Clinical characteristics of older patients: The experience of a geriatric short-stay unit dedicated to patients with COVID-19 in France
Authors: Lidvine Godaert, Emeline Proye, David Demoustier-Tampere, Pecory Souleymane Coulibaly, Fanny Hequet, Moustapha Dramé
Journal: Journal of Infection (2020)

We read with great interest the article by Liu et al.1Liu K. Chen Y. Lin R. Han K. Clinical feature of COVID-19 in elderly patients: a comparison with young and middle-aged patients.J Infect. 2020; Abstract Full Text Full Text PDF Scopus (1046) Google Scholar published recently in The Journal of Infection. We would like to share our experience as a geriatric short-stay unit exclusively for aged patients infected with coronavirus SARS-CoV-2 (COVID-19). COVID-19 infection was documented for the first time in January 2020 in France. From that date onwards, the infection spread rapidly throughout the country, mainly in the east and north. Our hospital is located in the north of France, in an area with a population of 400,000 inhabitants. In March 2020, we decided to open a short-stay geriatric unit for elderly polymorbid patients suspected of COVID-19 infection. In the first week, we received 22 patients, 17 of whom were infected with SARS-CoV-2 (confirmed by RT-PCR). Nine were female and median age was 86.5 years (range: 68.6–97.1). The main clinical and biological characteristics are detailed in Table 1, and compared with the results published by Liu et al.1Liu K. Chen Y. Lin R. Han K. Clinical feature of COVID-19 in elderly patients: a comparison with young and middle-aged patients.J Infect. 2020; Abstract Full Text Full Text PDF Scopus (1046) Google Scholar In our series, fever was the most common symptom (observed at home or at admission). Cough, delirium, dyspnea, and asthenia were the other most commonly observed signs.Table 1Main clinical and biological characteristics in elderly patients with COVID-19 infection at admission to a short-stay geriatric medical unit dedicated to COVID-19.CharacteristicsOur study population (N = 17) n (%)Study population by Liu et al. (1) (N = 18) n (%)P#Chi 2 test or Fisher's exact test when appropriate.Fever13 (76.5)14 (77.8)1Cough12 (70.6)6 (33.3)0.03Dyspnea11 (64.7)2 (11.1)0.001Sputum3 (17.6)Asthenia/Fatigue10 (58.8)2 (11.1)0.003Fall4 (23.5)Delirium9 (52.9)Diarrhea during stay6 (35.3)Oxygen therapy8 (47.1)17 (94.4)0.005Pulmonary infection on auscultation8 (47.1)Biology Neutropenia (< 4.103/mm3)4 (23.5) Lymphopenia (< 1500/ mm3)13 (76.5) Thrombopenia (< 15,000/ mm3)7 (41.2) Inflammation (CRP > 10 mg/liter)16 (94.1) Renal impairment*in comparison to the patient's usual renal function.10 (58.8) Liver impairment (ALAT or ASAT >40 U/liter)8 (47.1) in comparison to the patient's usual renal function.# Chi 2 test or Fisher's exact test when appropriate. Open table in a new tab Liu et al.1Liu K. Chen Y. Lin R. Han K. Clinical feature of COVID-19 in elderly patients: a comparison with young and middle-aged patients.J Infect. 2020; Abstract Full Text Full Text PDF Scopus (1046) Google Scholar compared the signs of COVID-19 in a population of young (n = 38) and older adults aged ≥ 60 years (n = 18). Fever was less frequent in older people (77.8%); there was no difference for cough, asthenia, or digestive signs. Guan et al.2Guan W.J. Ni Z.Y. Hu Y. Liang W.H. Ou C.Q. He J.X. et al.Clinical characteristics of coronavirus disease 2019 in China.New Eng J Med. 2020; Crossref Scopus (20093) Google Scholar described coronavirus infection in 1099 adults during the outbreak in China (median age 47 years). The most common symptoms in their study were fever (88.7%), cough (67.8%), asthenia/fatigue (38.1%), and sputum (33.7%). Diarrhea was rare (3.8%). Cough, dyspnea, asthenia, and oxygen therapy were observed more often in our series than in that of Liu et al.1Liu K. Chen Y. Lin R. Han K. Clinical feature of COVID-19 in elderly patients: a comparison with young and middle-aged patients.J Infect. 2020; Abstract Full Text Full Text PDF Scopus (1046) Google Scholar Our study population was older (median age: 86.5 versus 68.0 years). More than a quarter of our patients had diarrhea, while delirium was present in more than 60%. A fall was the first sign of the infection for more than a quarter of our patients. Thrombopenia and lymphopenia have been frequently observed in adult patients with COVID-19.2Guan W.J. Ni Z.Y. Hu Y. Liang W.H. Ou C.Q. He J.X. et al.Clinical characteristics of coronavirus disease 2019 in China.New Eng J Med. 2020; Crossref Scopus (20093) Google Scholar In our series, lymphopenia was more frequent than thrombopenia or leukopenia. Inflammation, renal impairment or liver impairment affected more than half of observed patients. Comorbidities or pre-existing frailty could influence the frequency of these signs in older people with COVID-19 infection. Elderly people are particularly affected by the coronavirus, both in terms of prevalence of disease and in terms of severity and mortality. 3Wu Z. McGoogan J.M. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese center for disease control and prevention.JAMA. 2020; Crossref Scopus (12457) Google Scholar,4Yang X. Yu Y. Xu J. Shu H. Xia Ja Liu H. et al.Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study.Lancet Respir Med. 2020; Abstract Full Text Full Text PDF Scopus (6897) Google Scholar It is likely that older people may develop uncommon signs of coronavirus infection. Differences in the clinical picture presented by elderly subjects compared to their younger counterparts are common in diseases in general,5Fried L.P. Storer D.J. King D.E. Lodder F. Diagnosis of illness presentation in the elderly.J Am Geriatr Soc. 1991; 39: 117-123Crossref PubMed Scopus (132) Google Scholar,6Beloosesky Y. Weiss A. Hershkovitz A. Grinblat J. Atypical illness presentation in the elderly.IMAJ. 2000; 2: 540-543Google Scholar and in infectious diseases in particular.7Godaert L. Najioullah F. Bartholet S. Colas S. Yactayo S. Cabie A. et al.Atypical clinical presentations of acute phase chikungunya virus infection in older adults.J Am Geriatr Soc. 2017; 65: 2510-2515Crossref PubMed Scopus (32) Google Scholar,8Janssens J. Krause K. Pneumonia in very old.Lancet Infect Dis. 2004; 4: 112-124Abstract Full Text Full Text PDF PubMed Scopus (355) Google Scholar This may result in a delayed diagnosis,9Abbara A. Collin S.M. Kon O.M. Buell K. Sullivan A. Barrett J. et al.Time to diagnosis of tuberculosis is greater in older patients: a retrospective cohort review.ERJ Open Res. 2019; 5Crossref PubMed Scopus (33) Google Scholar or even more frequent diagnostic errors,10Godaert L. Bartholet S. Gazeuse Y. Brouste Y. Najioullah F. Kanagaratnam L. et al.Misdiagnosis of chikungunya virus infection: comparison of old and younger adults.J Am Geriatr Soc. 2018; 66: 1768-1772Crossref PubMed Scopus (14) Google Scholar which is detrimental to the future of these elderly patients. Physicians caring for the elderly should consider the risk of atypical presentation of coronavirus infection. Perhaps the future will reveal that atypical signs of COVID-19 infection such as confusion, fall or diarrhea were in reality signs of severity.