Abstract
Background
Older adults from racial and ethnic minority groups are at higher risk for worse outcomes with COVID‐19. This study sought to characterize the symptomatology of COVID‐19 and the association of symptoms with all‐cause in‐hospital mortality and respiratory failure in a cohort of older, predominantly African American adults admitted to a tertiary hospital.
Methods
A retrospective chart review of all hospitalized patients 65 and older with a positive SARS‐CoV‐2 test was conducted in a 953‐bed academic, urban hospital. Measurements included demographics, symptoms, laboratory findings, and outcomes. The primary outcome was in‐hospital mortality, and the secondary outcome was respiratory failure.
Results
A total of 134 patients with a mean age of 76.4 years were studied. Fifty‐six percent were men and 90% were African American. Of these, 108 patients presented with typical symptoms, among whom 89.8% had co‐existing geriatric syndromes. Only 10.2% presented with typical symptoms alone. The most common typical symptoms were fever (57%), shortness of breath (SOB) (51.2%), and cough (48.8%). Atypical symptoms were present in 68 (51%) patients, of whom 83.8% had co‐existing typical symptoms and 76.5% had co‐existing geriatric syndromes. Only 17.2% of patients presented with atypical symptoms alone. Atypical symptoms identified were anorexia (43%), dizziness (12.4%), and syncope (7.4%). Geriatric syndromes were identified in 102 (76%) patients, including altered mental status (71.1%), weakness (26.4%), and falls (24.8%). Respiratory failure occurred in 65.8% of patients, with 35.4% requiring ventilators while 22.3% of patients died. Age, male gender, SOB, sepsis, and certain laboratory values were associated with outcomes.
Conclusion
Hospitalized older adults infected with SARS‐CoV‐2 may present with a range of symptoms encompassing typical, atypical, and geriatric syndromes. Early testing for COVID‐19 should be considered in hospitalized older adults.
Keywords: African American, COVID‐19, older adult
Key points
Nine out of ten hospitalized older adults infected with SARS‐CoV‐2 presented with typical symptoms of COVID‐19, and nine out of ten of these patients also presented with co‐existing geriatric syndromes.
Atypical symptoms of COVID‐19 (other than geriatrics syndromes) were also present in half of hospitalized older adults infected with SARS‐CoV‐2.
This patient population had high rates of morbidity and mortality with two‐thirds of them developing respiratory failure. Almost one‐quarter of the patients died.
Why does this paper matter?
Older adults with COVID‐19 may present atypically. With its significantly high morbidity and mortality rates, early identification and risk triage are needed. Healthcare providers should consider COVID‐19 in older adults with any significant change from baseline during the COVID‐19 pandemic.
INTRODUCTION
Older adults are at higher risk for worse outcomes from infection with SARS‐CoV‐2. 1 In addition, racial and ethnic minorities have higher contraction rates and worse outcomes from COVID‐19. 2 , 3 , 4 , 5 , 6 , 7 , 8 With the increased risk of fatality from COVID‐19 among these vulnerable populations, appropriate diagnostic protocols are needed to ensure early diagnosis and management. Guidelines by the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) for testing and diagnosis are based on the presence of typical symptoms of COVID‐19 which include fever (98%), cough (76%), dyspnea (55%), and myalgias or fatigue (up to 44%). 9 , 10 , 11 , 12 There have been a few studies that have evaluated the presenting symptoms of COVID‐19 exclusively among older adults. 13 , 14 , 15 , 16 A study of 21 older adults in Washington State admitted to the intensive care unit found that the most common presenting symptoms were shortness of breath (76%), fever (52%), and cough (48%). 13 There have been, however, several case reports of older adults with COVID–19 presenting atypically, 17 , 18 , 19 with symptoms found commonly among older adults presenting with an infectious process including falls, delirium, malaise, and poor oral intake. 20 Additionally, the National French Survey of Physicians about COVID‐19 symptoms in 353 persons aged 70 and older found that older adults appeared to exhibit fewer than three signs of infection in the first 72 hours of infection. Those over age 80 often exhibited falls and weakness and those with neurocognitive disorders exhibited delirium. 14
A large retrospective review done at Mount Sinai Health System in New York City also supports the atypical presentation of COVID‐19 among older adults. 21 Investigators performed a retrospective review of 11,992 adult emergency department visits who were tested for COVID‐19 from March 1, 2020, to May 13, 2020. They found that of the 10.9% of patients presenting with the constellation of weakness, falls, and altered mental status, 57.5% were COVID‐19 positive and they were more likely to be older adults with a mean age of 72.2 years. In a sub‐analysis of patients over 65, they found that 76.7% of patients presenting with diarrhea, 73.7% presenting with fatigue, 69.3% presenting with weakness, and 64.5% presenting with altered mental status had COVID‐19. 21 Of the entire cohort of patients, 1697 (26%) of COVID‐19 positive patients were African American. The authors did not report what proportion of the patients over 65 were African American.
Understanding the full spectrum of the presenting symptoms of COVID‐19 among older adults has significant implications for early detection and outcomes, infection control, and the promotion of safety among patients and healthcare providers. Recognizing the presenting symptoms, including atypical presentations, in nursing homes would facilitate early screening and cohorting with implications for a reduction in the spread of disease. In addition, determining the association of clinical presentations with outcomes could help guide the triage of disease severity risk, resulting in early attention and management. The present study sought to describe the symptomatology of COVID‐19 in an older, predominantly African American population admitted to a tertiary hospital and assessed which of these symptoms were associated with the outcomes of all‐cause in‐hospital mortality and respiratory failure.
METHODS
Setting and study design
This study was conducted at Grady Memorial Hospital (GMH), a 953‐bed academic, urban safety net hospital. GMH serves a largely African American low‐income population. A retrospective chart review of all patients 65 years or older admitted from March 4 to May 20, 2020, and found to have a positive SARS‐CoV‐2 test on polymerase chain reaction testing of a nasopharyngeal sample was conducted. Clinical outcomes were monitored until June 23, 2020. Study approval was obtained from the institutional review board of Emory University and the research oversight committee of Grady Memorial Hospital.
Data collection
Trained research assistants retrospectively collected study information, by reviewing electronic medical records including the emergency department provider notes, admission history, physical examination, nursing records, consulting notes, discharge summaries, laboratory tests, and radiologic examinations from the index hospitalization.
Demographic information and data regarding the symptoms and signs present on admission, laboratory findings, and outcomes as documented by the primary medical teams were retrieved from electronic medical records and retrospectively reviewed and analyzed. Presence of complications such as sepsis, septic shock, or respiratory failure during the hospital course was also documented. Race and ethnicity of the study population were determined by chart review as reported in the demographic information section of the electronic medical record (EMR). The categories for race used in our health system were: (1) Black or African American, (2) White or Caucasian, (3) Hispanic, (4) Asian, (5) American Indian and Alaskan Native, (6) Native Hawaiian and other Pacific Islander, or (7) Multiracial. Those for ethnicity were: (1) Hispanic or (2) Non‐Hispanic.
Presenting symptoms were classified as typical, atypical, or geriatric syndromes. Symptoms were classified as typical if they met the CDC guidelines for symptoms of COVID‐19. 22 Atypical symptoms were defined as other presenting symptoms (other than geriatric syndromes) that did not meet the CDC guidelines for symptoms of COVID‐19. Geriatric syndromes were identified based on recommended definitions in the literature. 23 , 24 Identified geriatric syndromes included falls, altered mental status (AMS), and weakness. AMS was further subcategorized into confusion, lethargy, and encephalopathy as documented by the primary medical teams. Patients were considered to have sepsis if they had a quick Sequential [Sepsis‐related] Organ Failure Assessment (qSOFA) score of two points or more in the setting of their COVID ‐19 infection. They were considered to have a septic shock if they had features of sepsis and a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater despite adequate volume resuscitation and serum lactate level greater than 2 mmol/L. 25 Respiratory failure was defined as PaO2 lower than 60 mmHg and/or PaCO2 higher than 50 mmHg. 26
Laboratory parameters were categorized as elevated and non‐elevated based on the hospital's laboratory reference values. The lowest and highest values of various laboratory parameters during the hospital course were also recorded. The primary outcome studied was all‐cause in‐hospital mortality, while the secondary outcome was respiratory failure.
Statistical analysis
Descriptive analysis of the total sample was done. A complete case analysis was conducted to address missing values while comparing variables of interest with primary and secondary outcomes. This was done to ensure that an unbiased approach was used to account for bias in the estimates and to avoid larger standard errors and wider confidence intervals for parameter estimates. The missing completely at random assumption was applied and patients in the dataset who had any data missing in those variables of interest were excluded from the analysis and only complete cases were analyzed. 27
Bivariate analysis was performed using Fisher's exact test to compare categorical variables (race, gender, smoking, typical and atypical symptoms, geriatric syndromes, AMS, falls) with outcomes. The Student's t test was used to compare numerical variables (age, laboratory values) with outcomes. Multivariate logistic regression models were used to explore the association of typical, atypical symptoms, and geriatric syndromes with all‐cause in‐hospital mortality and respiratory failure. Data were analyzed using R (version 4.2, R Foundation for Statistical Computing, Vienna, Austria).
RESULTS
A total of 134 patients were studied with a mean age of 76.4 (±9.2) years. Among these, 56.7% were male and 43.3% were female. 90.2% of the patients were African American. Hypertension was the most common co‐morbidity occurring in 87.3% of patients followed by dementia in 55.6% of patients (Table 1).
TABLE 1.
Distribution of patients' demographic and clinical characteristics
| Characteristic | N (%) |
|---|---|
| Mean Age (±SD) (N = 134) | 76.4 (9.2) a |
| Gender (N = 134) | |
| Male | 76 (56.7) |
| Female | 58 (43.3) |
| Race/Ethnicity (N = 122) | |
| African American (Non‐Hispanic) | 112 (90.2) |
| White (Non‐Hispanic) | 7 (5.7) |
| White (Hispanic) | 2 (1.6) |
| Asian (Non‐Hispanic) | 1 (0.8) |
| Co‐Morbidities (N = 126) | |
| Hypertension | 110 (87.3) |
| Dementia | 70 (55.6) |
| Tobacco use | 54 (42.9) |
| Diabetes | 51 (41) |
| Congestive heart failure | 15 (11.9) |
| COPD | 14 (11.1) |
| Asthma | 11 (8.7) |
| Chronic kidney disease | 8 (6.4) |
| Failure to thrive | 7 (5.6) |
| Coronary artery disease | 5 (4) |
| Asthma/COPD | 5 (4) |
| HIV | 2 (1.6) |
| Clinical manifestations | |
| Common typical symptoms (N = 121) | 108 (89.3) |
| Fever | 69 (57) |
| Shortness of breath | 62 (51.2) |
| Cough | 59 (48.8) |
| Atypical symptoms (N = 121) | 68 (56.2) |
| Anorexia | 52 (43) |
| Dizziness | 15 (12.4) |
| Syncope | 9 (7.4) |
| Geriatric syndromes (N = 121) | 102 (84.3) |
| Altered mental status (AMS) | 86 (71.1) |
| Weakness | 32 (26.4) |
| Falls | 30 (24.8) |
| Respiratory failure (N = 120) | 79 (65.8) |
| Supplemental oxygen | 50 (41.6) |
| Invasive ventilation | 28 (23.3) |
| Non‐invasive ventilation | 1 (0.83) |
| All cause in‐hospital mortality (N = 121) | 27 (22.3) |
Note: Complete case analysis was done to limit bias from missing data. Percentages are of complete cases excluding patients with missing data.
Abbreviations: COPD, chronic obstructive pulmonary disease; HIV, human immunodeficiency virus; SD, standard deviation.
Age is presented as a mean ± SD.
Clinical presentation
A total of 108 (89.3%) patients presented with typical symptoms, mostly in combination with geriatric syndromes (Table 1, Figure 1). Of the patients presenting with typical symptoms, 89.8% of them presented with typical symptoms in combination with geriatric syndromes, while only 10.2% of them presented with typical symptoms alone (Figure 1). The most common typical symptoms were fever (57%), shortness of breath (51.2%), and cough (48.8%) (Table 1). AMS was the most common geriatric syndrome occurring in combination with typical symptoms in up to 78.4% of the patients with co‐existing geriatric syndromes.
FIGURE 1.
Distribution of clinical presentations of COVID‐19 among hospitalized older adults
Sixty‐eight patients presented with atypical symptoms (Table 1). Of these patients, 83.8% had co‐existing typical symptoms, while 76.5% had co‐existing geriatric syndromes. 17.2% of patients presented with atypical symptoms alone (Figure 1). The most common atypical symptoms were anorexia (43.0%), dizziness (12.4%), and syncope (7.4%) (Table 1). AMS was the most common geriatric syndrome occurring in combination with atypical symptoms in 80.8% of the 52 patients with co‐existing geriatric syndromes.
Geriatric syndromes were identified in a total of 102 patients (Table 1). AMS was the most common geriatric syndrome found in 71.1% of patients, while 26.4% presented with weakness and 24.8% presented with a fall (Table 1). Among the patients with AMS, encephalopathy was the most common form described in 66.3%, while confusion was described in 22.1% and lethargy in 11.6% of patients (data not shown).
Complications and outcomes
Patients experienced multiple complications including sepsis in 44.3%, shock in 48.4%, respiratory failure in 65.8%, and multiorgan failure in 9% of patients, mostly involving lungs and kidneys (Table 2). Among patients with respiratory failure, 63.3% were managed on supplemental oxygen, while 35.4% were managed with invasive ventilation and 1.3% with non‐invasive ventilation (Table 1).
TABLE 2.
Association of demographic characteristics and clinical presentations with outcomes
| All cause in‐hospital mortality | Respiratory failure | |||||||
|---|---|---|---|---|---|---|---|---|
| Characteristic | Dead, N = 25 (%) | Alive, N = 85 (%) | Overall, N = 110 (%) | p‐value | Yes, N = 73 (%) | No, N = 37 (%) | Overall, N = 110 (%) | p‐value |
| Mean Age (±SD) a | 80.6 (8.88) | 75.6 (9.17) | 76.7 (9.30) | 0.001 | 76.5 (8.65) | 77.1 (10.6) | 76.7 (9.30) | 0.001 |
| Gender | 0.26 | 0.04 | ||||||
| Female | 8 (32) | 39 (45.8) | 47 (42.7) | 26 (35.6) | 21 (56.8) | 47 (42.7) | ||
| Male | 17 (68) | 46 (54.2) | 63 (57.3) | 47 (64.4) | 16 (43.2) | 63 (57.3) | ||
| Race | 0.73 | 0.53 | ||||||
| African American | 23 (92) | 75 (88.2) | 98 (89.1) | 66 (90.4) | 32 (86.5) | 98 (89.1) | ||
| Others | 2 (8) | 10 (11.8) | 12 (10.9) | 7(9.6) | 5 (13.5) | 12 (10.9) | ||
| Smoking | 9 (8.2) | 38 (34.5) | 47 (42.7) | 0.50 | 33 (45.2) | 14 (37.8) | 47(42.7) | 0.54 |
| Atypical COVID Symptoms | 12 (48) | 49 (57.6) | 61 (55.5) | 0.49 | 37 (50.7) | 24 (64.9) | 61 (55.5) | 0.22 |
| Geriatric Syndromes | 22 (88) | 70 (82.4) | 92 (83.6) | 0.73 | 62 (84.9) | 30 (81.1) | 92(83.6) | 0.60 |
| Typical COVID Symptoms | 24 (96) | 84 (98.8) | 108 (98.2) | 0.41 | 72 (98.6) | 36 (97.3) | 108 (98.2) | 1.00 |
| Number of typical symptoms | 0.65 | 0.69 | ||||||
| ≤3 | 13 (52) | 49 (57.6) | 62 (56.3) | 40 (54.8) | 22 (59.5) | 62 (56.4) | ||
| >3 | 12 (48) | 36 (42.4) | 48 (43.7) | 33 (45.2) | 15 (40.5) | 48 (43.6) | ||
| Complications | ||||||||
| Sepsis | 19 (76) | 31 (36.5) | 50 (45.5) | 0.001 | 40 (54.8) | 10 (27.7) | 50 (45.5) | 0.009 |
| Shock/Hypotension | 18 (72) | 39 (45.9) | 57 (51.8) | 0.03 | 45 (61.6) | 12 (32.4) | 57 (51.8) | 0.001 |
| Respiratory Failure | 24 (96) | 52 (61.1) | 77 (70) | <0.001 | N/A | N/A | N/A | N/A |
Note: Complete case analysis was done for variables of interest to limit bias from missing data. Percentages are of complete cases excluding patients with missing data. Results shown are from bivariate analysis. p < 0.05 indicates significant differences in outcomes.
Abbreviation: NA, not applicable.
Age is presented as a mean ± standard deviation (SD).
Primary outcome
Overall, 27 (22.3%) patients died. The results of bivariate analysis for associations between demographic and clinical characteristics and mortality are presented in Table 2. Age, sepsis, shock, and respiratory failure were associated with mortality in bivariate analysis. Compared to patients who survived, patients who died were older and more likely to have had sepsis, shock, or respiratory failure.
The results of bivariate analysis for associations between individual clinical symptoms and mortality are presented in Table 3. Compared to patients who survived, patients who died were more likely to have reported shortness of breath (70.4% vs. 51.7%, p = 0.031). Other individual clinical symptoms were not associated with mortality. The results of bivariate analysis for associations between laboratory values and mortality are presented in Table 4. Compared to patients who survived, patients who died were more likely to have had elevated levels of procalcitonin, troponin, ferritin, and liver enzymes. On average, compared to patients who survived, patients who died had higher values of alanine transaminase (ALT), aspartate transaminase (AST), and alkaline phosphatase.
TABLE 3.
Association of individual clinical symptoms with outcomes
| All cause in‐hospital mortality | Respiratory failure | |||||||
|---|---|---|---|---|---|---|---|---|
| Characteristic | Dead, N = 26 (%) | Alive, N = 93 (%) | Overall, N = 119 (%) | p‐value | Yes, N = 76 (%) | No, N = 43 (%) | Overall, N = 119 (%) | p‐value |
| Typical symptoms | ||||||||
| Fever | 19 (73.1) | 50 (53.8) | 69 (58) | 0.12 | 44 (57.9) | 25 (58.1) | 69 (58) | 1.00 |
| Cough | 9 (34.6) | 50 (53.8) | 59 (49.6) | 0.12 | 35 (46.1) | 24 (55.8) | 59(49.6) | 0.34 |
| SOB | 19 (73.1) | 43 (46.2) | 62 (52.1) | 0.03 | 47 (61.8) | 15 (34.9) | 62 (52.1) | 0.007 |
| Myalgia | 3 (11.5) | 12 (12.9) | 15 (12.6) | 1.00 | 9 (11.8) | 6 (14) | 15 (12.6) | 0.78 |
| Chest pain | 3 (11.5) | 14 (15.1) | 17 (14.3) | 0.76 | 12 (15.8) | 5 (11.6) | 17 (14.3) | 0.60 |
| Sore throat | 1 (3.8) | 8 (8.6) | 9 (7.6) | 0.68 | 7 (9.2) | 2 (4.7) | 9 (7.6) | 0.49 |
| Anosmia | 0 (0) | 4 (4.3) | 4 (3.4) | 0.58 | 1 (1.3) | 3 (7) | 4 (3.4) | 0.13 |
| Dysgeusia | 0 (0) | 2(2.2) | 2 (1.7) | 1.00 | 0 (0) | 2 (4.7) | 2 (1.7) | 0.13 |
| Diarrhea | 7 (25.9) | 24 (25.8) | 31 (26.1) | 1.00 | 19 (25) | 12 (27.9) | 31 (26.1) | 0.83 |
| Vomiting | 3 (11.5) | 5 (5.4) | 8 (6.7) | 0.37 | 5 (6.6) | 3 (7) | 8 (6.7) | 1.00 |
| Atypical symptoms | ||||||||
| Dizziness | 1 (3.8) | 14 (15.1) | 15 (12.6) | 0.19 | 10 (13.2) | 5 (11.6) | 15 (12.6) | 1.00 |
| Anorexia | 12 (46.2) | 40 (43) | 52 (43.7) | 0.83 | 33 (43.4) | 19 (44.2) | 52 (43.7) | 1.00 |
| Syncope | 0 (0) | 9 (9.7) | 9 (7.6) | 0.20 | 3 (3.9) | 6 (14) | 9 (7.6) | 0.70 |
| Geriatric syndromes | ||||||||
| AMS | 21 (80.8) | 56 (60.2) | 77 (64.7) | 0.14 | 53 (69.7) | 24 (55.8) | 77 (64.7) | 0.51 |
| Falls | 3 (11.5) | 19 (20.4). | 22 (18.4) | 0.39 | 12 (15.8) | 10 (23.3) | 22 (18.4) | 0.21 |
| Weakness | 7 (26.9) | 25 (26.9) | 32 (26.9) | 0.80 | 17 (22.4) | 14 (32.6) | 31 (26.1) | 0.28 |
Note: Complete case analysis was done for variables of interest to limit bias from missing data. Results shown are from bivariate analysis. p < 0.05 indicates significant differences in outcomes.
Abbreviations: SOB, shortness of breath; AMD, altered mental status.
TABLE 4.
Association of laboratory values with outcomes
| All cause in‐hospital mortality | Respiratory failure | |||||||
|---|---|---|---|---|---|---|---|---|
| Variables | Dead, N = 25 (%) | Alive, N = 86 (%) | Overall, N = 111 (%) | p‐value | Yes, N = 69 (%) | No, N = 42 (%) | Overall, N = 111 (%) | p‐value |
| Elevated laboratory variables | ||||||||
| D dimer a | 21 (84) | 63 (73.3) | 84 (75.7) | 0.68 | 58 (84.1) | 26 (61.9) | 84 (75.7) | 0.030 |
| LDH a | 20 (80) | 55 (64.0) | 75 (67.6) | 0.38 | 53 (76.8) | 22 (52.4) | 75 (67.6) | 0.001 |
| CRP a | 17 (68) | 43 (50.0) | 60 (54.1) | 0.19 | 44 (63.8) | 16 (38.1) | 60 (54.1) | 0.00 |
| Procalcitonin a | 19 (76) | 25 (29.1) | 44 (39.6) | <0.001 | 37 (53.6) | 7 (16.7) | 44 (39.6) | 0.001 |
| Troponin a | 20 (80) | 35 (40.7) | 55 (49.5) | 0.002 | 38 (55.1) | 17 (40.5) | 55 (49.5) | 0.011 |
| Ferritin a | 16 (64) | 35 (40.7) | 51 (45.9) | 0.08 | 39 (56.5) | 12 (28.6) | 51 (45.9) | 0.020 |
| Creatinine a | 13 (52) | 34 (39.5) | 47 (42.3) | 0.4 | 30 (43.5) | 17 (40.5) | 47 (42.3) | 0.030 |
| Liver enzymes a | 17 (68) | 38 (44.2) | 55 (49.5) | 0.04 | 36 (52.2) | 19 (45.2) | 55 (49.5) | 0.560 |
| Mean laboratory variables (SD) | ||||||||
| Mean ALT (SD) b | 175 (454) | 53.8 (81.3) | 81.1 (229) | <0.001 | 108 (287) | 36.9 (41.2) | 81.1 (229) | 0.001 |
| Mean ALK Phos (SD) b | 101 (55.5) | 95.8 (39.1) | 97.0 (43.1) | <0.001 | 102 (43.9) | 89.4 (41.2) | 97.0 (43.1) | 0.001 |
| Mean AST (SD) b | 750 (3110) | 67.2 (109) | 221 (1480) | <0.001 | 329 (1880) | 43.7 (27.9) | 221 (1480) | 0.001 |
| Other variables | ||||||||
| Lymphopenia | 11 (44) | 35 (40.7) | 46 (41.4) | 0.47 | 37 (53.6) | 9 (21.4) | 46 (41.4) | 0.001 |
| Abnormal CXR/Chest CT Scan | 1 (4) | 9 (10.5) | 10 (9) | 0.74 | 63 (91.3) | 29 (69) | 92 (82.9) | 0.009 |
Note: Complete case analysis was done for variables of interest to limit bias from missing data. Percentages are of complete cases with abnormal laboratory values, excluding patients with missing data. Results shown are from bivariate analysis. p < 0.05 indicates significant differences in outcomes.
Abbreviations: ALK Phos, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; CRP C‐ reactive protein; CT, computerized tomography; CXR, chest X‐ray; LDH, lactate dehydrogenase; SD, standard deviation.
Number (proportion) of patients with elevated laboratory values.
ALT, AST, Alk Phos are presented as a mean ± SD.
Older age and shortness of breath were associated with higher odds of death in adjusted (multivariable logistic) regression analysis (Figure S1a). The odds of dying increased by 7% with each additional year of age (odds ratio [OR] 1.07, 95% CI 1.01–1.14). Patients with shortness of breath had a more than three‐fold increase in the odds of dying (OR 3.44, 95% CI 1.17–11.24). Other predictors were not significantly associated with mortality.
Secondary outcome
Overall, 79 (65.8%) developed respiratory failure. The results of bivariate analysis for associations between demographic and clinical characteristics and respiratory failure are presented in Table 2. Patients who had respiratory failure were more likely to have been male and to have had sepsis or shock when compared to patients who had no respiratory failure.
The results of bivariate analysis for associations between individual clinical symptoms and respiratory failure are presented in Table 3. Compared to patients who had no respiratory failure, patients with respiratory failure were more likely to have reported shortness of breath. Other individual clinical symptoms were not associated with respiratory failure. The results of bivariate analysis for associations between laboratory values and respiratory failure are presented in Table 4. Compared to patients who had no respiratory failure, patients with respiratory failure were more likely to have had elevated levels of D‐dimer, lactate dehydrogenase (LDH), C‐reactive protein (CRP), procalcitonin, ferritin, and to have lymphopenia. Abnormal chest imaging was also associated with respiratory failure.
In adjusted (multivariable logistic) regression analysis (Figure S1b), the shock was associated with higher odds of respiratory failure (OR 3.71 95% CI 1.44–10.23). Patients with shock had a more than three‐fold increase in the odds of respiratory failure (OR 3.71, 95% CI 1.44–10.23). Other predictors were not significantly associated with respiratory failure.
DISCUSSION
This study evaluates the symptomatology of COVID‐19 among a primarily African American older adult population admitted to a tertiary care hospital and assessed which of these symptoms were associated with the outcomes of all‐cause in‐hospital mortality and respiratory failure. The study found that these older adults most often presented with typical and atypical symptoms in addition to geriatric syndromes. Only one‐tenth of patients presented with typical symptoms alone. The most common typical symptoms were fever, shortness of breath, and cough.
The most common atypical symptoms were anorexia, dizziness, and syncope, and the most common geriatric syndromes were altered mental status, weakness, and falls. Several studies have evaluated the clinical manifestations of COVID‐19. These studies have found that a high proportion of older adults from different nationalities have typical symptoms of COVID‐19. 13 , 14 , 15 , 16 Symptoms such as anorexia, dizziness, and syncope have also been documented in various studies as manifestations of COVID‐19. 28 , 29 , 30 , 31 , 32 , 33 The prevalence of anorexia, dizziness, and syncope were higher in the current study possibly due to the older age of the patient population as compared to the referenced studies. Data from this study also support the studies that have found altered mental status, weakness, and falls among older adults with COVID‐19 disease. 14 , 15 , 16 , 17 , 18 , 19 , 33 , 34 , 35 , 36 , 37 , 38 , 39 The incidence of altered mental status was higher in this study possibly due to the older age and higher prevalence of dementia among the patient population studied as compared to the referenced studies. This study adds to the body of literature by demonstrating that the cohort of patients studied presented with a wide range of symptoms encompassing typical symptoms, atypical symptoms, and geriatric syndromes.
This older, predominantly African American population with COVID‐19, had high rates of morbidity and mortality. Two‐thirds of patients developed respiratory failure and almost one‐quarter of the patients died. The latter is within the range of reported in‐hospital mortality rates for older adults with COVID‐19. 15 , 40 , 41 , 42 , 43 Specific patient characteristics and abnormal laboratory values were associated with respiratory failure and in‐hospital mortality, but presentation with atypical symptoms and geriatric syndromes were not associated with respiratory failure or mortality. Other studies that have evaluated the association between presenting symptoms of COVID‐19 with morbidity and mortality have had mixed results and we would recommend this as an area for further study. 15 , 16 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43
The current study was conducted within the first 6 months of the COVID‐19 pandemic prior to the availability of COVID‐19 vaccinations. The impact of vaccination on the presentation of symptomatic COVID‐19 in those who develop breakthrough infections is yet to be determined as the SARS‐CoV‐2 virus continues to evolve. At the time of the writing of this paper, the United States has just experienced the fifth wave of COVID‐19 infections due to the highly transmissible SARS‐CoV‐2 Omicron variant, which impacted both vaccinated and unvaccinated persons. Although rates of vaccination among older adults in the United States are relatively high, many older adults have not received a booster vaccination dose making them susceptible to infection and adverse outcomes from the Omicron variant and possibly future variants. Older adults, those from racial and ethnic minority groups, and other groups disproportionately negatively impacted by social determinants of health will likely continue to be at higher risk for COVID‐19 infection as they have been throughout this pandemic. Understanding the symptomatology of vaccinated older adults with COVID‐19 infections will be an important area for future study. Until such time as this data is available, we would recommend that studies such as ours guide healthcare professionals in the testing and disease severity risk stratification of older adults for SARS‐CoV‐2 infection regardless of their vaccination status.
The findings from this study add to the growing body of literature on the presentation of COVID‐19 among older adults. Additionally, the findings demonstrate possible atypical first‐line presentations of older adults with COVID ‐19 and highlight the need for early screening and triage of disease severity risk. With the increasing evidence that screening based on typical symptoms alone is insufficient to identify COVID‐19 in older adults, 44 , 45 this study supports the emerging recommendations emphasizing the consideration of COVID‐19 in older adults with any significant change from baseline. 46
Limitations
The limitations of this study include the fact that it was performed at a single site, and it is a retrospective chart review with data obtained based on documentation by the managing medical teams. A complete case analysis was done to limit the bias from missing data, however, there is a potential for bias through loss of information with the exclusion of incomplete cases. This was addressed by limiting the complete case analysis to variables of interest only. The study population being predominantly African American could limit the generalizability of the findings; however several of the findings are in keeping with reported findings by other studies on older adults of other nationalities. Additionally, as this was a population of patients hospitalized with COVID‐19, the findings may not be applicable to patients seen in the emergency room and discharged, or those managed in the outpatient setting.
The timing of this study, early in the COVID‐19 pandemic, may also limit the generalizability of the findings. First, the focus on testing guidelines at the time of the study on typical symptoms may have impacted who was tested for COVID‐19. It is possible that patients who did not present with typical symptoms were not tested for COVID‐19. The authors however think the likelihood of this is small given that this was a group of hospitalized patients and that almost all hospitalized patients were being tested for COVID‐19 in the healthcare system at that time in the pandemic. Secondly, as discussed above, the study was conducted before the availability of the COVID‐19 vaccination, and this may limit the applicability of the findings in vaccinated persons. At this time, however, a large proportion of the world's population remains unvaccinated, and the findings of this study would still be applicable to these persons.
CONCLUSION
This study has presented data on clinical presentations of COVID‐19 and its association with outcomes among one of the populations most vulnerable to morbidity and mortality from this disease. The findings, suggesting the association of certain symptoms with mortality and respiratory failure, provide important guidance for caring for this population, highlighting the need for early detection and triage of disease severity risk. Additionally, this study adds to the growing body of evidence of atypical symptoms and geriatric syndromes as common in the presentation of COVID‐19 among older adults and supports that guidelines on testing be updated to reflect these findings. Given this wide constellation of presenting symptoms of COVID‐19 and the high risk of morbidity and mortality, clinicians should have a low threshold for testing older adults presenting with atypical symptoms and geriatric syndromes for SARS‐CoV‐2 during the COVID‐19 pandemic.
AUTHOR CONTRIBUTIONS
Ohuabunwa, Afolabi, and Tom‐Aba had full access to all of the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis. Study concept and design: Ohuabunwa, Fluker. Acquisition of data: Ohuabunwa, Afolabi. Analysis and interpretation of data: Tom‐Aba, Ohuabunwa. Drafting of the manuscript: Ohuabunwa, Tom‐Aba, Fluker. Critical revision of the manuscript for important intellectual content: Ohuabunwa, Fluker. Statistical analysis: Tom‐Aba. Administrative, technical, or material support: Ohuabunwa, Fluker. Study supervision: Ohuabunwa, Afolabi.
CONFLICT OF INTEREST
The authors report no conflict of interest.
SPONSOR'S ROLE
Not applicable; this study was not funded.
FINANCIAL DISCLOSURE
None.
Supporting information
Figure S1. Predictors of Primary and Secondary outcomes
Figure S1a. Predictors of Mortality
Figure S1b. Predictors of Respiratory Failure
*Significant variables that predict outcomes.
Ohuabunwa U, Afolabi P, Tom‐Aba D, Fluker S‐A. Clinical presentation of COVID‐19 and association with outcomes among hospitalized older adults. J Am Geriatr Soc. 2022;1‐10. doi: 10.1111/jgs.18163
This paper was presented as an oral abstract at the Society of General Internal Medicine Annual Meeting in April 2021. This paper was also presented as a poster at the American Geriatrics Society Annual Meeting in May 2021.
Contributor Information
Ugochi Ohuabunwa, Email: uohuab2@emory.edu, @OhuabunwaUgochi.
Shelly‐Ann Fluker, Email: shelly-ann.fluker@emory.edu.
REFERENCES
- 1. Centers for Disease Control and Prevention . Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID‐19)—United States, February 12–March 16, 2020 (online). Accessed April 2, 2021. Available at https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm.
- 2. Azar KMJ, Shen Z, Romanelli RJ, et al. Disparities in outcomes among COVID‐19 patients in a large health care system in California. Health Aff (Millwood). 2020;39:1253‐1262. [DOI] [PubMed] [Google Scholar]
- 3. Holtgrave DR, Barranco MA, Tesoriero JM, Blog DS, Rosenberg ES. Assessing racial and ethnic disparities using a COVID‐19 outcomes continuum for New York State. Ann Epidemiol. 2020;48:9‐17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Hooper MW, Nápoles AM, Pérez‐Stable EJ. COVID‐19 and racial/ethnic disparities. JAMA. 2020;323:2466‐2467. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Yan BW, Ng F, Chu J, Tsoh J, Nguyen T. Asian Americans facing high COVID‐19 case fatality. Health Affairs Blog, July 13, 2020 (online). Accessed April 2, 2021. 10.1377/forefront.20200708.894552 [DOI]
- 6. Wadhera RK, Wadhera P, Gaba P, et al. Variation in COVID‐19 hospitalizations and deaths across New York City boroughs. JAMA. 2020;323:2192‐2195. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Li Y, Cen X, Cai X, Temkin‐Greener H. Racial and ethnic disparities in COVID‐19 infections and deaths across U.S. Nursing Homes. J Am Geriatr Soc. 2020;68(11):2454‐2461. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Ogedegbe G, Ravenell J, Adhikari S, et al. Assessment of Racial/Ethnic Disparities in Hospitalization and Mortality in Patients with COVID‐19 in New York City. JAMA Netw Open. 2020;3(12):e2026881. doi: 10.1001/jamanetworkopen.2020.26881. Available at: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2773538 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Global surveillance for COVID‐19 caused by human infection with COVID‐19 virus: Interim Guidance, 20 March 2020. World Health Organization (online). Accessed April 2, 2021. Available at: https://apps.who.int/iris/bitstream/handle/10665/331506/WHO-2019-nCoV-SurveillanceGuidance-2020.6-eng.pdf?sequence=1&isAllowed=y.
- 10. Overview of Testing for SARS‐COV‐2 (COVID‐19) . Centers for Disease Control (online). Accessed April 2, 2021. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html.
- 11. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497‐506. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Zhu W, Xie K, Lu H, Xu L, Zhou S, Fang S. Initial clinical features of suspected coronavirus disease 2019 in two emergency departments outside of Hubei, China. J Med Virol. 2020;92:1525‐1532. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Arentz M, Yim E, Klaff L, et al. Characteristics and outcomes of 21 critically ill patients with COVID‐19 in Washington State. JAMA. 2020;323:1612‐1614. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Annweiler C, Sacco G, Salles N, et al. National French survey of COVID‐19 symptoms in people aged 70 and over. Clin Infect Dis. 2020;72:490‐494. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. 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] [PMC free article] [PubMed] [Google Scholar]
- 16. Knopp P, Miles A, Webb TE, et al. Presenting features of COVID‐19 in older people: relationships with frailty, inflammation and mortality. Eur Geriatr Med. 2020;11:1089‐1094. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Norman R, Stall N, Sinha S. Typically atypical: COVID‐19 presenting as a fall in an older adult. J Am Geriatr Soc. 2020;68(7):E36‐E37. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Alkeridy W, Almaghlouth I, Alrashed R, et al. A unique presentation of delirium in a patient with otherwise asymptomatic COVID‐19. J Am Geriatr Soc. 2020;68(7):1382‐1384. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Ohuabunwa U, Turner J, Johnson T. Atypical presentations among older adults with COVID‐19 disease: a need for broadening the differential diagnosis. Gerontol Geriatric Med. 2021;7:233372142199931. doi: 10.1177/2333721421999313 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Samaras N, Chevalley T, Samaras D, Gold G. Older patients in the emergency department: a review. Ann Emerg Med. 2010;56:261‐269. [DOI] [PubMed] [Google Scholar]
- 21. Clifford CT, Pour TR, Freeman R, et al. Association between COVID‐19 diagnosis and presenting chief complaint from new York City triage data. Am J Emerg Med. 2020;46:520‐524. doi: 10.1016/j.ajem.2020.11.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Symptoms of Coronavirus . Centers for Disease Control (online). Accessed April 2, 2021. Available at: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html.
- 23. Flacker JM. What is a geriatric syndrome anyway? J Am Geriatr Soc. 2003;51(4):574‐576. [DOI] [PubMed] [Google Scholar]
- 24. Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc. 2007;55(5):780‐791. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis‐3). JAMA. 2016;315(8):801‐810. doi: 10.1001/jama.2016.0287 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26. Shebl E, Burns B. Respiratory failure. [Updated 2021 Nov 26]. StatPearls [Internet]. StatPearls Publishing; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526127/ [Google Scholar]
- 27. Jamshidian M, Mata M. Advances in analysis of mean and covariance structures when data are incomplete. In: Lee SY, ed. Handbook on Structural Equation Models. Elsevier; 2006:21‐44. [Google Scholar]
- 28. Dong ZY, Xiang BJ, Jiang M, Sun MJ, Dai C. The prevalence of gastrointestinal symptoms, abnormal liver function, digestive system disease and liver disease in COVID‐19 infection: a systematic review and meta‐analysis. J Clin Gastroenterol. 2021;55:67‐76. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29. Mao R, Qiu Y, He JS, et al. Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID‐19: a systematic review and meta‐analysis. Lancet Gastroenterol Hepatol. 2020;5:667‐678. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30. Mao L, Jin H, Wang M, et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020;77:1‐9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31. Saniasiaya J, Kulasegarah J. Dizziness and COVID‐19. Ear Nose Throat J. 2021;100:29‐30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. Syncope and COVID‐19 disease – a systematic review . Raquel Falcão de Freitas, Sofia Cardoso Torres, José Pedro L. Nunes. medRxiv: The Preprint Server for Health Sciences 2020. Doi: 10.1101/2020.12.30.20249060 [DOI]
- 33. Chachkhiani D, Soliman MY, Barua D, et al. Neurological complications in a predominantly African American sample of COVID‐19 predict worse outcomes during hospitalization. Clin Neurol Neurosurg. 2020;197:106173. doi: 10.1016/j.clineuro.2020.106173 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34. 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. Available at: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2773106 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35. Zazzara MB, Penfold RS, Roberts AL, et al. Probable delirium is a presenting symptom of COVID‐19 in frail, older adults: a cohort study of 322 hospitalized and 535 community‐based older adults. Age Ageing. 2021;50:40‐48. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Rozzini R, Bianchetti A, Mazzeo F, Cesaroni G, Bianchetti L, Trabucchi M. Delirium: clinical presentation and outcomes in older COVID‐19 patients. Front Psychiatry. 2020;11:586686. doi: 10.3389/fpsyt.2020.586686 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37. Godaert L, Proye E, Demoustier‐Tampere D, Coulibaly PS, Hequet F, Dramé M. Clinical characteristics of older patients: the experience of a geriatric short‐stay unit dedicated to patients with COVID‐19 in France. J Infect. 2020;81:e93‐e94. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38. Olde Rikkert MGM, Vingerhoets RW, van Geldorp N, de Jong E, Maas HAAM. Atypical clinical picture of COVID‐19 in older patients. Ned Tijdschr Geneeskd. 2020;164:D5004. [PubMed] [Google Scholar]
- 39. Berková M, Berka Z. Falls: a significant cause of morbidity and mortality in elderly people. Vnitr Lek. 2018;64:1076‐1083. [PubMed] [Google Scholar]
- 40. Zhao HL, Huang YM, Huang Y. Mortality in older adults with COVID‐19. J Am Geriatr Soc. 2020;68(8):1685‐1686. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41. Sun H, Ning R, Tao Y, et al. Risk factors for mortality in 244 older adults with COVID‐19 in Wuhan, China: a retrospective study. J Am Geriatr Soc. 2020;68(6):E19‐E23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42. Mehra MR, Desai SS, Kuy S, Henry TD, Patel AN. Cardiovascular disease, drug therapy, and mortality in Covid‐19. N Engl J Med. 2020;382:1‐8. doi: 10.1056/NEJMoa2007621 [DOI] [PMC free article] [PubMed] [Google Scholar] [Retracted]
- 43. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID‐19 in the New York City area. JAMA. 2020;323:2052‐2059. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44. Kimball A, Hatfield KM, Arons M, et al. Asymptomatic and Presymptomatic SARS‐COV‐2 infections in residents of a long term care skilled nursing facility – King County, Washington, March 2020. MMWR Morb Mortal Wkly Rep. 2020;69:377‐381. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45. Roxby AC, Greninger AL, Hatfield KM, et al. Detection of SARS‐COV‐2 among residents and staff members of an independent and assisted living Community for Older Adults – Seattle, Washington, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:416‐418. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46. D'Adamo H, Yoshikawa T, Ouslander JG. Coronavirus disease 2019 in geriatrics and long‐term care: the ABCDs of COVID‐19. J Am Geriatr Soc. 2020;68(5):912‐917. [DOI] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Figure S1. Predictors of Primary and Secondary outcomes
Figure S1a. Predictors of Mortality
Figure S1b. Predictors of Respiratory Failure
*Significant variables that predict outcomes.