key: cord-0810623-6d7az1sm
authors: Emily, Lubart; Gilad, Gal; Haim, Mizrahi Eliyahu; Galina, Goltsman
title: Functional dependency and COVID-19 in elderly patients with mild to moderate disease. Experience of tertiary geriatric hospital
date: 2021-11-03
journal: Exp Gerontol
DOI: 10.1016/j.exger.2021.111620
sha: 5ab33aad87c53d065a89c7f3835d88a53ddf71da
doc_id: 810623
cord_uid: 6d7az1sm

Clinical course of COVID-19 may be associated with functional dependency of geriatric patients. Data from the records of patients admitted to the COVID-19 Geriatric Unit were gathered during three months, including background, clinical aspects, time to resolution of infection and functional status. Functionally dependent patients had higher rates of diabetes (p = 0.03) and stroke (p = 0.004), as well as longer time to resolution of infection (p < 0.001), but less respiratory COVID-19 symptoms (p = 0.007), compared to independent patients. Time to resolution of infection was longer in women (p = 0.01) and positively associated with WBC level (p < 0.01) and age (p < 0.001). An adjusted analysis which controlled these variables confirmed the significant effect of functional status on the time to resolution of infection (p = 0.015). Functionally dependent geriatric patients with mild to moderate infection had less respiratory COVID-19 symptoms but showed longer time to resolution of infection compared to independent. Assessment of functional status in the elderly population may contribute to decision making for care of geriatric inpatients with COVID-19.

Older adults are particularly affected by Severe Acute Respiratory Syndrome -Coronavirus 2 (SARS-CoV-2), responsible for the Coronavirus Disease 2019 , which causes a broad spectrum of clinical manifestations, higher incidence of multi-organ dysfunction and mortality (Wu & Mc Googan, 2020; . Eight of ten COVID-19's deaths are in patients aged ≥65 years (Centers for Disease Control and Prevention, 2020) . This is not surprising, that geriatric patients are generally frail, cognitively impaired, bed ridden, suffer from decubitus ulcers and comorbid conditions. Chronic obstructive pulmonary disease (COPD), obesity, and diabetes mellitus have been shown to be associated with higher mortality risk, especially in COVID-19 cases (American Diabetes Association, 2018; Cortopassi et al,2017; Kalish, 2016; Yang et al,2020) . However, elderly patients widely differ in their functional condition, which may be associated to both COVID-19 variants of course and mortality risk. While data about the association between functional and mental condition and the clinical profile of older adults with COVID-19 is present in the literature (Aw et al, 2020; Azarpazhooh et al, 2020; Chen et al ,2020; Lian et al, 2020; Liu et al, 2020; Plotnikov et al,2021; Wu & Mc Googan, 2020) , the prognostic value of functional dependency on COVID-19 symptoms and time to resolution of infection is scarce. The aim of this study was to compare COVID-19 symptoms and time to resolution of infection between functionally dependent and independent geriatric patients.

Harofe hospital, a geriatric medical center affiliated to Tel Aviv University Medical School (390 beds). Only mild to moderate symptomatic patients were hospitalized in our COVID-19 unit. Thus, patients with hypoxemia <94% on room air or needed breathing support were not admitted.

COVID-19 diagnose was performed using reverse transcriptase polymerase chain reaction (RT-PCR) tests which is detected in samples from the throat and nasal swabs.

Data was collected from the electronic medical records of the patients (N=98) hospitalized in the COVID-19 Unit during three months; July-September 2020. The data included background, medical history, routine treatment, clinical presentation and condition, laboratory tests at the day of hospitalization, and outcomes of COVID-19 RT-PCR tests. In the study period of COVID-19 outbreak in Israel throat and nasal swabs for RT-PCR COVID-19 were collected one week after the initial positive test. In case of a negative outcome, an additional swab was taken 72 hours thereafter and in case of a positive outcome the next swab was taken after 7 days. Time to resolution of infection was defined as the number of days from the date of the first positive test to the date of the second consecutive negative PCR results (i.e., effective negative). Later, from November 2020, the discharge criteria were changed and based on ten days from the beginning of COVID-19 infection and symptoms only, while the PCR test was no longer applied.

Bivariate associations were tested using Pearson correlations, chi-square, and t-tests. An adjusted analysis of the time to resolution of infection performed using an analysis of covariance (ANCOVA). Possible confounders were added to the analysis according to their associations with both the dependent variable and the main factor (functional status). The threshold significance of confounders' associations was set on a significance of p<0.1.

Statistical significance was defined according to α=0.05, two-tailed. Analysis performed using SPSS 25 software (IBM Inc).

The patients were mostly women 54 (65%), average age was 84.5±7.1 years (mean ± SD).

According to functional status, measures 54 patients (55%) were FDP and 44 (45%) NFDP.

FDP were older (88.2±3.9) compared to NFDP (80.0±7.6) (t=6.9, df =96, p<0.001). A higher rate of women (67.2%) compared to men (32.4%) (χ 2 =10.9, df =1, p=0.001) was in FDP group.

Higher rates of diabetes and post stroke patients were seen among FDP. In addition, among FDP more frequent use of beta-adrenergic blockers and hypnotic drugs and lower rates of statins and acetylsalicylic acid were recorded (Table 1 ). The total number of comorbidities J o u r n a l P r e -p r o o f Journal Pre-proof did not differ between FDP (5.4±3.3) and NFDP (4.6±2.8) patients (t=1.3, df=96, p=0.19).

The frequency of respiratory COVID-19 signs and symptoms were lower in FDP (1.3±1.3) compared to NFDP (2.1±1.5) (t=2.8, df =1, p=0.007); cough (p<0.01) and breathlessness (p=0.02) ( Table 2) .

The time to resolution of infection was longer in FDP (43.7±10.6 days) compared to NFDP (25.8±16.5) (t=6.5, df =96, p<0.001) (Figure 1 ). In addition, it was longer in women (38.7±15.8) than men (29.9±15.6) (t=2.6, df=96, p=0.01), and positively associated with age 

This study compared COVID-19 symptoms and time to resolution of infection according to the functional status of geriatric patients. The main finding was that FDP with mild to moderate infection had less respiratory COVID-19 symptoms, such as cough and dyspnea compared to NFDP. The second main finding was that FDP had longer time to resolution of infection compared to NFDP.

It is well known that age can make the diagnosis more complex, as older adults with infections frequently have atypical manifestations (Gómez-Belda et al, 2020; Limpawattana et al, 2016) , that make common infections, such as pneumonia less likely to present with classically recognized features (e.g., cough and sputum production), and they more commonly present with a change in cognitive (e.g., confusion) or physical function (e.g., inability to perform ADL or falls) (Berman et al, 1986; Deandrea et al, 2010) .

The high rate of atypical presentations for a general medical patient cohort, aged more than 80 years presenting to an emergency department, observed by Hofman et al (2017) . Ming J o u r n a l P r e -p r o o f Gan et al (1971) concerning presentations of COVID-19 old age patients, described similar findings. The most common atypical presentation reported was weakness, demonstrated in our study too, but there was no difference in both groups. Those finding suggests, that the physiological response of older adults towards COVID-19 may be parallel to that seen in other disease processes.

Resembling to our study Ming Gan (1971) showed the increased numbers of patients with underlying dementia and high premorbid clinical frailty scores seen in atypical presentation group.

This is well known that aging COVID-19 patients with multiple comorbidities had a more prolonged recovery time (Atkins et al, 2020; Hewitt et al, 2020; Tenforde et al, 2020; Wang et al,2020; Wei et al, 2020; ) . In our study we shown that in addition to comorbidity and age, functional status has an additional role in duration of time to resolution of infection even in mild-to-moderate patients. Furthermore, despite of the fact that there was a significantly higher number of diabetes and stroke patients in FDP group, the functional status was statistically significant independent predictor for recovery.

Additional interesting finding of this our study was a clear association with age and prolongation of time to resolution of infection within FDP group, this is opposite to our previous study (Lubart et al, 2021) , where the age was not associated with the time to resolution of infection. Plotnikov et al (2021) study showing, that chronological age should not be used as a sole prognostic factor for elderly patients with COVID-19. 

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