Atypical COVID-19 presentations in older people – the need for continued vigilance
By Tarun Solanki
Over the past month, the landscape of healthcare has dramatically changed as a consequence of the COVID-19 pandemic. All acute trusts, primary care organisations and social services have had to remodel their working patterns in order to manage the rising number of patients with COVID-19. Many staff will have been redeployed to areas which may be unfamiliar to them. This is true for senior and junior medical staff, nursing staff, allied health professionals and support staff on the wards.
The majority of systems will have specific areas where potential patients with COVID-19 are triaged. These triage areas are separate from the usual admissions areas in emergency departments, medical and surgical admissions units. In the UK, the current triage is based on the presence of fever, cough, shortness of breath and fatigue1. In addition, it is recognised that some patients may present with anosmia. Such patients, if requiring hospitalisation will be admitted to a specified COVID-19 cohort ward and all staff on these wards will be aware of the risk of infection transmission to them and to others. Furthermore, the staff will be aware of the need to ensure appropriate PPE is utilised as per the latest PHE guidance.
Geriatric medicine has always recognised that older people may not present with typical symptoms and it is apparent that this is the case with COVID-19. Furthermore, older people have also been recognised as having a greater risk of infection and death from COVID-19. While there is little research data, frontline experience both in the UK and in other countries suggests that many older people may present atypically and therefore slip through the triaging net. These patients are likely to be admitted to a general medical or a Care of Older Peoples ward. It is therefore important that staff on these wards are aware of the atypical patients and remain vigilant to the risk of infection.
COVID-19 results in a massive cytokine storm which results in a variety of symptoms including fever, fatigue, loss of appetite, myalgia and arthralgia, nausea, vomiting, diarrhoea, rash, tachypnoea, tachycardia seizures, headache, delirium, tremor and loss of coordination. On the basis of the pathophysiology of COVID-19 infection, it is clear that its manifestations may be legion.
In a recent Twitter survey, the common atypical presentations reported in older people were delirium (hypo and hyperactive), diarrhoea, lethargy, falls and reduced appetite. Interestingly a number of respondents also reported that fever, cough and breathlessness were uncommon in older adults and that even in the absence of breathlessness, hypoxia was a common feature. Those with significant experience in dealing with COVID-19 patients have noted that even when there are other plausible causes of presentation eg CAUTI, these patients turned out to be COVID positive. Another respondent noted that if there is even the slightest doubt over a negative COVID swab result, with ongoing clinical suspicion that the patient may have COVID-19, there should be no hesitation to repeat this after 24-48 hours.
Guidance from the Regional Geriatric Program of Toronto succinctly summarises the atypical presentations in older adults2:
Typical symptoms of COVID-19 such as fever, cough, and dyspnoea may be absent in the elderly despite respiratory disease (1)
Only 20-30% of geriatric patients with infection present with fever (1)
Atypical COVID-19 symptoms include delirium, falls, generalized weakness, malaise, functional decline (1), and conjunctivitis, anorexia, increased sputum production, dizziness, headache, rhinorrhea, chest pain, haemoptysis, diarrhoea, nausea/vomiting, abdominal pain, nasal congestion, and anosmia (2)
Tachypnoea, delirium, unexplained tachycardia, or decrease in blood pressure may be the presenting clinical presentation in older adults (2)
The threshold for diagnosing fever should be lower, i.e. 37.5°C or an increase of >1.5°C from usual temperature (3)
The atypical presentation may be due to several factors, including physiologic changes with age, comorbidities, and inability to provide an accurate history (4)
Older age, frailty, and an increasing number of comorbidities increase the probability of an atypical presentation (1)
Older adults may present with mild symptoms that are disproportionate to the severity of their illness (1)
On the basis of the current knowledge and experience, it is important to recognise that presentation of COVID -19 may be atypical and patients may slip through the normal screening process and may inadvertently be admitted to a general medical ward rather than a COVID-19 cohort ward. It is therefore imperative that all staff on such wards remain vigilant, ensure appropriate PPE is utilised as per the PHE guidance. It is also important that local guidance on managing such patients with suspected COVID-19 are adhered to. Furthermore, if the first swab test is negative and there is clinical suspicion of COVID-19 then it is important that a repeat test is requested.
This pandemic has resulted in very different working patterns for many of us and we may be working in areas which are unfamiliar. In order to ensure that we manage our patients appropriately and efficiently, it is important to recognise the atypical presentations of COVID-19 and by doing so we can ensure we maintain the safety of patients and staff. It is imperative that staff on general wards are appropriately trained to recognise these atypical presentations and also have the appropriate PPE to ensure their personal safety as well as their colleagues.