Are we under-diagnosing COVID-19 in older people?

Shane O’Hanlon is Consultant Geriatrician and Associate Clinical Professor at St. Vincent’s University Hospital and University College Dublin. He tweets @drohanlon

Sharon Inouye is a Geriatrician and Professor of Medicine at Harvard Medical School and Hebrew SeniorLife, Boston, MA. She tweets @sharon_inouye

It is concerning to see the high rates of COVID-19 infection among older people in hospitals and care homes, and even more worrying to see the death rates for this vulnerable group. This is a disease that disproportionately affects older people and therefore geriatricians have an important role in providing care. As we learn more about COVID-19, some things are becoming clear. One of the important features that we feel has not received enough attention is its ability to present “atypically” in older people.

As specialists in the care of older people will tell you, this is not really atypical at all. Our patients are more likely to come in with a range of common symptoms such as falls, sudden confusion (delirium), low energy, loss of appetite and dehydration – among others, rather than the typical screening criteria of fever, sore throat, cough, and shortness of breath. We are used to diagnosing respiratory infections that present with atypical complaints, so it is no surprise that COVID-19 is also following this pattern. An example was published in Age and Ageing, of a 94 year old man who presented with delirium, a low grade fever and abdominal pain and was diagnosed with COVID-19.

If you look at the guidelines for identifying COVID-19 cases, this really important point has not been stressed enough. For example, the WHO guidance mentions “atypical symptoms” in older people but does not provide any detail. The Public Health England case definitions do not consider these at all – instead there is a focus on objective findings such as a high temperature, respiratory distress or “clinical or radiographic evidence of pneumonia”. But we know that 40% of all COVID-19 cases have no radiographic abnormalities on presentation. And we also know that older adults with infection often do not mount a temperature, and many do not manifest breathing difficulty even in the face of low oxygen levels.

In our editorial, we argue that current guidance may be leading to under-detection of COVID-19 in older patients. Delirium is a particularly important syndrome to identify, as it is a 'barometer’ for severe illness especially in older adults. This has strong relevance in the hospital and also in care homes, where as well as the concerning evidence of high mortality rates associated with delirium, there is also the risk for subsequent long-term cognitive and functional decline.

Failure to detect delirium may lead to:

• missed diagnoses of infection where delirium is the presenting symptom, which may lead to the accelerated spread of an outbreak in settings such as care homes
• lack of appreciation of the severity of an infection leading to increased mortality
• and enhanced risk for longterm adverse outcomes.

Many of us have also seen reduced use of non-pharmacological interventions to manage delirium, despite good evidence for their use and a strong recommendation that they are the first-line management. This is coupled with greater use of antipsychotics and other sedating medications to control symptoms, despite the lack of evidence for their use and potential for adverse effects. We suggest practical solutions in our paper, including the HELP Toolkit developed for use in persons on COVID-19 isolation precautions, and also emphasise the importance of “Whole-Human Care” rather than just organ-system care.

We will never get everything right as we deal with this pandemic. But we can and should get the basics right - our best practices in the clinical management of older adults. We strongly recommend that guidelines should include delirium in the assessment and management of older people with COVID-19. Screening for delirium should be a standard of care, and nonpharmacologic approaches for delirium prevention and management need to be implemented as early and often as possible.

Read the Age and Ageing paper Delirium: a missing piece in the COVID-19 pandemic puzzle