Study risk factors, clinical profile, and outcome in hospitalized COVID-19 geriatric patients

ABSTRACT

Background:

Coronaviruses are from the family of viruses that cause respiratory illness in humans. Severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and the common cold are examples of coronaviruses that cause illness in humans. COVID-19, the new strain of coronavirus was first reported in Wuhan, China in December 2019. The virus has since spread all over the world creating havoc. The zoonotic origin of the virus has been a significant area of investigation. The infected person spreads the virus to two or three other people in a chain reaction-like pattern. India, like many countries, experienced a significant number of confirmed cases and deaths.Variations in fatality rates were observed globally.

Purpose:

The aim of the study is to study risk factors, clinical profile, and outcomes in hospitalized elderly (age >60) with COVID-19 and the correlation of disease severity with comorbidities and laboratory and radiological parameters by comparing the differences between young elderly (60-70 years old), old elderly (71-80 years old), and very old elderly (>81 years old). It is important to identify the risk factors and high-risk groups to aid early, aggressive intervention, facilitate equitable hospital resources, and alleviate the critical care crisis that has arisen in the country and the world.

Method:

This is a retrospective observational study of all the hospitalized elderly patients (>60 years old) who were diagnosed with COVID-19 and admitted to a tertiary care hospital from April 1, 2020, to December 31, 2020. Data such as clinical history along with associated comorbidities, clinical parameters, radiological imaging, signs and symptoms, treatment given and oxygen requirements, and hospital stay including ICU were collected from a computer-based data acquisition system.

Conclusion:

Out of 654 confirmed hospitalized elderly patients with COVID-19, 60.1% (n = 393) were young adults, 31.2% (n = 204) were old adults and 8.7% (n = 57) were very old adults. Among these, hypertension, diabetes mellitus, hypothyroidism, and chronic artery disease (CAD) were the most common comorbidities in the data collected. The frequent symptoms observed were fever in almost 89% of the patient’s upper respiratory tract infection (which commonly includes sore throat, nasal stuffiness, runny nose, and cough) was observed in more than 60% of the admitted patients, and approximately 20% of the patient’s complaint of shortness of breath (SOB). Adults above 60 years are considered vulnerable group who are more prone to develop severe disease and tend to have more complications as the age increases. The number of ICU admissions is also amplified with age and related comorbidity. It is observed in the study that the duration of hospital stay is reduced significantly with the advent of antiviral use such as Remdesivir and other experimental protocols including plasma therapy and tocilizumab in COVID-19. The clinical parameters such as elevated ferritin, CRP, D-dimers, lymphocytopenia, and CTSS are important to determine the severity of the ongoing disease in the patients.

Introduction

COVID-19 (coronavirus disease 2019) is a highly contagious illness caused by the novel coronavirus SARS-CoV-2, first identified in Wuhan, China, in December 2019. It was named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by 60 the International Committee on Taxonomy of Viruses (ICTV).[1] This virus, an enveloped RNA virus, is known to infect humans, other mammals, and birds, causing respiratory, enteric, hepatic, and neurological symptoms.[2,3] India reported its first COVID-19 case on January 30, 2020, in an individual returning from China.[4] Since then, the pandemic has posed unprecedented challenges to primary care providers and family physicians worldwide. COVID-19 rapidly spread globally, causing significant disruption, except in Antarctica.[5] Several researchers have highlighted that it was introduced to humans from bats.[6,7] A study by Zhou P. et al. (2020)[8] provided crucial early insights into the novel coronavirus (SARS-CoV-2) responsible for the COVID-19 outbreak. Key inferences from their research are: the study identified and characterized the genome of the novel coronavirus from patients in Wuhan, finding it distinct from SARS-CoV and MERS-CoV, and showed its probable origin from bats, sharing high sequence identity with bat coronaviruses (specifically RaTG13, which is closely related to ZC45 mentioned in some summaries). Furthermore, the research demonstrated that this new coronavirus utilizes the ACE2 receptor for entry into human cells, the same receptor used by SARS-CoV. As of April 19, 2022, India had reported 43,045,527 confirmed COVID-19 cases and 521,966 total deaths. On the same date, India’s case fatality rate (CFR) for COVID-19 was documented at 1.21%, noted as among the lowest globally.[9]

Patients with COVID-19 exhibit a broad spectrum of symptoms. Mild to moderate symptoms include fever, cough, fatigue, myalgia, sore throat, diarrhea, chills, and dizziness. Severe presentations can involve dyspnea, persistent fever (≥38°C), confusion, and chest pain or pressure, often requiring urgent medical intervention.[10,11]

Older adults are disproportionately affected, particularly those with pre-existing conditions such as hypertension, diabetes, cardiovascular disease, chronic lung disease, kidney problems, and compromised immunity.[12,13,14] These comorbidities not only increase susceptibility to severe disease but also complicate management strategies in primary and family care settings.

Despite extensive global research, data on the clinical progression of COVID-19 in hospitalized elderly patients, particularly from primary care perspectives, remains limited.

This retrospective cohort study analyzed 651 confirmed COVID-19 geriatric patients admitted to Medanta Medicity, Gurugram. Among them, 101 required intensive care. The average hospital stay was 8.4 days, with a mean age of 71.8 years among nonsurvivors. The study highlights the criticality of cases in patients aged 60 and older, providing insights into differences in disease progression among young elderly (60–70 years), old elderly (71–80 years), and very old elderly (>80 years). Hypertension (54.5%, n = 422), diabetes (52.3%, n = 342), hypothyroidism (13.1%, n = 86), coronary artery disease (8.6%, n = 56), and kidney problems (3.4%, n = 22) were the most common chronic conditions observed.

These findings underscore the importance of proactive management and early intervention in primary care to mitigate poor outcomes in the geriatric population. By offering detailed insights into the clinical course of COVID-19 in elderly patients, this study aims to assist primary care providers and family physicians in optimizing care strategies and improving outcomes for this vulnerable population.[15]

Materials and Method

This multicenter, retrospective study included 651 patients with laboratory-confirmed SARS-CoV-2 infection, according to WHO interim guidelines.[16] Patients were aged 60 years and above and were admitted to Medanta Medicity, Gurugram, from April 1, 2020, to December 31, 2020.

To better understand the diverse characteristics of the older adult population within this cohort, participants were categorized into three distinct age groups: young elderly (60-70 years old), old elderly (71-80 years old), and very old elderly (over 80 years old). This approach acknowledges the progressive changes in health, functional status, and social engagement often observed as individuals advance through later life.

The interim guidance from the World Health Organization (WHO) outlines the clinical management of severe acute respiratory infection (SARI) when COVID-19 is suspected, emphasizing early recognition, infection prevention and control, and supportive care for hospitalized adult and paediatric patients.[17] This framework helped inform the clinical assessment and categorization approach used in our study.

All the clinical data of these patients such as name, age, sex, clinical symptoms, and laboratory records including nonspecific inflammatory markers, for instance, CRP, D-dimers, serum ferritin, TLC, kidney function test, liver enzymes, PT-INR, treatment is given, oxygen requirement, ICU stay and HRCT chest was recorded from hospital records. Ethical approval for the study was obtained from the Medanta Institutional Review Board on 24^th February, 2021.

Clinical features and outcomes of the different age groups were compared.

Definition

Table 1[18] categorizes the clinical presentations of COVID-19 patients into five levels of severity: Asymptomatic, Mild Illness, Moderate Illness, Severe Illness, and Critical State. Here’s a detailed rundown of each category:

Table 1.

Different clinical types of presentation in SARS-CoV-2 patients[18]

Severity of disease	Presentation
Asymptomatic	• No clinical symptoms • Positive nasal swab test • Normal chest X-ray
Mild illness	• Fever, sore throat, dry cough, malaise and body aches or • Nausea, vomiting, abdominal pain, loose stools
Moderate illness	• Symptoms of pneumonia (persistent fever and cough) without hypoxemia • Significant lesions on high-resolution CT chest
Severe illness	• Pneumonia with hypoxemia (Sp02<92%)
Critical state	• Acute respiratory distress syndrome, along with shock, coagulation defects, encephalopathy, heart failure and acute kidney injury

Asymptomatic: Individuals in this category show no clinical symptoms. They test positive via nasal swab, and chest X-rays appear normal.

Mild Illness: Symptoms include fever, sore throat, dry cough, malaise, and body aches. Some individuals may experience gastrointestinal symptoms like nausea, vomiting, abdominal pain, or loose stools.

Moderate Illness: Patients have symptoms of pneumonia, such as persistent fever and cough, but without hypoxemia. High-resolution CT scans reveal significant lesions in the lungs.

Severe Illness: This group has pneumonia accompanied by hypoxemia, with oxygen saturation levels below 92%.

Critical State: Patients experience acute respiratory distress syndrome, along with complications like shock, coagulation defects, encephalopathy, heart failure, and acute kidney injury.

Symptoms of SARS-CoV-19 are expected to appear from day 2 to 14 after exposure to the virus; hence, it is recommended to be quarantined for 14 days.[19] It is observed that changes in infection and severity of the disease increase with comorbidities.[20] Based on the latest statistics and clinical proficiency, the geriatric age group, especially those who have underlying chronic conditions such as diabetes and cardiovascular disease or lung, liver, kidney disease, hypertension, cancer patients on chemotherapy, immunocompromised patients taking steroids persistently are at greater risk of developing severe state and have increased rate of mortality.[19,20]

Results

From April 1, 2020, to December 31, 2020, 654 total geriatric (>60 years old) were admitted to tertiary care hospitals in India and were SARS-CoV-2 positive (by laboratory-confirmed method). Out of these, 393 patients were above 60-70 years, 204 cases were 71-80 years, and 57 patients were 81 years and above. The median age of all geriatric populations was 68 years (64-74). In this study, 22.8% of females and males comprised 77.2% of the COVID-19 admissions to the hospital. Reference data are summarized in Tables 2 and 3. Among these, 15.6% of the sick patients needed ICU admission. In the age group of 60-70 years old, 88% have some chronic illness, hypertension (65.4%) being the most predominant, followed by diabetes mellitus in 51.9% of the admitted cases. Also among the old elderly (71-80 years), hypertension (61.3%) is seen to be the most common disease, and subsequently diabetes mellitus was noted in 52.9% of the patients. Following the same pattern, very old elderly (>81 years) had hypertension (64.5%) as the most common disease.

Table 2.

Descriptive statistic of elderly COVID-19 patients admitted in the hospital

	n=654	Percentage
Age
60−70	393	60.1
71−80	204	31.2
>80	57	8.7
Mean±S.D.	69.5±7.4 (60–99)
Median (IQR)	68 (64–74)
Gender
Male	505	77.2
Female	149	22.8
Comorbidities
HTN	422	64.5
DM	342	52.3
Hypothyroidism	86	13.1
CAD	56	8.6
CKD	22	3.4
COPD	12	1.8
Asthma	6	0.9
CLD	4	0.6
ILD	4	0.6
TB	2	0.3
Symptoms
Fever	578	88.4
URTI	411	62.8
SOB	128	19.6
Sore throat	62	9.5
General weakness	56	8.6
Death/Alive
Death	72	11.0
Alive	582	89.0

Table 3.

Comorbidities in different age group of geriatric patients

	60−70 (n=393) (%)	71−80 (n=204) (%)	>80 (n=57) (%)	Total (n=654) (%)	P
Gender
Male	296 (75.3)	163 (79.9)	46 (80.7)	505 (77.2)	0.362
Female	97 (24.7)	41 (20.1)	11 (19.3)	149 (22.8)
Comorbidities
HTN	257 (65.4)	125 (61.3)	40 (70.2)	422 (64.5)	0.970
DM	204 (51.9)	108 (52.9)	30 (52.6)	342 (52.3)	0.393
Hypothyroidism	48 (12.2)	24 (11.8)	14 (24.6)	86 (13.1)	0.028*
CAD	31 (7.9)	22 (10.8)	3 (5.3)	56 (8.6)	0.434
CKD	12 (3.1)	9 (4.4)	1 (1.8)	22 (3.4)	0.316
COPD	9 (2.3)	3 (1.5)	0 (0)	12 (1.8)	0.533
Asthma	4 (1)	2 (1)	0 (0)	6 (0.9)	0.646
CLD	2 (0.5)	2 (1)	0 (0)	4 (0.6)	0.748
ILD	2 (0.5)	2 (1)	0 (0)	4 (0.6)	0.804
TB	1 (0.3)	1 (0.5)	0 (0)	2 (0.3)	0.646

Clinical features and laboratory outcomes

In this study, clinical symptoms of the admitted elderly population were also recorded. In young elderly 88.3% of the patients had fever. URTI was noted in more than 60% of the patients. Other symptoms were also prevalent such as generalized weakness and SOB. Likewise, in old elderly, fever in more than 88% of the admitted patients was the most common clinical manifestation, following that was URTI and SOB.

At last in the very old elderly, a similar clinical pattern was seen where the fever was the predominant symptom, affecting more than 88% of the patients. The patients also experienced generalized weakness, URTI, and SOB. Table 4 shows clinical symptoms in different age groups of geriatric patients who were included in the study.

Table 4.

Clinical manifestation in elderly COVID-19 patients

	60−70 (n=393) (%)	71−80 (n=204) (%)	>80 (n=57) (%)	Total (n=654) (%)	P
Symptoms
Fever	347 (88.3)	181 (88.7)	50 (87.7)	578 (88.4)	0.975
URTI	239 (60.8)	126 (61.8)	46 (80.7)	411 (62.8)	0.014*
General weakness	30 (7.6)	17 (8.3)	9 (15.8)	56 (8.6)	0.119
SOB	76 (19.3)	37 (18.1)	15 (26.3)	128 (19.6)	0.382
Sore throat	46 (11.7)	15 (7.4)	1 (1.8)	62 (9.5)	0.026*

Relevant laboratory tests were done on admitted geriatric patients. The mean leukocyte levels were 16.1 × 10⁹/L in elderly people. Certain nonspecific inflammatory markers were tested, which were revealed in young elderly, The median CRP in young elderly patients was 24.5 (13.2-45.3) (P = .029). had elevated CRP, whereas in the old elderly, the median value of CRP was noted to be 22.5 (12.5-36.8) (P = .029), and lastly, the median value of the same in the very old elderly was 30.3 (17.7-65.2) (P = .029). All of these values point towards a significant increase in CRP in COVID-19 patients.

Correspondingly, increased D-dimers were observed in these patients. The median value of D-dimers in the age group 60-70 years was reported to be 0.5 (0.3-0.9) (P = .001), 0.06 (0.3-1.1) (P = .001) in 71-80 years, and lastly 0.08 (0.5-1.7) (P = .001) in patients 81 years and above. The mean CRP was 41.7, and the mean D-dimers was 1.6 in all the admitted geriatric patients.

Serum ferritin was also seen to be raised in the geriatric population admitted for COVID-19 infection. The median value of serum ferritin was 228 (125-425) ng/mL (P = .284) in young adults, 245 (128-457) ng/mL (P = .001) in the old elderly, and 301 (123-623) ng/mL (P = .001) of very old elderly. The mean value of all the mentioned patients is 416 ng/mL.

It was also very often observed that geriatric patients developed AKI and dyselectrolytemia during their course of illness.

The HRCT chest severity (CTSS) score of these patients was assessed and the mean CTSS value was reported to be 15/20.

Table 5 shows laboratory and radiological findings in elderly infected patients who were hospitalized in tertiary hospitals from April 1, 2020, to December 31, 2020.

Table 5.

Comparison of median values of laboratories parameters with age group

	60−70 (n=393) Median (IQR)	71−80 (n=204) Median (IQR)	>80 (n=57) Median (IQR)	P
TLC	8.9 (6.5−12.9)	9.3 (6.3−14.3)	8.5 (6.1−11.5)	0.119
Eosinophils	0 (0−0)	0 (0−0.2)	0 (0−0.1)	0.158
Lymphocytes	12.5 (9.9−20.3)	14.4 (12.3−21.3)	12.5 (6.3−20.4)	0.049*
Monocytes	3.2 (2.3−6.2)	3.6 (2.3−6.7)	3.6 (2.3−6)	0.142
Basophils	0.2 (0.1−0.3)	0.2 (0.1−0.5)	0.2 (0.1−0.3)	0.348
Ferritin	228 (125−425)	245.5 (128−457)	301 (123−623)	0.284
CRP	24.5 (13.2−45.3)	22.5 (12.5−36.8)	30.3 (17.7−65.2)	0.029*
Serum creatine	0.8 (0.7−1)	0.8 (0.7−1)	0.9 (0.8−1)	0.296
D-dimers	0.5 (0.3−0.9)	0.6 (0.3−1.1)	0.8 (0.5−1.7)	0.001*
HRCT	14 (7−20)	13 (7−20)	15 (8−26)	0.263
Oxygen REQ	0 (0−4)	0 (0−4)	2 (0−6)	0.081

Treatment given, course of illness, and disease outcome in the different age groups of geriatric patients admitted to the hospital

The mortality rate in the young elderly was seen to be 9.7% (P = .37) in our data, whereas it was found to be 10.8% (P = .37) in old elderly and the highest in the very old elderly, that is, 21.1% (P = .37). The recovery rate was found to be 89% in these patients. Out of these admitted patients, 93.1% were given antivirals (Inj. Remdesivir) and 73.9% received steroids.

Table 6 and 7 shows the treatment given, clinical parameters, oxygen requirement, andclinical outcomes in different age groups of patients.

Table 6.

Comparison of mean values of clinical parameters with age group

	60−70 (n=393) Mean±SD	71−80 (n=204) Mean±SD	>80 (n=57) Mean±SD	P
Fever (No. of days)	6+3	6+4	6+3	0.463
Hb	12.9+1.7	12.5+1.7	11.9+1.7	<0.0001*
Neutrophils	68.9±14.6	69.9±13.9	71.2±17.2	0.474
Sodium	137±7	136±5	135±5	0.224
Potassium	4.1±0.5	4.2±0.6	4.1±0.5	0.226
PT	31.1±12.5	30.7±11.9	30.3±11.8	0.863
INR	3.5±1.5	3.4±1.4	3.4±1.4	0.816
ICU (No. of days)	4±2	4±3	3±1	0.214
Ventilator	78.5±20.9	70±26.5	65 ±	0.713
Hospital stay (days)	8±4	9±4	8±4	0.097

Table 7.

Treatment given to all the geriatric patients

Treatment	n=654	Percentage
Oxygen REQ	256	39.2
ICU	102	15.6
Steroid	483	73.9
Fabiflu	54	8.3
Remdisivir	609	93.1
Tocilizumab	71	10.9
Plasma	105	16.1
Ventilator	21	3.2

As per Table 6, Clinical parameters varied across age groups, with hemoglobin levels significantly lower in patients above 80 years (P < 0.0001), while other parameters like neutrophil count, sodium, potassium,and ICU stay did not show significant differences.

Plasma was transfused in 16.1% of patients and an anti-interleukin-6 receptor monoclonal antibody (Inj. Tocilizumab) was given to 10.9% of the sick patients. The highest percentage of receivers of plasma were very old elderly (33.3%) (P = .001).

Similarly, Inj. Tocilizumab was maximally given to patients above 70 years of age.

Oxygen requirement was observed in 39.2% (n = 256) of the patients. About 3.2% of the patients required a mechanical ventilator.

As of December 31, 2020, 89% of the geriatric patients were discharged from the hospital.

Repeat RTPCR was not followed up; hence, the time for negative RTPCR cannot be commented upon.

Table 8 presents data on treatment, critical care admission, and ventilation requirements across different geriatric age groups with COVID-19. Oxygen requirement, ICU admission, and ventilator use increase with age, with the >80 group showing the highest dependency (52.6% needing oxygen, 26.3% in ICU). Remdesivir was widely used (93.1% overall), while plasma therapy was significantly more frequent in the oldest group (33.3%, P = 0.001). Mortality was highest in patients >80 years (21.1%, P = 0.037), indicating age-related severity in COVID-19 outcomes.

Table 8.

Treatment given, critical care admission and ventilation requirement in different age groups of geriatric patients

	60−70 (n=393) (%)	71−80 (n=204) (%)	>80 (n=57) (%)	Total (n=654) (%)	P
Treatment
Oxygen REQ	147 (37.4)	79 (38.9)	30 (52.6)	256 (39.2)	0.088
ICU	56 (14.2)	31 (15.2)	15 (26.3)	102 (15.6)	0.063
Steroid	292 (74.3)	144 (70.6)	47 (82.5)	483 (73.9)	0.187
Fabiflu	29 (7.4)	21 (10.3)	4 (7)	54 (8.3)	0.442
Remdisivir	371 (94.4)	183 (89.7)	55 (96.5)	609 (93.1)	0.057
Tocilizumab	36 (9.2)	28 (13.7)	7 (12.3)	71 (10.9)	0.221
Plasma	57 (14.5)	29 (14.2)	19 (33.3)	105 (16.1)	0.001*
Ventilator	17 (4.3)	3 (1.5)	1 (1.8)	21 (3.2)	0.139
Death/Alive
Death	38 (9.7)	22 (10.8)	12 (21.1)	72 (11)	0.037*
Alive	355 (90.3)	182 (89.2)	45 (78.9)	582 (89)

*P<0.05, statistically significant

Table 7 shows the treatment given, oxygen requirement, and clinical outcomes in different age groups of patients.

Discussion

This retrospective cohort study examined the clinical characteristics, laboratory findings, and outcomes of elderly patients with laboratory-confirmed SARS-CoV-2 infection who were admitted to tertiary care hospitals, in India, from April 1 to December 31, 2020. A total of 654 elderly patients were included, categorized by age: young elderly (60-70 years), old elderly (71-80 years), and very old elderly (>81 years).[5] The study aimed to provide insights into the clinical course and management of COVID-19 in the elderly, a demographic that is of particular concern in primary care settings due to the prevalence of comorbid conditions and frailty.

Geriatric patients made up almost three-fourths of the total admissions in COVID care. Among these, more than 84% of the patients were admitted to the ward, and around 15% required ICU. Very old elderly patients (26.3%) (P = .063) required more critical care than old elderly and young elderly. Evidently, a greater number of elderly men (77.2%) (P = .36) were hospitalized than women (22.8%) (P = .36). However, a large study is required to infer the gender difference in COVID-19 disease. Many patients in our study had comorbidities. The risk of severity increases with age[21] and the elderly with chronic medical conditions need special attention and care as they are at a higher risk of developing the critical illness.

The elderly population, especially those with multiple comorbidities, should be considered at high risk for poor outcomes, and primary care providers must prioritize these patients for close monitoring and preventative care, including vaccination and early medical intervention.

Sara Hägg et al., 2020,[22] included 250 patients from a geriatric care hospital in Sweden from March 1 to June 11, 2020. It was evaluated in the study that 24% was the mortality rate and 44% of the patients were discharged home.

Progressing age was linked with higher mortality, and higher death rate in patients 70 years old and above, largely affecting men. Patients having acute kidney injury had a higher number of hospital mortality whereas hypertensive patients were mainly discharged. Further comorbidities (diabetes, asthma, cancer, cardiovascular disease, chronic kidney disease, chronic obstructive pulmonary disease) were seen to be noncontributory to either of the outcomes.

From a primary care perspective, elderly patients with pre-existing conditions like hypertension, diabetes, cardiovascular disease, and chronic respiratory disorders face a higher risk of progressing to severe illness.[23] In our study, the presence of these comorbidities was a significant factor in determining the severity of illness, which is consistent with other studies. As primary care providers, it is essential to monitor these conditions closely and tailor management strategies accordingly, ensuring that elderly patients receive appropriate care before complications arise.

Fabio Perrotta et al., 2020,[24] in the metanalysis study concluded that as aging is frequently accompanied by chronic illness, the elderly population needs vigilant diagnostic and therapeutic care. The decreased ability to clear potentially harmful inhaled particles via the mucociliary clearance mechanism in old age is also one of the contributing aspects of predominant respiratory symptoms.[25] In addition, Martin et al.[26] proposed that the size of the airway decreases with progressing age and men are at higher risk of respiratory collapse. SARS-CoV-2 binds with human cells with the help of spike (S) protein, a basic element found in the virus after fusing with host protease.[27,28]

Angiotensin-converting enzyme-2 is detected in the cell entry receptor of SARS-CoV-2 which binds with spike protein and causes infection.[24,29] The severity of the lung disease is caused by the degradation of the ACE2 receptor.[30] The multiorgan damage in COVID-19 can involve the kidney, heart, urothelium, small intestine, colon, spleen, liver, brain, bone marrow, thymus, and skin.[23,31] Inflammatory markers are recorded to be elevated in critically ill patients, such as D-dimers, PT-INR, lactate dehydrogenase, troponin-I, ALT, creatine kinase, and serum ferritin, procalcitonin, IL-6, C-reactive protein, thrombocytopenia, along with increased neutrophils and decreased monocytes, lymphocytes.[23,32] The characteristic finding of HRCT chest in COVID patients was bilateral ground-glass opacities more pronounced in the lower lobes, distributed peripherally or posteriorly.[13]

Additionally, a large proportion of elderly men (77.2%) were hospitalized compared to women (22.8%), though no significant gender differences were observed in disease outcomes. This finding suggests that while gender may not be a key determinant in disease severity, it remains important for primary care providers to recognize the general higher risk of severe disease in elderly men and adapt care strategies where appropriate.

The antiviral drug Remdesivir, a nucleoside triphosphate analog is used in injectable form against SARS-CoV-1, Middle East respiratory syndrome (MERS-CoV), and SARS-CoV-2.[33] John H. Beigel et al., 2020,[34] in their randomized, placebo-controlled, double-blind trial of 1062 patients analyzed that the median recovery time taken by the patients who were given remdesivir was 10 days, whereas it was 15 days in patients receiving placebo. The mortality rate of remdesivir by the 15^th day of the illness was 6.7% compared to 11.9% with placebo therapy.[34]

Remdesivir notably reduced disease severity, and oxygen requirement in patients who had high oxygen demand, and hence, hospital stay was decreased.[33] Remdesivir should be cautiously used in kidney disease patients and those with chronic liver impairment.[23] It is not to be given in patients having a glomerular filtration rate <30 mL/min. Some of the side effects of this therapy are diarrhea, acute kidney injury, rashes, impaired liver enzymes, and low blood pressure.[35]

The use of corticosteroids, such as methylprednisolone, dexamethasone, and hydrocortisone, has shown marked improvement in the patient’s condition.[23] Nonetheless, in geriatric patients, the advantages are surpassed by the metabolic side effects and can further accelerate the already persisting comorbidity, for example, diabetes, hypertension, weight gain, cataracts, increased risk of bone fracture, depression, hypernatremia, and peptic ulcer.[36,37] Corticosteroids with their anti-inflammatory and antifibrotic effects alleviate the risk of ARDS and lower mortality in COVID-19 pneumonia as well as reduce the duration of hospital stay.[38] Despite many debates currently ongoing to prove the risk-benefit ratio of using corticosteroids in COVID-19 pneumonia, it remains a hopeful, cost-effective, and efficacious treatment among doctors.

Another successful treatment used in a small number of severe COVID-19 patients is Tocilizumab injection, an IL-6 receptor antagonist. Prof Giovanni Guaraldi, MD et al., 2020,[39] investigated 1351 adult (>18 years) patients hospitalized in Italy from February 21 to March 24, 2020, and were treated with tocilizumab. It was concluded in the study that tocilizumab lowers mortality as well as the need for invasive mechanical ventilation. It supposedly suppresses the cytokine storm.[40] Even though old age is not a prohibiting criterion, there are limitations to the use of tocilizumab, for instance, it is advised to be used with caution or avoided in patients with heart, kidney, and liver disease.[23]

Guo T et al., 2020,[41] in a retrospective study analyzed the difference in the clinical course as well as outcomes in different age groups of the geriatric population admitted to different tertiary care centers in Hunan province, China. It was summarized that the elderly population especially those with somatic illness are more prone to develop severe illness. It was noted that hypertension, diabetes, and cardiac disease are among the commonest comorbidity in such populations.

Very old patients (>80 years) developed more complications than young old. Comparatively, the risk of hypercoagulability, ARDS, Acute kidney injury, and sepsis also increases with age, with very old patients being the most affected. Similarly, n-specific inflammatory markers, such as CRP, LDH, and serum ferritin, are more elevated in very old patients.[41]

Clinical presentation in the elderly could be variable ranging from typical, such as fever, dry cough, and dyspnea, to atypical symptoms, such as sore throat, weakness, dizziness, vomiting, diarrhea, myalgia, delirium, and chest pain.[42] Due to decreased basal temperature, disordered thermal homeostasis, and blunted immune system in elderly patients’ fever may not be the typical presentation.[40,42]

Adekunle Sanyaolu et al., 2020,[43] in their study with 344 ICU, elderly patients admitted in China and another set of 633 elderly patients from China observed that elderly patients with underlying chronic diseases such as hypertension, diabetes mellitus, lung diseases, kidney diseases, and immunocompromised patients or patients on steroids are more likely to get infected with COVID-19 and have higher incidences of mortality compared to younger age groups with the same disease.

It is seen that 1 in 6 confirmed cases develop critical conditions with breathing difficulty, especially in geriatrics with comorbidities. Patients with diabetes and cardiovascular diseases are more likely to progress to severe illness.[44,45]

To summarize, geriatric patients with underlying comorbidities are more likely to progress into grave diseases. Clinical manifestations could range from typical or atypical symptoms due to decreased host immune response and altered homeostasis in old age. Very old patients are inclined to develop further disease-related complications than young-old patients. Extra nursing care, vigilant monitoring, and inflammatory biomarkers along with kidney function tests and liver enzymes can be used as predictive indicators to assess the severity of the disease.

Finally, the role of primary care providers extends beyond direct clinical care. Education on preventive measures, including proper hygiene, vaccination, and the management of chronic conditions, is key to reducing the risk of severe outcomes in the elderly. As many elderly patients may not present to the hospital until late in the disease course, primary care physicians should be the first line of defense in identifying, managing, and referring at-risk patients for specialized care.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.