key: cord-0956480-b6w1z76u authors: Janus, Sarah I.M.; Schepel, Angelique A.M.; Zuidema, Sytse U.; de Haas, Esther C. title: How Typical Is the Spectrum of COVID-19 in Nursing Home Residents? date: 2020-12-29 journal: J Am Med Dir Assoc DOI: 10.1016/j.jamda.2020.12.028 sha: f16168ce7cdc9195f9e758614118ba63f66a0f88 doc_id: 956480 cord_uid: b6w1z76u nan How Typical Is the Spectrum of COVID-19 in Nursing Home Residents? Q 1 To the Editor: Older persons living in long-term care facilities are underrepresented in studies on the clinical spectrum of Coronavirus Disease 2019 (COVID-19), especially regarding the broad range of COVID-19 signs/symptoms and course over time. In the context of advance care planning and, in the Netherlands, elderly care physicians providing nursing home care, diagnostics, and optimal supportive care are mostly provided within the nursing home. In this setting, COVID-19 testing is dependent on either signaling signs/symptoms via medical history, observation, and physical examination, or known contact with a confirmed case. However, an atypical disease presentation and course, as signaled by initial studies in hospitalized older persons, may hamper identification of COVID-19 cases. 1e3 Our aim was to gain insight into the broad spectrum of signs/symptoms, disease course, and outcome in nursing home residents with COVID-19. We performed a retrospective cohort study among residents with confirmed COVID-19 in the period March to April 2020 at 4 long-term care organizations in the Netherlands (see Supplementary Methods). Electronic health records were searched for demographics; comorbidity; 22 signs/symptoms, including clinical criteria of the World Health Organization (WHO) case definitions from March and August 2020 4, 5 ; dates on first registration; decrease in or full recovery from signs/symptoms; and disease outcome. For registered signs/symptoms, we assessed prevalence at presentation; period prevalence; and time to onset, decrease, and full recovery. We explored differences in characteristics between deceased and recovered residents. In total, 88 of 94 eligible residents were included (see Supplementary Table 1) . Fever and respiratory symptoms, especially cough and shortness of breath, were the most frequently registered signs/symptoms, at presentation as well as over the disease course. Nevertheless, only up to 63 residents (71.6%, 95% confidence interval [CI] 62.6%e81.0%) fulfilled the clinical criteria of the initial WHO case definition (March 2020). Using the current definition (August 2020), up to 84 residents (95.5%, 95% CI 91.1%e99.8%) would have fulfilled the criteria ( Figure 1 ). Frequently reported signs/symptoms from this list are of a more general nature (up to 83.0% malaise/fatigue; 72.7% loss of appetite/decreased intake) or related to the gastrointestinal tract (46.6% diarrhea; 36.4% nausea/vomiting) or altered mental status (20.5% confusion/delirium; 25.0% behavioral change). Behavioral change includes agitation/wandering (13.6%), mood changes/anxiety (5.7%), and apathy (4.5%). In addition, 61.4% of the residents experienced reduced mobility (20.5% unstable walking and/or falling; 40.9% becoming bedridden). Cough and malaise/fatigue were mostly present at presentation, that is, after median 0 days (interquartile range [IQR] 0e4) (see Supplementary Table 2 ). Fever developed mostly within 1 day (IQR 0e4), peaked with median 38.7 C (IQR 38.4e39.2 C, maximum 41.6 C) after 1 day (IQR 0e5) and disappeared after 3 days (IQR 1e9). Other respiratory and general symptoms were observed after median 2 to 3 days and mostly disappeared after 2 to 3 weeks. Gastrointestinal complaints appeared to occur later, after median 4 to 5 days, and to disappear within a week. Oxygen therapy was started in 49 (55.7%) residents after median 5 days (IQR 3e8), for a period of 9 days (IQR 1e24) and with maximum supplementation after 1.5 days (IQR 0e5). Lowest oxygen saturation during supplementation was median 89% (IQR 84e93). At data collection 32 residents (36.4%, 95% CI 26.3%e46.4%) had died at median 10.5 days (range 6e96) after first signs/symptoms; 30 died of COVID-19 after 6 to 23 days, and 2 from general health decline afterward. Full recovery was registered in 47 (53.4%) residents after median 26 days (range 4e47) and partial recovery in 9 (10.2%) after 50 days (range 39e128) follow-up. Several signs/symptoms were associated with death, including higher fever and lower oxygen saturations during supplementation: median 38.9 C (IQR 38.4e39.6 C) versus 38.5 C (38.2e38.8 C) and 85% (79%e88%) versus 91% (88%e93%) (see Supplementary Table 3 ). Male residents and residents with dementia or another chronic neurological disorder were at increased risk for 4-week mortality, with the following hazard ratios in multivariable Cox regression analysis: 2.02 (95% CI 0.93e4.40), 2.22 (95% CI 0.97e5.08), and 1.97 (95% CI 0.89e4.39). Our findings underline the importance of awareness of the broad spectrum of signs/symptoms to identify nursing home residents with COVID-19. A large proportion of these residents (28.4%) did not develop fever with 1 respiratory symptoms, thereby not fulfilling the initial WHO case definition. The observed spectrum of signs/symptoms includes atypical symptoms and geriatric syndromes (eg, gastrointestinal symptoms, confusion/ delirium, behavioral change, and decreased mobility). Therefore, the current, extended WHO case definition covers our cases better (95.5%). Because we actively searched for this broad range of signs/ 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 symptoms (at presentation as well as over the disease course), our results complement studies on symptomatology in nursing home residents. 6e9 The observed mortality rate (36.4%) and the increased 4-week mortality risk in male residents and residents with dementia are confirmed by recently published studies. 7e9 These findings may serve as point of departure for future studies on prognostic factors. COR 5.6.0 DTD JMDA3784_proof 24 January 2021 11:51 am ce SF 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 SUPPLEMENT e To Research Letter "Clinical presentation and course of COVID-19 in nursing home residents: a retrospective cohort study" We performed a retrospective cohort study in nursing home residents with COVID-19 during the first COVID-19 wave in the Netherlands (MarcheApril 2020). Five health professionals from 4 long-term care organizations in the north and east of the Netherlands, all members of University Network of Elderly Care, collected data from electronic health records. Exemption from full medical ethical review was received from the Medical Ethics Review Board of University Medical Centre Groningen, because the research falls outside the scope of the Dutch Medical Research with Human Subjects Law. The health professionals obtained informed consents from the residents or legal representatives if necessary and possible, in accordance with the Dutch Medical Treatment Agreement Act. The researchers had no access to health records, encryption keys, and other directly identifiable data. Nursing home residents were eligible if they (1) stayed at a ward for long-term stay or geriatric rehabilitation in the period March to April 2020, and (2) had confirmed COVID-19, that is, a positive reverse transcriptaseepolymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 on nasopharyngeal swab. Participating health professionals extracted data from the electronic health records with a standardized electronic data collection form, which had been developed in collaboration. Collected data consisted of the following: demographics (age, sex); type of stay (long-term, geriatric rehabilitation); comorbidity (chronic conditions, mobility, body mass index, actual smoking); dates and results of COVID-19 tests; date of first registered sign/ symptom (ie, day of presentation); a prespecified list of 22 signs/ symptoms based on the WHO case record form; dates on first registration, decrease or full recovery of signs/symptoms; related physical parameters (eg, highest body temperature, lowest oxygen saturation); received supportive care (eg, oxygen therapy); and disease outcome (hospitalization, death, partial or full recovery). For each sign/symptom, the prevalence was calculated for the day of disease presentation and for the total period (ie, period prevalence). In addition, we estimated how many residents fulfilled the clinical criteria of the WHO suspected case definition: (1) the definition from March 2020, that is, fever combined with 1 respiratory symptoms (cough, shortness of breath, rhinorrhoea/nasal congestion, sore throat), and (2) the definition from August 2020, that is, either the combination of fever and cough, or 3 of the following signs/symptoms: fever, cough, general weakness/fatigue, headache, myalgia, sore throat, rhinorrhea/nasal congestion, dyspnea, anorexia/nausea/vomiting, diarrhea, altered mental status (combination of our categories confusion/delirium and behavioral change). 7 To describe the clinical course of the disease, we estimated the rates of death and partial or full recovery, total disease duration, and for individual signs/symptoms time from presentation to onset and, if applicable, time from onset to decrease and full recovery, as noted in the health record. Descriptive statistics were used to describe the following: the baseline characteristics; the prevalence of signs/symptoms and the time to onset, decrease, and full recovery; and disease outcome. Categorical variables are presented with their absolute frequency and frequency in %. Continuous variables, which were not normally distributed, are presented with median and IQR or full range. Differences in baseline characteristics and signs/ symptoms between deceased and recovered residents were tested with the c 2 test for categorical variables and the Mann-Whitney U test for continuous variables. Subsequently, baseline characteristics that were potentially associated with time to death were tested in a Cox regression model; first in a univariable model and then combined, together with age, in a multivariable model. All analyses were performed in IBM SPSS Statistics 23 (IBM Corp, Armonk, NY). 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 Supplementary z Related variables are presented for the group of individuals with the sign/symptom concerned, that is, shortness of breath or fever. COVID-19 in older people: A rapid clinical review Presenting features of COVID-19 in older people: Relationships with frailty, inflammation and mortality Clinical characteristics of older patients infected with COVID-19: A descriptive study World Health Organization. Global Surveillance for COVID-19 Caused by Human Infection With COVID-19 Virus: Interim Guidance The authors declare no conflicts of interest. This research project was performed within the University Network of Elderly Care e UMCG, which is financially supported by the We thank the following health professionals for their assistance in the study set-up and data collection: Coran Ongering and Michelle Nijhuis-Geerdink from TriviumMeulenbeltZorg and Wanda Rietkerk from Zorggroep Noorderboog; and the following for their assistance in data collection: Martin Ketellapper from Noorderbreedte and Christine de Boer from Meriant.