matter volume across several paralimbic and limbic areas.

There is considerable evidence regarding various possible underlying neurobiological processes in psychopathy although it is insufficient to suggest a single biological etiology and environmental influences cannot be excluded from a complete understanding of this disorder. The neurobiological correlates found hold promise for new research and treatment.

Executive functions (EF) are associated to frontal lobes and cognitive decline (CD) with worse results on EF tests.

Analyze if the Frontal Assessment Battery/FAB assessing EF discriminates elders with CD (vs. with no CD; Montreal Cognitive Assessment/MoCA), and if the results obtained with the Rey Osterreith Complex Figure Test/ROCF (copy's quality, immediate, and delayed memory) are associated with the CD presence/absence. Moreover, we wanted to assess if copy's quality and 3 minutes memory test are associated with FAB results, since these two tests are supposedly associated with EF and with frontal lobes assessed by the FAB, contrarily to the 20 minutes memory (supposedly related to the temporal area).

556 institutionalized elders (age: M ± SD =80.2 ± 5.23; range=60-100) filled in voluntarily a sociodemographic questionnaire, ROCF, MoCA and FAB.

FAB and all ROCF tests were associated with the absence/presence of CD. Regarding variables stratified by age and education, FAB was associated with immediate memory but not with copy's quality nor with delayed memory. With no stratified ROCF and FAB, correlations confirmed the previous associations, but also between FAB and copy's quality.

Results follow the literature regarding the association between immediate memory and EF (associated to frontal lobes), in contrast to the long-term memory which is associated with the temporal area and that was not associated with FAB. Results concerning copy's quality (ROCF) are not consensual.

When cognitive decline (CD) is present, attention is one of the impaired mental functions. CD is also associated with anxious/depressive symptoms and with some demographic variables, particularly, age.

Investigate the associations between selective attention (Stroop Test: Stroop_Word, Stroop_Color, Difference between Stroop_Word and Stroop_Color, Stroop Ratio_Word, Stroop Ratio_Color and Difference between Stroop Ratio_Word and Stroop Ratio_ Color) and CD (Montreal Cognitive Assessment/MoCA) in institutionalized elders; explore the predictive value of Stroop variables for CD, controlling anxious/depressive symptoms and sociodemographic variables.

140 institutionalized elders (mean age, M = 78.4, SD = 7.48, range = 60-97) voluntarily answered to sociodemographic questions, the MoCA, the Geriatric Anxiety Inventory/GAI, the Geriatric Depression Scale/GDS and Stroop test.

73 elders (52, 1%) had CD. Dichotomized MoCA was associated with Stroop_Word, Stroop_Color, Stroop Ratio_Word, Stroop Ratio_Color, GDS and the sociodemographic variable schooling × profession. Age and education were not tested, since MoCA was stratified according to those variables. GDS, Stroop Ratio_Word and Stroop Ratio_Color showed to predict CD.

There was an association between Stroop_Word, Stroop_Color, Stroop Ratio_Word and Stroop Ratio_Color and CD, confirming that selective attention is smaller when the elderly reveal CD. GDS and CD were, also, associated. However, there was no association between MoCA dichotomized and differences between the correct answers (Stroop_Word and Stroop_Color) and Ratios (Stroop Ratio_Word and Stroop Ratio_Color). Selective attention and depressive symptoms predicted CD. It would be important to intervene through cognitive rehabilitation with the elders to improve their attention.