Reports of atypical presentations of COVID-19 have been emerging as the SARS-CoV-2 pandemic has grown across the globe. Atypical presenting features refer to patients where the constitutional or respiratory symptoms are absent or minimal and other non-respiratory symptoms or signs are early or predominant features.
Studies have shown that the greatest risk factor for severe COVID-19 is increasing age, particularly patients with multimorbidity and/or higher frailty scores. Like many infections affecting elderly patients, COVID-19 can present as a non-specific decline. While most studies report elderly patients presenting with a fever and productive cough, this may be related to the case definition criteria being used to diagnose COVID-19. Elderly patients may in fact not develop the typical fever seen in SARS CoV-2 infection due to a blunted response caused by immune senescence.
Another unusual presentation of COVID-19 that appears to particularly affect the elderly population is “silent hypoxemia” where patients develop respiratory failure without signs of respiratory distress. This is an especially worrying presentation as patients may feel well and treatment may be delayed.
Delirium is another clinical manifestation and elderly patients may present with delirium during illness. Smell and taste dysfunction has been reported in 34%-59% of patients with COVID-19. The loss of smell usually presents early in the disease process.
- COVID-19 may present as viral pneumonia and is easily identified by pattern recognition of the typical respiratory symptoms
- A number of atypical presentations affecting a variety of organ systems have become apparent including anosmia (loss of sense of smell), diarrhea and neurological features
- Diagnostic reasoning using intuitive processes can rapidly identify typical COVID-19 cases in a pandemic situation but alternative cognitive processes are required to consider other COVID-19 “mimic” diagnoses
These are some things to consider as you assess your residents for signs and symptoms of COVID-19; they may not present with the same symptoms as a younger patient. Be tuned in, pay attention, understand the symptoms and when to throw up the flag. Remember, we are here to care for a frail population with multiple comorbidities and don’t want to miss the early signs of infection!
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