At advanced ages, "someone's immune response may be blunted and their ability to regulate temperature may be altered," said Dr. Joseph Ouslander, a professor of geriatric medicine at Florida Atlantic University's Schmidt College of Medicine.
"Underlying chronic illnesses can mask or interfere with signs of infection," he said. "Some older people, whether from age-related changes or previous neurologic issues such as a stroke, may have altered cough reflexes. Others with cognitive impairment may not be able to communicate their symptoms."
Recognizing danger signs is important: If early signs of COVID-19 are missed, seniors may deteriorate before getting needed care. And people may go in and out of their homes without adequate protective measures, risking the spread of infection.
Dr. Quratulain Syed, an Atlanta geriatrician, describes a man in his 80s whom she treated in mid-March. Over a period of days, this patient, who had heart disease, diabetes and moderate cognitive impairment, stopped walking and became incontinent and profoundly lethargic. But he didn't have a fever or a cough. His only respiratory symptom: sneezing off and on.
The man's elderly spouse called 911 twice. Both times, paramedics checked his vital signs and declared he was OK. After another worried call from the overwhelmed spouse, Syed insisted the patient be taken to the hospital, where he tested positive for COVID-19.
"I was quite concerned about the paramedics and health aides who'd been in the house and who hadn't used PPE (personal protective equipment)," Syed said.
Dr. Sam Torbati, medical director of the Ruth and Harry Roman Emergency Department at Cedars-Sinai Medical Center, describes treating seniors who initially appear to be trauma patients but are found to have COVID-19.
"They get weak and dehydrated," he said, "and when they stand to walk, they collapse and injure themselves badly."
Torbati has seen older adults who are profoundly disoriented and unable to speak and who appear at first to have suffered strokes.
"When we test them, we discover that what's producing these changes is a central nervous system effect of coronavirus," he said.
Dr. Laura Perry, an assistant professor of medicine at the University of California-San Francisco, saw a patient like this several weeks ago. The woman, in her 80s, had what seemed to be a cold before becoming very confused. In the hospital, she couldn't identify where she was or stay awake during an examination. Perry diagnosed hypoactive delirium, an altered mental state in which people become inactive and drowsy. The patient tested positive for coronavirus and is still in the ICU.
Dr. Anthony Perry, an associate professor of geriatric medicine at Rush University Medical Center in Chicago, tells of an 81-year-old woman with nausea, vomiting and diarrhea who tested positive for COVID-19 in the emergency room. After receiving IV fluids, oxygen and medication for her intestinal upset, she returned home after two days and is doing well.
Another 80-year-old Rush patient with similar symptoms—nausea and vomiting, but no cough, fever or shortness of breath is in intensive care after getting a positive COVID-19 test and due to be put on a ventilator. The difference? This patient is frail with "a lot of cardiovascular disease," Perry said. Other than that, it's not yet clear why some older patients do well while others do not.
