Atypical Presentation of Covid in the Elderly

Original Editor - Ewa Jaraczewska based on the course by Scott Buxton
Top Contributors - Ewa Jaraczewska, Lucinda hampton, Tarina van der Stockt, Wanda van Niekerk, Kim Jackson, Jess Bell, Oyemi Sillo, Olajumoke Ogunleye and Aminat Abolade

Introduction

The COVID-19 pandemic shows how vulnerable elderly persons are and that the low capacity of the immune system leads to a fatal outcome. Quick implementation of preventive and therapeutic strategies was not possible due to the worldwide nature of COVID.   Protection of those at risk who already carried the load of other health issues was limited.

COVID in the Elderly

Older adults are more likely to experience complications of COVID-19 than younger adults. Older adults with COVID-19 might need hospitalization, intensive care, or a ventilator to help them breathe and increase their chances of survival. The risk rises for people in their 50s and escalates in the 60s, 70s, and 80s. People 85 and older are the most likely to get very sick. It affects people of all ages everywhere in the world, but most deaths from this disease occur in the elderly. The most susceptible individuals 65 years and older are those suffering two or more comorbidities. Furthermore, elderly with a history of cardiovascular disease, diabetes mellitus, chronic obstructive pulmonary disease, malignancy and chronic kidney disease are most at risk of dying from COVID. Additional factors include disabilities, cognitive and mood disorders (eg depression, bipolar), polypharmacotherapy, social isolation, and nutritional deficits often present in the residents of long-term care facilities.

Infection and the Elderly

The immune system is responsible for overcoming infections due to the production of IgG anti-virus antibodies. The immune system's effectiveness can be influenced by several factors, including nutritional deficits in the elderly. This can lead to severe inflammatory disease affecting the heart, lungs, kidneys and vascular system.

Cells' capacity to respond to infections is defined by the senescence process that begins when cells are dividing but not dying. Cells division is a natural cell ageing process, yet their resistance to death can lead to age-related pathologies. The accumulation of old (senescence) cells in various tissues can be responsible for cells' unnecessary damage.Changes in the development and function of the immune system are called immunosenescence. This process can lead to an increased risk for disease development in the elderly.

Inflammaging (chronic low-grade inflammation that develops with advanced age) presents with elevated levels of blood inflammatory markers frequently described in the elderly population and caused by three geriatric conditions: malnutrition, sarcopenia and frailty.

Nutritional Deficits in the Elderly

According to a study completed in European hospitals, residential care and community settings nutritional deficits in the elderly can be caused by reduced dietary intake in addition to age-related problems such as malabsorption, increased nutrient losses and augmented metabolic demands. Malnutrition caused by low intake of food high with vitamins, minerals and proteins directly affect the body's immune responses:

• Low intake of food high in vitamins, especially:
  • Vitamin A: has an important role in the development and functioning of the immune system and increases the efficacy of T-cell-based viral vaccines
  • Vitamin B: affects cell and immune system function and energy metabolism. Deficiency of Vitamin B leads to inflammation
  • Vitamin C: promotes antimicrobial activity and the production of antibodies. Tends to be depleted during infections resulting in coagulopathy
  • Vitamin D: reduces the risk of infections and assists in immune responses
  • Vitamin E: stimulates T-cell function.

• Low intake of food high in minerals, especially:
  • Zinc: enhances the total number and function of T-cells
  • Iron: both an excess and a deficiency of iron affect the functioning of the immune system
  • Magnesium: co-factor for immunoglobulin synthesis, immune cell adherence, antibody-dependent cytolysis
  • Copper: supports the immune system

• Low protein intake: leads to wasting syndrome.See also Muscle Function and Protein

Muscle wasting syndrome in the elderly can be the result of the negative net protein balance as shown by research. Inability of the aged person's muscles to synthesise protein in response to anabolic stimuli (diet, exercise) is a characteristic of anabolic resistance. Based on the scientific evidence, it is recommended that the elderly person increase protein intake with each meal to effectively stimulate protein synthesis.

The risk of malnutrition can be assessed using the Mini Nutritional Assessment. This tool can identify if the individual is well-nourished, is at risk for malnutrition or is malnourished.

Sarcopenia

Sarcopenia is a disease that originates at the cellular level. Faulty metabolism can be a causative factor, and symptoms include decreased muscle strength and muscle mass. The progressive cellular processes lead to poor outcomes in an individual's strength, mobility, and functional capacity. It is considered one of the risk factors for COVID-19; at the same time, hospitalisation with COVID-19 infection may lead to sarcopenia.

Factors that cause and worsen muscle quantity and quality

Clinically, patients with sarcopenia demonstrate compromised function of the respiratory system, immunological, and metabolic systems, among others. Definition for this clinical presentation was revised in 2018 by the European Working Group on Sarcopenia in Older People (EWGSOP2) and is now used internationally for diagnostic purposes.Clinical assessment should follow recommendations published by the International Working Group on Sarcopenia that include:

• assessment of physical capabilities
• ruling out sarcopenia in non-ambulatory patients
• 4 meters usual walking pace test
• body composition measurement.

The following are the most commonly used physiotherapy assessment tools:

• gait speed (timed 4-metre walk test)
• sit-stand time
• standing balance
• muscle power measurement
• self-reported measures of ADLs.

Frailty

Frailty is a risk factor for COVID. An individual with frailty must present with three or more symptoms, including:

• Unintentional weight loss (10 lbs/ 4.5kg in the past year)
• Self-reported exhaustion
• Weakness (grip strength)
• Slow walking speed
• Low physical activity

A person with two or fewer deficits listed above is considered in the pre-frail stage. An individual with no deficits is identified as robust.

Due to a reduction in 'physiological reserve affecting immune function and adaptation to acute stressors', frailty is considered high risk for mortality, institutionalisation, falls, and hospitalisation.

Typical Presentation of COVID

The European Centre for Disease Prevention and Control (ECDC) conducted the study on clinical characteristics of COVID-19. However, the study indicated that 40% of COVID-19 cases are asymptomatic. The most common symptoms included:

• Cough
• Fever
• Fatigue
• Myalgia (muscle aches and pain)
• Headache
• Loss of smell
• Nasal obstruction
• Asthenia (lack of energy, physical weakness)
• Rhinorrhoea ( nasal discharge)
• Olfactory and gustatory dysfunction (taste disturbance)
• Soar throat

Atypical Presentation of COVID in the Elderly

With age‐related changes in immunity, COVID may present atypically in the elderly population.

1. Hypoactive Delirium

There are three motor subtypes of Delirium:

Subtype	Clinical Manifestations
Hyperactive	Agitation, restlessness, emotional lability, hallucinations
Hypoactive	Lethargy, decreased responsiveness, slowed motor skills
Mixed	Fluctuation between hyper- and hypoactive symptoms

Hypoactive delirium is the most common subtype of delirium in the geriatric population. The symptoms include lethargy, confusion, and apathy. Because the patient displays no signs of agitation, irritation, anger or aggression, they are often wrongly diagnosed with depression or dementia. Hypoactive delirium is associated with systemic infection aetiologies and has a lower overall burden of delirium symptoms than the other motor subtypes. However, it has been linked to increased mortality risk.

Assessment Tools

Diagnostic tools to determine a patient's status include standardised testing, information received from the medical record, and reports from the patient's care team: nursing staff and the family.

Standardised tests:

• Diagnostic and Statistical Manual of Mental Disorders (DSM IV)
• Short Form of the Informant Questionnaire on Cognitive Decline in the Elderly (Short IQCODE)
• Delirium Motor Subtype Scale (DMSS-4)
• Delirium Aetiology Checklist (DEC)
• Delirium Rating Scale Revised-98 (DRS R98)
• 4AT
• AMT

Clinical Management

Management of hypoactive delirium includes pharmacological and non-pharmacological approaches.

Non-pharmacological treatment:

• Reorientation
  • Living room (scheduled activity with occupational therapist, interaction with other patients)
  • Orientation box (clock, diary, information leaflet, radio, TV, music)
  • Circadian rhythm (healthy sleep-wake cycle)
  • MDT (Multidisciplinary Team) and family participation (family staying at night, room filled with family photos, personal items, pillow, blanket)
• Psychosocial
  • Delirium consultation (consultation by a specialist: nurse practitioner, geriatrician, psychiatrist)
  • Delirium observation screening score (delirium severity measurement: 13 observations)
• Other
  • Respiratory Treatment (ACBT)
  • Repositioning
  • Passive Range of Motion

2. Falls

Syncope, near syncope, or non-mechanical falls are atypical features of COVID. The aetiology of syncope or near syncope fall can be cardiogenic and non-cardiogenic, including:

• History of cardiovascular disease
• Supplemental oxygen requirement
• Gastrointestinal symptoms
• Elevated troponin level

The consequences of falls are one of the main causes of disability among the elderly population leading to a reduction in quality of life, loss of independence and limited social functioning.

Assessment Tools

Holistic, multidisciplinary assessment should be considered when evaluating elderly patients with COVID who are at risk of falls and should include:

• Fall risk assessment
• Evaluation of motor functions
• Assessment of cognitive impairment
• Mental performance assessment

Clinical Management

Key principles for clinical management of patients with fall risk are:

• Education and support for caregivers
• Close surveillance to ensure patients' adherence to pharmacological treatment
• Providing access to nutritious food, social and mental health support and information to maintain patients' emotional well-being
• Early planning of post-discharge care

3. Anorexia of Ageing

Anorexia is a loss of appetite due to the ageing process, and it can lead to:

• Decrease oral intake
• Weight loss
• Increased risk of malnutrition
• Sarcopenia  
• Frailty  

It is a condition present among the elderly living in all environments. It affects patients admitted to acute care hospitals the most (42%). 30% of individuals living in care homes and 22% of community-dwelling elderly individuals have been diagnosed with anorexia. Pathogenesis of the anorexia of ageing has a direct relationship with changes occurring in three "regulators" of appetite: physiological signalling, hedonism and external cues.

Anorexia was diagnosed in 8.4% of the elderly with COVID-19, and the mortality rate was high due to malnutrition.

Assessment Tools

Standardised tools for assessing appetite are not yet available.

The most commonly used appetite assessment instruments are

• Self-assessment
• Subjective Assessment of Appetite
• Visual Analogue Scale (VAS)
• Functional Assessment of Anorexia/Cachexia Therapy (FAACT) score
• Anorexia Questionnaire (AQ)
• 4-item Simplified Nutritional Appetite Questionnaire (SNAQ)
• Mini Nutritional Assessment

Clinical Management

When managing an individual with a poor appetite, medical causes need to be ruled out first. Medical conditions known to affect appetite are:

• Chronic heart disease
• Chronic pulmonary disease
• Chronic pain disease
• Acute inflammatory illness
• Medication side effects
• Swallowing deficits (dysphagia).

If no medical causes are identified, there is a lack of evidence-based treatments to manage anorexia. It is suggested that the treatment plan should include the following:

• Nutritional recommendations
• Oral nutritional supplements (ONS)
• Psychological support
• Family-based therapy

4. Fatigue

Patients with COVID often complain about fatigue. This symptom is one of the most common problems affecting 44 to 69.6% of individuals with COVID. Factors causing fatigue can be biological, social, behavioural, cognitive and emotional. Others include immune system alteration (immune dysregulation).

• Chronic fatigue syndrome (CFS) is a problem associated with a lack of endurance that is persistent and lasts over six months.

Assessment Tools

Fatigue can be assessed using various tests and scales. The Chalder Fatigue Scale (CFQ-11) is a validated tool where patients' responses are measured on a Likert scale. Pattern and character of fatigue must be evaluated in addition to exercise tolerance and cognitive exertion.

Common tests include routine haematology and biochemistry with full blood count, urea and electrolytes, thyroid function tests, liver function tests, bone profile, erythrocyte sedimentation rate and vitamin B12.

Clinical Management

A lack of an evidence-based management strategy for COVID fatigue necessitates using treatment methods developed to manage chronic fatigue syndrome. This approach includes:

• Educating the patient
• Improving the quality of rest (see sleep deprivation and sleep disorders)
• Choosing activities that do not exacerbate symptoms
• Learning energy conservation and relaxation techniques eg meditation
• Learning pacing techniques
• Incorporating cognitive behavioural therapy (CBT)