Probable delirium is a presenting symptom of COVID-19 in frail, older adults: a cohort study of 322 hospitalised and 535 community-based older adults

  1. Maria Beatrice Zazzara
  2. Rose S Penfold
  3. Amy L Roberts
  4. Karla A Lee
  5. Hannah Dooley
  6. Carole H Sudre
  7. Carly Welch
  8. Ruth C E Bowyer
  9. Alessia Visconti
  10. Massimo Mangino
  11. Maxim B Freidin
  12. Julia S El-Sayed Moustafa
  13. Kerrin S Small
  14. Benjamin Murray
  15. Marc Modat
  16. Mark S Graham
  17. Jonathan Wolf
  18. Sebastien Ourselin
  19. Finbarr C Martin
  20. Claire J Steves
  21. Mary Ni Lochlainn

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Abstract

Background

Frailty, increased vulnerability to physiological stressors, is associated with adverse outcomes. COVID-19 exhibits a more severe disease course in older, comorbid adults. Awareness of atypical presentations is critical to facilitate early identification.

Objective

To assess how frailty affects presenting COVID-19 symptoms in older adults.

Design

Observational cohort study of hospitalised older patients and self-report data for community-based older adults.

Setting

Admissions to St Thomas’ Hospital, London with laboratory-confirmed COVID-19. Community-based data for older adults using the COVID Symptom Study mobile application.

Subjects

Hospital cohort: patients aged 65 and over (n = 322); unscheduled hospital admission between 1 March 2020 and 5 May 2020; COVID-19 confirmed by RT-PCR of nasopharyngeal swab. Community-based cohort: participants aged 65 and over enrolled in the COVID Symptom Study (n = 535); reported test-positive for COVID-19 from 24 March (application launch) to 8 May 2020.

Methods

Multivariable logistic regression analysis performed on age-matched samples from hospital and community-based cohorts to ascertain association of frailty with symptoms of confirmed COVID-19.

Results

Hospital cohort: significantly higher prevalence of probable delirium in the frail sample, with no difference in fever or cough. Community-based cohort: significantly higher prevalence of possible delirium in frailer, older adults and fatigue and shortness of breath.

Conclusions

This is the first study demonstrating higher prevalence of probable delirium as a COVID-19 symptom in older adults with frailty compared to other older adults. This emphasises need for systematic frailty assessment and screening for delirium in acutely ill older patients in hospital and community settings. Clinicians should suspect COVID-19 in frail adults with delirium.

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  1. ScreenIT

    SciScore for 10.1101/2020.06.15.20131722: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Limitations: There are several limitations to this study. For the hospital cohort, admissions data were collected retrospectively from electronic health records. CFS was not always documented systematically and, in approximately one-third of cases, had to be retrospectively calculated using relevant information from admission clerking. In the community-based cohort, COVID-19 test result and symptoms were self-reported and entered directly by participants or by-proxy. The proportion of total app users ≥65 years of age is 11.7%, whereas only 4.8% of app users with a confirmed positive COVID-19 test were ≥65 years of age. Since 18.3% of the UK population are aged over 65[45], older adults overall, and especially laboratory-tested for COVID-19, are likely to be under-represented. Sampling using a mobile application will under-represent individuals without mobile devices and is likely to under-represent those severely affected by the disease. These biases may mean we underestimate the differences in symptoms in frail people in the community study. The fact that the most significant finding from the community-based study was recapitulated in the clinical study is reassuring. Furthermore, of app users ≥65 years of age, 16.4% are categorised as frail. This is a similar proportion to the 15-20% of older adults categorised as moderate or severely frail during validation of the electronic Frailty Index[46]. For community-based data, note that COVID-19 tests were not widely available in ...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  2. Version published to 10.1093/ageing/afaa223
  3. ScreenIT

    SciScore for 10.1101/2020.06.15.20131722: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementThe app was upgraded in April 2020 to allow family members or care-givers to submit data by-proxy, with consent.Randomizationnot detected.Blindingnot detected.Power Analysisnot detected.Sex as a biological variableMean age of 322 individuals with confirmed COVID-19 RT-PCR was 78.58 years (standard deviation (SD) +/7.93); 154 (48%) were females. 165 (51%) patients were classified as frail.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    QC was performed by an automated python script developed independent of data analysis.
    python
    suggested: (IPython, SCR_001658)

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:

    • There are several limitations to this study.
    • For the hospital cohort, admissions data were collected retrospectively from electronic health records.
    • CFS was not always documented systematically and, in approximately one-third of cases, had to be retrospectively calculated using relevant information from admission clerking.

    Results from OddPub: We did not find a statement about open data. We also did not find a statement about open code. Researchers are encouraged to share open data when possible (see Nature blog).

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore is not a substitute for expert review. SciScore checks for the presence and correctness of RRIDs (research resource identifiers) in the manuscript, and detects sentences that appear to be missing RRIDs. SciScore also checks to make sure that rigor criteria are addressed by authors. It does this by detecting sentences that discuss criteria such as blinding or power analysis. SciScore does not guarantee that the rigor criteria that it detects are appropriate for the particular study. Instead it assists authors, editors, and reviewers by drawing attention to sections of the manuscript that contain or should contain various rigor criteria and key resources. For details on the results shown here, including references cited, please follow this link.

  4. Version published to 10.1101/2020.06.15.20131722v1 on medRxiv