Many Older Adults With Severe COVID Presented With Atypical Symptoms

Over a third of older adults who were hospitalized with COVID-19 during the early months of the pandemic had an atypical presentation, with a mix of typical and atypical symptoms, researchers found.

Almost a quarter of patients ages 65 and older presented with functional decline, while 11.3% presented with altered mental status and around 9% had gastrointestinal symptoms, reported Allison Marziliano, PhD, from the Feinstein Institutes for Medical Research in Manhasset, New York, and colleagues.

Moreover, among those with an atypical presentation, 49% presented with atypical symptoms only, the authors wrote in the Journals of Gerontology: Series A.

“I agree with the finding in the article that older and more medically complex patients have often presented with atypical symptoms such as altered mental status, falls, worsening of functions, changes in behaviors, diminished appetite [and] dehydration,” Saket Saxena, MD, of Cleveland Clinic Center for Geriatric Medicine, told MedPage Today.

“Earliest identification of these atypical symptoms and studying them as diagnostic/prognostic criteria for COVID-19 symptoms in elderly and medically complex patients is something to learn from the first surge of the pandemic,” said Saxena, who was not involved in this study.

Marziliano’s group noted that advancing age is more often linked to sensory or cognitive impairments, which can lead to “vague and nonspecific presentations of acute illness” due to an inability to perceive or accurately report symptoms. Patient demographics and clinical characteristics of atypical COVID-19 have not been fully investigated, though previous smaller studies found a proportion of hospitalized adults had atypical presentations, such as altered mental status and generalized weakness.

“Our findings provide evidence for guidelines by a number of organizations […] that screening older adults based on typical symptoms or signs of COVID (fever, cough, shortness of breath) alone is insufficient,” Marziliano and colleagues stated.

Researchers aimed to assess the frequency of atypical COVID-19 presentations compared to typical presentations in older hospitalized adults occurring during the first pandemic surge.

They examined electronic health records from 4,961 patients at Northwell Health Hospitals in New York who were ages 65 and older and hospitalized with COVID-19 from March 1 to April 20, 2020.

Outcomes for hospitalized patients included length of stay, 30-day readmission, the need for intensive care unit (ICU) care (i.e., use of intubation or vasopressors), and death.

Mean age was 77, about 56% were men, and 47% were white. About one-fifth of patients lived in a facility rather than their home prior to hospitalization. Common patient comorbidities included hypertension (61%), diabetes mellitus (37%), chronic kidney disease (16%), and atrial fibrillation (14%).

Half of patients presented with shortness of breath, 38% presented with fever, and 27% with cough. Most participants were not considered severely ill, only 30% presented with severe illness. About two-thirds of patients required a nasal cannula (Venturi mask), 10% required non-invasive ventilation, and about 5% of patients required intubation.

Average length of hospital stay was 10 days. About 23% of patients required ICU level care, and 35% of patients died while hospitalized. Interestingly, patients with typical symptoms were 1.39 times more likely to be admitted to the ICU than those with atypical symptoms (P=0.0007).

Demographics associated with atypical presentation included Black race, non-Hispanic ethnicity, female sex, older age, and having dementia, diabetes, or a greater number of comorbidities.

Place of residence prior to hospitalization, illness severity, length of stay, hospital readmission, and hypertension did not have a statistical significance on atypical symptom presentation, the authors noted.

Authors suggested future areas of research should focus on atypical presentation subtypes, particularly in women, involving long-term outcomes in older adults.

Limitations of this study included the lack of documented facility types patients came from and that not all symptom presentations can be definitively proven to have been the result of COVID-19. They also acknowledged that their data was from the early stages of the pandemic, and not generalizable to any later COVID surges.