Atypical symptoms of Covid-19 in the older patient

The coronavirus pandemic has had a profound impact on global health, with the older population being particularly impacted by its effects. This virus utilises receptor mediated endocytosis, via its spike glycoproteins, to enter host cells and uses RNA-dependent RNA synthesis to generate mRNA and viral proteins.¹ High levels of heterogeneity have been shown by the virus and while this is poorly understood, it can partly be attributed to patient factors. One of which is age.²

A rise in the number of comorbidities and immunosenescence with increasing age, along with lack of adequate care, has resulted in the geriatric population and care homes being hit with a higher burden of the disease.

Following the incubation period, patients may range from being asymptomatic to having an upper respiratory tract infection with symptoms of headache, anosmia, ageusia and rhinitis. This is commonly seen in younger patients. Older patients and patients with comorbidities tend to have a lower respiratory tract infection with pneumonia symptoms.

The virology phase may then be followed by a cytokine storm phase with coagulopathy and acute respiratory distress syndrome.³ The long-term effects are not yet clear but pulmonary fibrosis may be one of the more significant post infective complications of this virus.⁴

Diagnosis of Covid-19: signs and differentials

According to the Regional Geriatric Program of Toronto, only 20-30% of older patients with Covid-19 report experiencing a fever, and many of them may not present with the main symptoms we associate with this novel virus, such as a cough and breathing difficulties.

In UK healthcare centres and hospitals patients are allocated to different areas or departments according to their main symptoms. If they present with a fever, cough, shortness of breath, tiredness and loss of taste and smell they are typically tested and sent to a specific Covid-19 cohort ward if they are in need of hospitalisation. Staff in these areas act with appropriate caution to prevent a patient to staff viral transmission.

However, experts in geriatric medicine have always acknowledged that older people frequently present with unusual symptoms in any medical circumstance and this appears to be happening in the context of Covid-19 too. As a result of the atypical presentation in older people who are particularly vulnerable to infections, they may not be recognised as having Covid-19 at the time of admission and may result in delays in diagnosis and management.

In addition while patients are tested for infection with coronavirus, the tests are not 100% sensitive and specific so a clinical acumen is essential so that older people are not side-lined on the basis of a single negative test. Failing to recognise infection with Covid-19 has consequences for the patient and for the staff responsible for their care.

Atypical symptoms of Covid-19 in older patients

The main symptoms of Covid-19, which we have all come to be familiar with over the past few months, include fever, sore throat, breathing difficulties, fatigue and loss of smell and taste. However, there are some rarer symptoms which many have experienced.

In a recent survey that I conducted on Twitter, many of the respondents reported that the commonly recognised symptoms of Covid-19 were uncommon in elderly patients; instead, more atypical symptoms were seen.

This was further backed up by The Regional Geriatric Program of Toronto, who have described a whole host of symptoms that elderly patients may present with when being admitted to a healthcare centre.

Covid-19 symptoms in older patients include: delirium, lethargy, malaise, falls, loss of coordination, decreased mobility, generalised weakness, anorexia, functional decline, tremor, diarrhoea, reduced appetite, nausea, vomiting, abdominal pain, dizziness, tachycardia, chest pain, increased sputum production, haemoptysis, seizures, headaches, conjunctivitis, rhinorrhea, nasal congestion and a rash.

Those with significant experience in dealing with Covid-19 patients reported that even when there were other reasonable causes to these symptoms, such as a catheter-associated urinary tract infection, some of the patients turned out to be Covid-positive.

This may be due to several factors ranging from physical changes due to age, the simultaneous presence of more than one chronic disease, the inability to regulate physiological systems and the variation in presentations in older people related to frailty. All of these factors increase the likelihood of an older patient having non-typical symptoms of Covid-19.

It is imperative that all healthcare and social staff everywhere, on both a local and national level, are made aware of these symptoms and the high probability of older patients experiencing unusual Covid-19 symptoms. Failure to correctly identify these may mean that older patients are sent to the wrong wards where staff are not as well trained and vigilant and may unknowingly spread the coronavirus.

Additionally, it is important that staff on all wards where elderly patients are admitted ensure they wear the correct PPE and take the correct safety measures to reduce the risks of viral transmission. In regard to swab tests, if the first is negative, but there is a clinical suspicion that Covid-19 may be present, then a repeat test is absolutely advised 24-48 hours later.

Treatment of Covid-19 in older patients

Patients admitted to hospital receive a wide array of treatments with options including oxygen therapy, corticosteroids, antivirals, mechanical therapy as well as anticoagulation therapy and use of immunomodulators in the later stages.⁵

The immunomodulatory properties of hydroxychloroquine have been shown to reduce the severity of the cytokine storm.⁶ Early diagnosis and care plays a significant role in prognosis. Oxygen therapy can be made available in some care home settings to avoid hospital admission or shorten hospital stay. However, limitations to staff and resources has meant that care homes residents have not received the same treatment as the rest of the population.

Care home patients and Covid

Care homes have been advised by the British Geriatric Society (BGS) to use the RESTORE2 tool,⁷ a modified NEWS score, to help recognise and manage deteriorating patients. This tool includes an escalation pathway to ensure that the patient is directed to the right place. Patients on dexamethasone and oxygen therapy need continuous monitoring and management and this has put a further strain on care home staff.

Family visiting in care homes has changed remarkedly during the pandemic. According to government guidelines (as of 8th March 2021), each resident is to appoint one visitor who has to receive a lateral flow test and wear the correct PPE when visiting. Physical contact is to be kept to a minimum and both residents and visitors should take the opportunity to be vaccinated when it arises.⁸

Patients with cognitive impairment may be confused by social distancing rules, this should nonetheless not prevent them from being able to receive visitors as isolation could result in deterioration.

Primary care and Covid

General practices have seen a dramatic change in the way they see and care for patients. A rapid uptake of virtual and telephone consultations was seen across the country with views that this will become a core part of primary care going forward. However with a reduced capacity to see patients face to face, there has been a loss of follow up and routine appointments in patients with long-term conditions and co-morbidities. Inevitably, a lack of adequate care and follow up results in an increased risk for developing more severe disease.

Hospital care and Covid

Discrepancies in signs and symptoms of Covid positive patients and as a result a reliance on a PCR test to confirm the Covid status of patients has resulted in patients being sent to the wrong wards. Additionally, inter ward transfer once a diagnosis is established can be difficult for some older patients. Given that some patients have neurological deficits, this can make expressing symptoms and alerting physicians difficult. It can therefore lead to late discovery of deterioration and increase mortality.

Covid-19 vaccines

As of writing this article, 31.6 million people have been given the first dose of the vaccine in the UK. 5.5 million have received both doses. While the data gives a detailed overview of vaccination count by day and region, it does not specify the groups that are being vaccinated.

The website states that the over-80s population, care home residents and workers and NHS staff were initially prioritised but does not go on to specify if and what changes have been made to this priority list. No numbers are given to show what proportion of these priority groups have been vaccinated.⁹ However, Care UK states that over 90% of their residents and over 70% of the staff have received the first dose of the vaccine which are promising results.¹⁰

Long-term prognosis of Covid in older patients

Coronavirus infection is a multisystem disorder and currently, our knowledge of the long-term consequences are unclear. However, on the basis of reports, it appears that many older people have persistent tiredness, lethargy and poor appetite. This can result in weight loss, loss of interest in social activities and subsequent isolation leading to a spiral of decline in physical, cognitive and mental wellbeing.

Tackling the isolation hurdle has been a source of discussion with the BGS going as far as calling it a “public health priority”.¹¹

Worse prognosis is seen in older patients with pre existing comorbidities particularly cardiovascular disease, chronic obstructive pulmonary disease and coagulopathies. In these patients, a rapid progression in disease is reported.¹²

Further care

Taking all of this evidence into consideration, staff on general wards must be appropriately trained and wear the correct PPE to ensure not just their own safety, but the safety of their colleagues, all their patients and everyone in their immediate surroundings. Prevention via social distancing and vaccination is the best strategy to reduce the spread of the virus to the most vulnerable in the population.

For more news and articles on Covid-19 go to our Covid-19 section

Dr Irfan Muneeb, Consultant Geriatrician

Dr Ahmad Raza, Respiratory consultant University Hospital of Derby and Burton

Ms Mariam Omar, 3rd Year Medical Student, Leicester university

References

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