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Inicio Revista Española de Geriatría y Gerontología Atypical symptoms of COVID-19 in hospitalised oldest old adults
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Vol. 56. Núm. 2.
Páginas 120-121 (Marzo - Abril 2021)
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Vol. 56. Núm. 2.
Páginas 120-121 (Marzo - Abril 2021)
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Atypical symptoms of COVID-19 in hospitalised oldest old adults
Síntomas atípicos de COVID-19 en el adulto mayor hospitalizado
Isabel Lozano-Montoyaa,b,
Autor para correspondencia

Corresponding author.
, Maribel Quezada-Feijoob,c, Javier Jaramillo-Hidalgoa,b, Francisco J. Gómez-Pavóna,b
a Servicio de Geriatría, Hospital Central de la Cruz Roja San José y Santa Adela, C/Reina Victoria, 24, 28003 Madrid, Spain
b Facultad de Medicina, Universidad Alfonso X el Sabio, Avda. de la Universidad, 1, 28691 Villanueva de la Cañada, Madrid, Spain
c Servicio de Cardiología, Hospital Central de la Cruz Roja San José y Santa Adela, C/Reina Victoria, 24, 28003 Madrid, Spain
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Table 1. Demographic characteristics and symptoms at admission.
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Infection misdiagnosis is common in older adults since infections may present differently than in the general population1 COVID-19 is typically signalled by three symptoms: fever, cough and dyspnoea and is particularly fatal for older adults.2,3 Atypical symptoms recognition in these extremely vulnerable populations is critical for early detection, screening and intervention. However, atypical symptoms in older adults are not well established. We report clinical characteristics and presenting symptoms of COVID-19 in advanced age patients attended in a specialized geriatric hospital in Madrid, a city where the SARS-CoV-2 pandemic was particularly bad. The study protocol was approved by the Ethics Committee, under the ID: PI-4131.

Between March 20 and April 30, 2020, we attended 111 patients with probable or definitive COVID-19 diagnosis.4Table 1 shows demographic and clinical characteristics, including geriatric assessments. Mean age (85.5±6.6y) is higher than in studies, which defined COVID-19 clinical characteristics.5 Many patients were frail with significant co-morbidities. However, a high proportion had no or only mild functional or cognitive impairment (Table 1). 47 patients (42.3%) did not present fever and 27 (24.3%) neither fever nor cough. Amongst atypical symptoms stands out the delirium (hyperactive or hypoactive) assessed by Confusion Assessment Method (CAM),6 present in more than 40% of patients, and high prevalence of falls as presenting symptom (14.4%). Fever absence was significantly more frequent in patients with falls compared to patients with other presenting symptoms (68.5%, vs. 37.9%; p=0.021). Nearly 93% of patients had radiographically confirmed pneumonia.

Table 1.

Demographic characteristics and symptoms at admission.

n  111 
Female, n (%)  54 (48.6) 
Age (years)  85.5±6.6 
Age range (years)  70–97 
Duration of symptoms before diagnosis  5.7±3.5 
Nursing home residents  55 (49.5) 
Type of diagnosis
Clinical and radiologic  27 (24.3) 
Laboratory  84 (75.7) 
Polypharmacy (5–10 drugs)  49 (44.1) 
Excessive polypharmacy (≥10 drugs)  24 (21.6) 
Charlson Comorbidity Index  2.5 (±2.0) 
Charlson Comorbidity Index categories
No comorbidity (CCI: 0–1)  30 (27.0) 
Low comorbidity (CCI: 2)  31 (27.9) 
High comorbidity (CCI3)  49 (44.1) 
Barthel index  69.1±30.3 
Barthel index categories
Independent (BI: 100)  27 (24.3) 
Mild dependence (BI: 60–99)  47 (42.3) 
Moderate dependence (BI: 40–55)  13 (11.7) 
Severe dependence (BI: 20–35)  8 (7.2) 
Total dependence (BI<20)  12 (10.8) 
Global deterioration scale
No cognitive decline (GDS: 1)  47 (42.3) 
Age associated memory impairment/Mild cognitive decline (GDS: 2,3)  23 (20.7) 
Mild Dementia (GDS: 4)  19 (17.1) 
Moderate Dementia (GDS: 5)  13 (11.7) 
Moderately Severe Dementia (GDS: 6)  3 (2.7) 
Severe Dementia (GDS: 7)  5 (4.5) 
Clinical frailty scale; n (%)
Robust (CFS: 1–3)  34 (30.6) 
Vulnerable (CFS: 4)  4 (3.6) 
Mild (CFS: 5)  28 (25.2) 
Moderate (CFS: 6)  20 (18.0) 
Severe (CFS: 7)  17 (15.3) 
Very severe (CFS: 8)  7 (6.3) 
Classical symptoms
Cough  63 (56.8) 
Fever  64 (57.7) 
Dyspnoea  64 (57.7) 
Cough+fever  43 (38.7) 
Cough+fever+dyspnoea  25 (22.5) 
Atypical symptoms
Any type of delirium  47 (42.3) 
Hyperactive delirium  33 (29.7) 
Hypoactive delirium  14 (12.6) 
Falls  16 (14.4) 
Diarrhoea  4 (3.6) 
Asthenia or loss of appetite  63 (53.8) 
Pneumonia  103 (92.8) 
Death, n (%)  51 (45.9) 
Length of hospital stay  12.2±7.8 

BI: Barthel index. CCI: Charlson Comorbidity Index. CFS: Clinical Frailty Scale. GDS: Global Deterioration Scale. Longitudinal data are shown as mean (±standard deviation).

Global in-hospital mortality was 45.9%. Patients with delirium had nearly double in-hospital death risk compared to those with other presenting symptoms (61.7% vs. 34.4%; p=0.004). Interestingly, patients with delirium presented lower functional status (Barhtel Index: 58.5±30 vs. 77.2±27.7; p=0.001), more frailty (proportion of at least moderate frailty: 54.3% vs. 29.6%; p=0.009) and more cognitive impairment (proportion of at least moderate dementia: 28.3% vs. 12.5%; p=0.038) than patients without delirium. Fever is the key method for COVID-19 screening.7 However, in older adults awareness of other clinical features is mandatory, including falls and delirium, which may coincide with infection onset.1,8 Cardinal delirium manifestations are cognitive disturbances with impaired orientation, temporal fluctuation, and onset in few hours or days.9,10 In our series it is associated to poorer prior functional and cognitive status, and higher mortality.

Physicians and general population must gain knowledge of the COVID-19 special and unique aspects in geriatric populations lowering thus suspicion and testing thresholds for SARS-CoV-2 in older adults.

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