Patient Factors and Hospital Outcomes Associated With Atypical Presentation in Hospitalized Older Adults With COVID-19 During the First Surge of the Pandemic

Abstract

Background Literature indicates an atypical presentation of COVID-19 among older adults (OAs). Our purpose is to identify the frequency of atypical presentation and compare demographic and clinical factors, and short-term outcomes, between typical versus atypical presentations in OAs hospitalized with COVID-19 during the first surge of the pandemic. Methods Data from the inpatient electronic health record were extracted for patients aged 65 and older, admitted to our health systems’ hospitals with COVID-19 between March 1 and April 20, 2020. Presentation as reported by the OA or his/her representative is documented by the admitting professional and includes both symptoms and signs. Natural language processing was used to code the presence/absence of each symptom or sign. Typical presentation was defined as words indicating fever, cough, or shortness of breath; atypical presentation was defined as words indicating functional decline or altered mental status. Results Of 4 961 unique OAs, atypical presentation characterized by functional decline or altered mental status was present in 24.9% and 11.3%, respectively. Atypical presentation was associated with older age, female gender, Black race, non-Hispanic ethnicity, higher comorbidity index, and the presence of dementia and diabetes mellitus. Those who presented typically were 1.39 times more likely than those who presented atypically to receive intensive care unit–level care. Hospital outcomes of mortality, length of stay, and 30-day readmission were similar between OAs with typical versus atypical presentations. Conclusion Although atypical presentation in OAs is not associated with the same need for acute intervention as respiratory distress, it must not be dismissed.

Age‐related differences in symptoms in older emergency department patients with COVID‐19: Prevalence and outcomes in a multicenter cohort

“…Symptoms were abstracted from electronic health records and categorized as “typical” (cough, fever, or shortness of breath) or “alternate symptoms” based on existing literature. 10 …”

“…Fever, cough, and shortness of breath were considered typical symptoms due to frequent occurrence across all age groups in our study and literature search. 10 , 11 , 12 Any other symptoms experienced by patients pertaining to COVID‐19 were considered alternate symptoms. Phenotype was coded into a three‐level categorical variable with options of “2 or more typical symptoms,” “any single typical symptom,” and “no typical symptoms.”…”

“…We developed a phenotype variable that discerned typical and alternate COVID‐19 symptoms to assess the association with each outcome measure. Fever, cough, and shortness of breath were considered typical symptoms due to frequent occurrence across all age groups in our study and literature search 10–12 . Any other symptoms experienced by patients pertaining to COVID‐19 were considered alternate symptoms.…”

“…Treatment delay is associated with poorer treatment efficacy, 8 potentially leading to higher mortality rates 9 . Most SARS‐CoV‐2‐positive patients present to U.S. emergency departments (EDs) with fever, cough, and dyspnea 10–12 . However, older adults with COVID‐19 can present “atypically” or with alternate presentations such as falls or syncope, 13 drowsiness, 14 or acute mental status changes 15,16 …”

“…9 Most SARS-CoV-2-positive patients present to U.S. emergency departments (EDs) with fever, cough, and dyspnea. [10][11][12] However, older adults with COVID-19 can present "atypically" or with alternate presentations such as falls or syncope, 13 drowsiness, 14 or acute mental status changes. 15,16 While the link between age and worse clinical outcomes in older patients with SARS-CoV-2 infection has been wellestablished, 2,17 few studies in the United States have explored the ED presentation of older adults with COVID-19 and its impact on clinical outcomes in this population.…”