COVID-19 in the Elderly
- Dec 21st, 2020
- Sam Rouleau
Authors: Sam Rouleau, BS (Mayo Clinic Alix School of Medicine, Rochester, MN) and Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Stephen Y. Liang, MD, MPHS (EM/ID, Washington University School of Medicine)
An 82-year-old female presents to the ED with worsening mental status over the last 48 hours. She was transported via EMS from a skilled nursing facility, where she has been living for the last several years after a car accident left her wheelchair bound. She is otherwise healthy. The EMS report is brief, noting that nursing home staff reports the patient has been intermittently confused and sleeping for 90 minutes for the last two nights. Further collateral history is unable to be attained. The patient is unable to provide additional history, repeatedly asking “where am I?” and asserting “I feel fine.” She is oriented to self, but not place or time. Physical exam is normal. Temperature is 36.4 °C, blood pressure 130/95, pulse 95, and respiratory rate 18. Laboratory evaluation reveals lymphopenia but is otherwise unremarkable. Head computed tomography is also unrevealing, but her nasopharyngeal RT-PCR for SARS-CoV-2 returns positive.
COVID-19 has continued to proliferate across the United States, reaching over 15 million cases by mid-December 2020 . As the interface between the community and healthcare system, ED systems and practitioners have adapted operations and practice in an effort to meet the challenge of the pandemic . COVID-19 is particularly dangerous in the elderly population, as this population is more likely to have comorbid factors that are correlated with risk of severe COVID-19 infection. A systematic review and meta-analysis of comorbid conditions and risk in COVID-19 identified 6 studies with a total of approximately 1,500 COVID-19 patients. The authors found that hypertension (OR: 2.29), diabetes (OR: 2.47), COPD (OR: 5.97), cardiovascular disease (OR: 2.93), and cerebrovascular disease (OR: 3.89) were statistically significant independent risk factors for COVID-19 risk based on clinical symptoms and ICU admission . Notably, there was no correlation between liver disease, malignancy, and renal disease with severity of COVID-19 infection . Elderly patients are substantially more likely to have chronic conditions; the CDC found that out of 37 million Americans over the age of 65, 31 million (85%) had at least one chronic health condition, 56% had at least two, and 23% had three or more chronic health conditions . These data were based on a 2008 survey conducted by the CDC and National Center for Health Statistics, where chronic conditions were defined as diabetes, cardiovascular disease, COPD, asthma, cancer, and arthritis .
In addition, age is a risk factor for severe infection and mortality [5, 6]. An ecological study spanning 16 countries over 6 weeks in the spring of 2020 demonstrated that age was associated with mortality with 153,923 out of 178,568 (82%) COVID-19 deaths occurring in those above the age of 65 . Antibody testing of 109,000 random subjects in England revealed an infection fatality rate (IFR) of 0.9% (9 deaths per 1,000) for the entire sample. However, the IFR for those between 65–74 years was 3.1% and increased to 11.6% for those 75 and above . A similar study design in Spain of 61,000 random individuals revealed similar age-associated mortality with an overall sample IFR of 0.8%, 3.4% in those 70-79, and 7.2% for those above the age of 80 . Importantly, men exhibited a higher mortality risk than women and died at 2x the rate of woman in the Spanish cohort . Specifically, the vulnerability of older adults to COVID-19 and frequency in which they visit the ED necessitates that practitioners are aware of the unique facets of the disease manifestations in this population [9, 10].
The symptomology of COVID-19 is broad and includes: fever, cough, fatigue, anorexia, dyspnea, sore throat, headaches, chills, anosmia, and ageusia, among others . However, the constellation of symptoms may present differently in the elderly population.
Fever can be difficult to evaluate in geriatric patients and has limited clinical utility in COVID-19. In a 788 patient cohort from China, subjects > 60 years of age (n = 136) were found to have comparable rates of fever to those under 60 (n = 652), 84% v 80% . However, the variability in temperature in the older cohort was marked, with 14 (10%) having normal temperatures < 37.3 °C, 48 (35%) with temperature falling in the range of 37.3 – 38.1 °C, and 74 (54%) with temperatures > 38.1 °C . Two nursing home cohorts demonstrated that temperature screening for COVID-19 in the elderly has poor predictive accuracy and should not be relied upon exclusively . One cohort consisted of 1,301 residents in 134 VA facilities, and the other was composed of 3,368 nursing home residents across 282 community facilities. Of note, the VA cohort was on average younger, 75 compared to 79, and almost exclusively male (< 10 females out of 330 who tested positive for COVID-19. Retrospective analysis of individuals who contracted COVID-19 illustrated that a temperature threshold of 38.0 °C had a 43% sensitivity for the VA cohort and 12% sensitivity for the community cohort. When the temperature threshold was decreased to 37.2 °C the sensitivity increased to 76% and 34% for the VA and community cohorts respectively . The combination of lower basal body temperature and blunted fever response makes fever a less reliable indication of infection and infection severity . Infectious fever in the elderly is defined as: oral or tympanic membrane temperature ≥ 37.2 °C, persistent rectal temperature ≥ 37.5 °C, or 1.3 °C increase in baseline temperature regardless of measurement site .
While dyspnea is a common symptom in COVID-19, it may present more frequently in the elderly. In the same 788 patient cohort, 17 (12.5%) of those above the age of 60 presented with dyspnea compared to only 20 (3.07%) of those under the age of 60 . Another cohort of 204 patients > 60 from Wuhan found that dyspnea occurred in 65 (31.9%) patients (note: this was a descriptive study with no comparison group) . Although the difference among frequency in dyspnea between elderly patients and non-elderly patients remains poorly elucidated, dyspnea is an important symptom to note. One meta-analysis of 11 studies with 2091 cases of COVID-19 found that dyspnea was significantly associated with higher mortality in COIVD-19 patients (OR 4.34, 95% CI 2.68–7.05) .
Silent hypoxia, or decreased oxygen saturation without any other symptoms, has been described in the setting of COVID-19 infection . While there are various hypotheses on the cause of this clinical phenomenon, testing guidelines around mildly hypoxic and otherwise asymptomatic patients remain unclear. In May 2020, the American Lung Association recommended against “widespread monitoring for low blood oxygen” as a method of detection for COVID-19 . However, hypoxia can be a marker of severity for COVID-19 infection, and Britain has implemented at-home pulse oximetry monitoring for mild COVID-19 cases, noting that those over 65 years with consistent oxygen saturations under 93% may further deteriorate . While oxygen saturation may not be helpful as a screening tool for COVID-19 in elderly individuals, COVID-19 testing should be seriously considered in asymptomatic elderly patients with consistently lower than normal pulse oximeter readings, especially when other causes have been ruled out.
Although other symptoms (ie, cough, GI symptoms, myalgias, headache) seem to occur at similar rates between non-geriatric and geriatric populations, a recent study in JAMA revealed that delirium is a frequent symptom in elderly patients with COVID-19. The study population included 815 older adults (> 65 years) presenting to the ED with COVID-19. 226 (28%) of the patients were delirious at initial presentation. Furthermore, 84 of whom had delirium as the primary symptom of COVID-19 infection. Delirium upon presentation was associated with worse hospital outcomes, defined as ICU stay, discharge to facility rather than home, and death . Furthermore, COVID-19 may be associated with geriatric falls. This phenomenon was illustrated by a French patient cohort with 76 COVID-19 patients who were between the ages of 86–92, which reported initial falls in 19 (25%) of their cohort . Additionally, 54 (71%) presented with delirium as one of their symptoms . It is possible delirium associated with COVID-19 contributes to at-home falls in the geriatric population. Elderly patients in the ED should be tested for COVID-19 if delirious, and the threshold to screen for delirium in elderly patients must be low.
Lastly, setting is an important consideration when considering symptoms and testing for COVID-19. Given the unique nature and high-risk setting of nursing homes, universal screening may be warranted. West Virginia undertook universal screening home of all nursing home residents and staff within the state from April 21–May 8, 2020 . After testing 8,911 residents and 13,687 staff, 42 cases were identified at 28 (23%) of the nursing homes in the state, where no outbreaks had occurred previously . Importantly, the positivity rate of (0.1%) in the residents tested during universal screening was vastly lower than the strategy of daily symptom-based resident screening (38.1% positive rate) and pre-shift employee screening (16.3% positive rate) that was used earlier in the year . Furthermore, the universal screening protocol successfully identified 6 staff members and 2 residents who were asymptomatic, likely preventing further transmission . After implementation of universal screening protocols, 18 COVID-19 outbreaks were identified between May and July 2020 in West Virginian nursing homes, 12 of which had fewer than 6 cases . Any patient who presents to the ED from a nursing facility should be seriously considered for COVID-19 diagnostic testing.
While COVID-19 has many patterns on both chest radiograph and CT scan, recent research has found different patterns on CT scan associated with age. In a cohort of 307 COVID-19 patients in Zhejiang, China, CT findings varied between the age groups (group 1 < 40 years-old, group 2 40–60 years-old, group 3 > 60 years old) . The study found a statistically significant increase in number of lobes involved and number of lesions between groups 1 and 2, as well as groups 1 and 3. 46 (44%) of the 104 in group 1, 109 of the 137 (80%) in group 2, and 57 of the 66 (86%) in group 3 demonstrated multilobar involvement . The number of lesions were classified into categories of: one or two, more, and subpleural lesions. While 81 (80%) in group 1 had more than one or two lesions, the frequency of those with more than two lesions in groups 2 and 3 was around 95% for each group . Other non-specific findings that were correlated with age were pleural thickening (4% in group 1, 15% in group 2, 17% in group 3), bronchodilation (37% in group 1, 50% in group 2, 59% in group 3), and the “crazy paving” sign (17% in group 1, 48% in group 2, 50% in group 3) . Of note, none of the imaging criteria were statistically between groups 2 and group 3. The presence of pleural thickening may be a result of bronchiolar and alveolar invasion by the virus. The researchers also hypothesize that bronchiectasis may be a risk factor for severe COVID-19 infections, but did not collect specific data to address this question . Nevertheless, it remains unclear how these differences in age correlate to treatment approach and more work remains to be done.
In addition to CT imaging, elderly patients have particular laboratory diagnostic findings. A small cohort of 56 COVID-19 patients from China demonstrated a statistically significant decrease in lymphocyte to total white blood cell count when comparing their elderly patients (60 years and above) to patients under the age of 60 . The average lymphocyte ratio was 19% (11–27%) for the 18 elderly patients compared to 29% (24–34%) of the 38 younger patients . This same study also noted higher CRP values in the elderly cohort compared to the non-elderly cohort, 23 (13–35) and 6 (1–17) respectively . Notably, decrease lymphocyte ratio occurred in 9 (50%) of the elderly patients, but was not universal and cannot be relied upon . A separate cohort of 105 elderly individuals (>60) with COVID-19 demonstrated that approximately one-third had lymphopenia, increased D-dimer, and decreased albumin on laboratory testing .
Overall, while certain diagnostic findings may be associated with age in the setting of COVD-19 infection, the clinical generalizability remains unclear. However, certain situations may help guide treatment. For example, an elderly patient with dyspnea, non-specific chest radiograph findings, and lymphopenia should be tested and treated for COVID-19 while diagnostic work-up continues.
- Age is a risk factor for increased morbidity and mortality in COVID-19 infections.
- Elderly men have increased mortality compared to elderly women.
- Elderly patients can present differently. Delirium can be the primary symptom of COVID-19 infection, as can persistent hypoxia.
- Consider COVID-19 in the setting of altered mental status and geriatric falls.
- Elderly patients in the ED who live in nursing homes should undergo COVID-19 testing.
- Elderly individuals with COVID-19 tend to have increased lesions and lobar involvement on chest CT.
- Laboratory diagnostics may differ based on age, and the geriatric population may have lymphopenia, higher CRP values, and increased D-dimer on testing.
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