COVID-19 Study: Prevalence of Unusual Symptoms in Older Adults

While many hospitalized patients with COVID-19 come to the hospital with symptoms of fever, cough, or shortness of breath, a new large-scale study conducted by The Feinstein Institutes for Medical Research notes that older adults commonly present with atypical symptoms–like functional decline and altered mental status. The study, published online in the Journal of Gerontology, also evaluates demographic factors and clinical outcomes that are associated with this atypical symptomatology.

Scientists examined the electronic health records of 4,961 patients who were admitted across Northwell Health hospitals, the largest health system in New York State, during the nation’s initial surge of COVID-19 between March 1 and April 20, 2020, with a confirmed COVID diagnosis. Each patient’s clinical course and outcomes were followed until June 10, 2020.

While many of the older adults presented with typical COVID-19 symptoms, including shortness of breath (50%), fever and chills (38%), and cough (26%), substantial numbers of older adults also presented atypically, characterized by functional decline (25%) and altered mental status (11%). Other symptoms included gastrointestinal, cardiovascular, and neurological. Of those with atypical presentation, nearly one-half (49%) had atypical symptoms alone, and 51% had both atypical and typical symptoms and signs.

“While older adults account for the majority of COVID-19 hospitalizations, there is a lack of research on symptoms this population may experience at the onset of the disease including uncharacteristic symptoms like weakness, delirium, agitation or lethargy,” says Allison Marziliano, PhD, an assistant professor in the Institute of Health System Science at the Feinstein Institutes and the study’s principal investigator. “By identifying these atypical presentations, as well as the demographic profiles and clinical outcomes they are related to, clinicians can better assess older adults and make more informed decisions about who needs testing.”

The average hospital length of stay was 10 days and less than 7% were readmitted to the hospital within 30 days of discharge. Overall, 23% of the patients received ICU level of care. Patients with atypical presentations were more likely to be older, female, Black, and non-Hispanic, with a higher comorbidity index, and have dementia and/or diabetes.

While the results found that atypical presentation in older adults does not necessitate the same need for ICU-level care as typical presentation (often characterized by respiratory distress), it should not be dismissed. Patients presenting atypically have just as poor short-term outcomes as those older adults presenting typically.

As COVID-19 numbers decline and testing may become less a standard as it once was, the conclusions from this study highlight the need for heightened awareness when it comes to older patients and how they may present with COVID-19, which at times could be with weakness and/or confusion as their only symptoms. These findings have been thus far largely unexplored in the research community with the goal of this work and future research is to aid clinicians who are faced with the challenge of determining if their older adult patients should be tested for COVID-19 and potential outcomes.

This study was done in collaboration with Northwell Health's Division of Geriatrics and Palliative Medicine. During the pandemic, they assembled a research workgroup to focus on COVID-19 and the geriatric population. The Older Adult COVID Workgroup is part of CAARE (Collaboration of Aging and Advanced Illness Research and Education), the research arm of the Division, which sits within the Department of Medicine. Their work aims to examine geriatrics-relevant factors that significantly impact decisions around medical care and response to treatments.

“Dr. Marziliano and her team have provided valuable insight into a patient population that is often understudied, particularly in regards to COVID-19,” says Kevin J. Tracey, MD, president and CEO of the Feinstein Institutes. “This study and future research will improve the care for older adults with COVID-19 and better inform the frontline workers tasked with assessing these patients’ needs.”

Source: The Feinstein Institutes for Medical Research