COVID-19 in older adults ======================== * Saket Saxena * Ardeshir Z. Hashmi ## ABSTRACT The impact of COVID-19 varies by age group, and it has become clear that individuals over 65 years are disproportionately impacted by COVID-19 both in terms of severity of illness and mortality. Atypical presentations in older adults may result from pathophysiologic changes during aging and immune dysregulation because of the cumulative impact of chronic comorbidities. Herein we review the different clinical presentations of illness for older adults, the unique challenges faced by this population, and strategies for treatment. ## INTRODUCTION Understanding how different age groups are impacted by COVID-19 has rapidly evolved since the start of the pandemic. It has become clear that those over 65 years of age are disproportionately impacted by COVID-19 both in terms of severity of illness and mortality.1–6 In March 2020, some of the earliest documented cases at a US long-term care facility in Kings County, Washington,1 and New York City incidence and mortality2 between February and June 2020 were significantly higher in older adults. Studies and data have continued to confirm higher risk for mortality and morbidity in those older than 65 years of age.3–6 ## ATYPICAL PRESENTATIONS OF COVID-19 IN THE OLDER POPULATION Atypical presentations in older adults may result from pathophysiologic changes during aging.3,7 Immunosenescence or “age-related dysfunction of the immune system, which leads to enhanced risk of infection”8 demonstrates a functional decline in immunity. Clinical presentation differs in older adults, and COVID-19 symptoms may need to be evaluated in a slightly altered approach for this patient population. ### Fever Mean body temperature decreases with age giving older patients a lower baseline temperature.7 A fever of 38.3°C (101°F) or higher in geriatric patients implies serious infection and warrants immediate attention.7,8,9 The Infectious Disease Society of America recommends modification of fever definition in older adults as a single oral temperature over 100°F, 2 oral repeat readings over 99°F, or an incremental increase of 2°F over baseline temperature.9 Thus, fever may not be a sufficient determinant symptom of COVID-19 in older adults, especially in the frailest older adults including those in senior living facilities who are at high risk for infection. ### Cold and cough symptoms It is difficult to differentiate acute cough, shortness of breath in older adults with chronic lung condition. Loss of taste or smell is also difficult to differentiate in older patients as many commonly used medications or neurodegenerative processes can cause such sensory impairment.10 Fatigue and body aches are also common in older adults and hence nonspecific. Some minor symptoms such as sore throat, new onset congestion, nausea, vomiting, or diarrhea can be more valuable as diagnostic criteria for COVID-19 illness in older adults.11 ### Delirium or altered mental status as a symptom In a multicenter study from 7 US emergency departments, delirium was one of the presenting symptoms in 226 (28%) of 817 patients with COVID-19 and exclusively the primary presenting complaint in 16% of patients with a mean age of 77.7 years.11 Of note, 37% of patients lacked classic COVID-19 symptoms of fever or shortness of breath. Age greater than 75, residence in an assisted living facility or nursing home, prior use of psychoactive medication, hearing and vision impairment, stroke, and Parkinson disease were predictive of delirium. In addition, delirium was associated with hospitalization, intensive care unit (ICU) stay, short-term rehabilitation, and mortality.11 Rates of delirium in patients with COVID-19 vary from 25% in hospitalized patients to 66% in ICU patients.6,12 Despite this, current guidance does not include delirium as a symptom for diagnosis of COVID-19.13 COVID-19 hospital management strategies, such as restricting visitors, isolation, personal protective equipment for caregiving personnel, and physical and chemical restraints to manage delirium can contribute to disorientation in patients and increase the risk for development of delirium, prolong the duration, and lead to poor outcomes and mortality.13 ### Falls and frailty Estimates of the occurrence of falls as a presenting symptom of COVID-19 have ranged between 23.5% and 32%.14,15 Frailty and prefrailty as characterized by a simple frailty scale16 have been associated with increased severity of COVID-19 per prospective study data from Wuhan, China.17 Of note, frail status was also associated with lower lymphocyte count and specifically lower CD8+ counts (see Prognostic indicators below) illustrating the interplay of frailty, immunosenescence, and COVID-19.17 ### Anorexia The symptom of anorexia can lead to dehydration and failure to thrive in older adults and remains an important presentation of COVID-19.11,18 ### COVID-19 presentation in patients above age 85 Falls and sudden or new onset fatigue in patients with good baseline function status should be considered a symptom of illness.18 Specifically, in a large (N = 76) French case series of COVID-19 patients older than 85 years, most common presenting symptoms were asthenia, (76.3%), fever (75%), and delirium (71%).18 ### Prognostic indicators C-reactive protein peaks and lymphocyte nadirs have been found to be independent serological predictors of death, as were shortness of breath and oxygen desaturation symptom predictors in the oldest COVID-19 patients.18 Of note, these patients had a median Clinical Frailty Scale score of 6 indicating moderate frailty. Male sex, history of cardioneuro-vascular disease, low albumin, serum creatinine, and elevation of troponins and brain natriuretic peptide have also been noted as additional predictors associated with death in this patient population.18 ### Imaging It has been reported that 40% of older COVID-19 patients have no radiographic abnormalities.19 ## UNIQUE CONSIDERATIONS AND STRATEGIES ### Hospitalized older adults with delirium Delirium during hospitalization (ICU/non-ICU) is closely related to mortality and poor functional outcome in older adults.20 Delay in detection and cognitive sequela can have a negative impact on patient rehabilitative potential.20 Pharmacological management of delirium in the elderly has been shown to have significant adverse effects.21 In view of this, pharmacological delirium management in the elderly has only been advised for those at risk of self-harm owing to threat of extubation or interruption of essential medical therapy.13 The Elder Life Program is an entirely non-pharmacological-based prevention strategy shown to significantly decrease delirium rates in the hospitalized older population with an emphasis on cognitive impairment, sleep deprivation, dehydration, visual and hearing impairment, and immobility.22 A COVID-19-specific toolkit for the Elder Life Program is available at [https://www.hospitalelderlifeprogram.org/for-clinicians/covid19-resources](https://www.hospitalelderlifeprogram.org/for-clinicians/covid19-resources). Strict lock down measures for residents of Continuing Care Retirement Communities (residential spectrum of independent living, assisted living, and memory care facilities) result in increased rates of social isolation and related depression, anxiety, worsening of behavioral manifestations of dementia, as well as delirium among other mental health challenges.23 Clinicians should be cognizant of the significant role played by social isolation in these residential settings and avoid “quick fix” potentially inappropriate medications in the older patient as much as possible as this can paradoxically lead to worsening mental status and falls. Staying indoors extensively can also potentially disrupt sleep-wake cycles. These altered circadian rhythms can in turn be a trigger of delirium and at the molecular level alters immune systems including CD4/CD8 cells and cytokine levels24 thereby impacting physiological reserve to fight infections. Hospital Elder Life Program interventions can assist to prevent delirium by preserving sleep as well as cognitive preservation.22 ### Patients with dementia and COVID-19 In older patients with moderate to advanced cognitive impairment, the pandemic has been particularly daunting. With this “double hit” of COVID-19 and dementia, it is difficult to consistently implement public health measures of consistent social distancing, mask wearing, and hand hygiene.24 Further, in hospi-talized patients, pre-existing diagnosis of dementia is an independent risk factor for mortality.20 Personal protective equipment and restricted visitation policies are disorienting and scary. Increased behavioral manifestations have resulted from this milieu placing additional strain both on older patients with dementia and their families. The Alzheimer’s Association has a 24/7 help line for clinicians, patients, and families ([https://www.alz.org/help-support/caregiving/coronavirus-(covid-19)-tips-for-dementia-care](https://www.alz.org/help-support/caregiving/coronavirus-(covid-19)-tips-for-dementia-care)). ### Multidisciplinary care Successful older patient care is multidisciplinary by nature. Physicians, nurses, geriatric specialists, social workers, pharmacists, physical and occupational therapists work together to deliver care. Many of these services in the home setting have been disrupted by the pandemic. Therefore, it is imperative to think creatively for alternative home care such as using virtual platforms, encouraging home exercises, maintaining consistent nutrition (especially protein intake), hydration, and enlisting family support. ### Communication nuances Lip reading is critical for communication with older patients with impaired hearing. Face shields and masks have regrettably taken this out of the equation.13 Speaking clearly and asking for verbal confirmation are key strategies to overcome this barrier. In a world where healthcare is increasingly delivered virtually, senior patients’ comfort with technology should be carefully considered. Families and caregivers can potentially help as well as harnessing technology geared toward seniors. Many older patients may be financially disadvantaged and after retirement are no longer in the workforce making affordability an additional challenge. ## FUTURE FOR OLDER PATIENTS AND COVID-19 The poignant reality remains that COVID-19 still does not have a definitive cure and that older adults are at higher risk for associated morbidity and mortality. Given this, it may be prudent to determine overall goals of care and care preferences for any acute critical illness scenarios in advance so that the patient’s wishes can be honored.13,25 ## DISCLOSURES The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest. ## Footnotes * The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and the available literature as of the date posted. While we try to regularly update this content, any offered recommendations cannot be substituted for the clinical judgment of clinicians caring for individual patients. * Copyright © 2021 The Cleveland Clinic Foundation. All Rights Reserved. ## REFERENCES 1. Life Care Center of Kirkland. Press briefing: Update from Life Care Center of Kirkland - March 13, 2020. [https://lcca.com/downloads/kirkland/Kirkland-Update-03132020.pdf](https://lcca.com/downloads/kirkland/Kirkland-Update-03132020.pdf) Accessed September 1, 2021. 2. Thompson CN, Baumgartner J, Pichardo C, et al. COVID-19 outbreak – New York City, February 29 – June 1, 2020. MMWR 2020;69(46): 1725–1729. [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.15585/mmwr.mm6946a2&link_type=DOI) [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=33211680&link_type=MED&atom=%2Fccjom%2Fearly%2F2021%2F09%2F14%2Fccjm.88a.ccc080.atom) 3. Akbar Arne N, Gilroy Derek W. Aging immunity may exacerbate COVID-19. Science 2020; 369(6501):256–257. doi:10.1126/science.abb0762 [Abstract/FREE Full Text](http://www.ccjm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6Mzoic2NpIjtzOjU6InJlc2lkIjtzOjEyOiIzNjkvNjUwMS8yNTYiO3M6NDoiYXRvbSI7czo0NDoiL2Njam9tL2Vhcmx5LzIwMjEvMDkvMTQvY2NqbS44OGEuY2NjMDgwLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 4. 1. Blagosklonny MV . From causes of aging to death from COVID-19. Aging (Albany, NY) 2020; 12(11):10004. doi: 10.18632/aging.103493 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.18632/aging.103493&link_type=DOI) 5. Stancati M. Italy, with aging population, has world’s highest daily deaths from virus. Wall Street Journal. March 9, 2020. [https://www.wsj.com/articles/italy-with-elderly-population-has-worlds-highest-death-rate-from-virus-11583785086](https://www.wsj.com/articles/italy-with-elderly-population-has-worlds-highest-death-rate-from-virus-11583785086) Accessed September 1, 2021. 6. Docherty AB, Harrison EM, Green CA, et al. Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. BMJ 2020; 369:m1985. doi:10.1136/bmj.m1985 [Abstract/FREE Full Text](http://www.ccjm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjE3OiIzNjkvbWF5MjJfMS9tMTk4NSI7czo0OiJhdG9tIjtzOjQ0OiIvY2Nqb20vZWFybHkvMjAyMS8wOS8xNC9jY2ptLjg4YS5jY2MwODAuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 7. El Chakhtoura NG, Bonomo RA, Jump RLP. Influence of aging and environment on presentation of infection in older adults. Infect Dis Clin North Am 2017; 31(4):593–608. doi: 10.1016/j.idc.2017.07.017 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1016/j.idc.2017.07.017&link_type=DOI) [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fccjom%2Fearly%2F2021%2F09%2F14%2Fccjm.88a.ccc080.atom) 8. Gavazzi G, Krause K-H. Ageing and infection. Lancet Infect Dis 2002; 2(11):659–666. doi:10.1016/s1473-3099(02)00437-1 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1016/S1473-3099(02)00437-1&link_type=DOI) [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=12409046&link_type=MED&atom=%2Fccjom%2Fearly%2F2021%2F09%2F14%2Fccjm.88a.ccc080.atom) [Web of Science](http://www.ccjm.org/lookup/external-ref?access_num=000178957900018&link_type=ISI) 9. Norman DC. Fever in the elderly. Clin Infect Dis 2000; 31(1):148–151. doi:10.1086/313896 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1086/313896&link_type=DOI) [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=10913413&link_type=MED&atom=%2Fccjom%2Fearly%2F2021%2F09%2F14%2Fccjm.88a.ccc080.atom) [Web of Science](http://www.ccjm.org/lookup/external-ref?access_num=000088950900028&link_type=ISI) 10. Ehrlich JR, Ramke J, Macleod D, et al. Association between vision impairment and mortality: a systematic review and meta-analysis. Lancet Glob Health 2021; 9(4):e418–e430. [doi.org/10.1016/S2214-109X(20)30549-0](http://doi.org/10.1016/S2214-109X(20)30549-0) 11. Kennedy M, Helfand BKI, Gou RY, et al. Delirium in older patients with COVID-19 presenting to the emergency department. JAMA Netw Open 2020; 3(11):e2029540. doi:10.1001/jamanetworkopen.2020.29540 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1001/jamanetworkopen.2020.29540&link_type=DOI) 12. Helms J, Kremer S, Merdji H, et al. Neurologic features in severe SARS-CoV-2 infection. N Engl J Med 2020; 382(23):2268–2270. doi:10.1056/nejmc2008597 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1056/NEJMc2008597&link_type=DOI) [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fccjom%2Fearly%2F2021%2F09%2F14%2Fccjm.88a.ccc080.atom) 13. O’Hanlon SKIS. Delirium: a missing piece in the COVID-19 pandemic puzzle. Age Ageing 2020: 49(4):497–498. doi:10.1093/ageing/afaa094. [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1093/ageing/afaa094&link_type=DOI) [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=32374367&link_type=MED&atom=%2Fccjom%2Fearly%2F2021%2F09%2F14%2Fccjm.88a.ccc080.atom) 14. Gawronska K, Lorkowski J. Falls as one of the atypical presentations of COVID-19 in older population. Geriatr Orthop Surg Rehabil 2021; 12:2151459321996619. doi:10.1177/2151459321996619 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1177/2151459321996619&link_type=DOI) 15. Norman RE, Stall NM, Sinha SK. Typically atypical: COVID-19 presenting as a fall in an older adult. J Am Geriatr Soc 2020; 68(7):E36– E37. doi: 10.1111/jgs.16526 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1111/jgs.16526&link_type=DOI) 16. Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Heal Aging 2012; 16(7):601–608. doi:10.1007/s12603-012-0084-2 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1007/s12603-012-0084-2&link_type=DOI) 17. Ma Y, Hou L, Yang X, et al. The association between frailty and severe disease among COVID-19 patients aged over 60 years in China: a prospective cohort study. BMC Med 2020; 18(1):274. doi:10.1186/s12916-020-01761-0 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1186/s12916-020-01761-0&link_type=DOI) [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fccjom%2Fearly%2F2021%2F09%2F14%2Fccjm.88a.ccc080.atom) 18. Vrillon A, Hourregue C, Azuar J, et al. COVID-19 in older adults: a series of 76 patients aged 85 years and older with COVID-19. J Am Geriatr Soc 2020; 68(12):2735–2743. doi:10.1111/jgs.16894 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1111/jgs.16894&link_type=DOI) 19. Guan W-J, Ni Z-Y, Hu Y, et al. Clinical characteristics of coronavi-rus disease 2019 in China. N Engl J Med 2020; 382(18):1708–1720. doi:10.1056/NEJMoa200203 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1056/NEJMoa2002032&link_type=DOI) [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fccjom%2Fearly%2F2021%2F09%2F14%2Fccjm.88a.ccc080.atom) 20. Mcloughlin BC, Miles A, Webb TE, et al. Functional and cognitive outcomes after COVID-19 delirium. Eur Geriatr Med 2020; 11(5):857–862. doi:10.1007/s41999-020-00353-8 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1007/s41999-020-00353-8&link_type=DOI) [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=32666303&link_type=MED&atom=%2Fccjom%2Fearly%2F2021%2F09%2F14%2Fccjm.88a.ccc080.atom) 21. Nikooie R, Neufeld KJ, Oh ES, et al. Antipsychotics for treating delirium in hospitalized adults a systematic review. Ann Intern Med 2019;171(7):485–494. doi:10.7326/M19-1860 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.7326/M19-1860&link_type=DOI) [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fccjom%2Fearly%2F2021%2F09%2F14%2Fccjm.88a.ccc080.atom) 22. Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340(9):669–676. doi:10.1056/nejm199903043400901 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1056/NEJM199903043400901&link_type=DOI) [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=10053175&link_type=MED&atom=%2Fccjom%2Fearly%2F2021%2F09%2F14%2Fccjm.88a.ccc080.atom) [Web of Science](http://www.ccjm.org/lookup/external-ref?access_num=000078955200001&link_type=ISI) 23. Cerami C, Canevelli M, Santi GC, et al. Identifying frail populations for disease risk prediction and intervention planning in the Covid-19 era: a focus on social isolation and vulnerability. Front Psychiatry 2021; 12:626682. doi:10.3389/fpsyt.2021.626682 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.3389/fpsyt.2021.626682&link_type=DOI) 24. Wang H, Li T, Barbarino P, et al. Dementia care during COVID-19. Lancet 2020; 395(10231):1190–1191. doi:10.1016/S0140-6736(20)30755-8 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1016/S0140-6736(20)30755-8&link_type=DOI) [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fccjom%2Fearly%2F2021%2F09%2F14%2Fccjm.88a.ccc080.atom) 25. Inouye SK. Joining forces against delirium-from organ-system care to whole-human care. N Engl J Med 2020; 382(6):499-501. doi: 10.1056/NEJMp1910499 [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1056/NEJMp1910499&link_type=DOI)