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Aging and disease    2020, Vol. 11 Issue (4) : 988-1008     DOI: 10.14336/AD.2020.0620
Review |
COVID 19 - Clinical Picture in the Elderly Population: A Qualitative Systematic Review
Neumann-Podczaska Agnieszka1,*, Al-Saad Salwan R1, Karbowski Lukasz M1, Chojnicki Michal2,3, Tobis Slawomir4, Wieczorowska-Tobis Katarzyna1,5
1Geriatrics Unit, Department of Palliative Medicine, Poznan University of Medical Sciences, Poznan, Poland.
2Department of Biology and Environmental Protection, Poznan University of Medical Sciences, Poznan, Poland.
3Department of Infectious Diseases, Jozef Strus Hospital, Poznan, Poland
4Occupational Therapy Unit, Geriatrics and Gerontology, Poznan University of Medical Sciences, Poznan, Poland
5Geriatric Outpatient Clinic, University Hospital of Lord’s Transfiguration, Poznan, Poland.
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Abstract  

The SARS-CoV-2 tendency to affect the older individuals more severely, raises the need for a concise summary isolating this age population. Analysis of clinical features in light of most recently published data allows for improved understanding, and better clinical judgement. A thorough search was performed to collect all articles published from 1st of January to 1st of June 2020, using the keywords COVID-19 and SARS-CoV-2 followed by the generic terms elderly, older adults or older individuals. The quality assessment of studies and findings was performed by an adaptation of the STROBE statement and CERQual approach. Excluding duplicates, a total of 1598 articles were screened, of which 20 studies were included in the final analysis, pertaining to 4965 older COVID-19 patients (≥60 years old). Variety in symptoms was observed, with fever, cough, dyspnea, fatigue, or sputum production being the most common. Prominent changes in laboratory findings consistently indicated lymphopenia and inflammation and in some cases organ damage. Radiological examination reveals ground glass opacities with occasional consolidations, bilaterally, with a possible peripheral tendency. An evident fraction of the elderly population (25.7%) developed renal injury or impairment as a complication. Roughly 71.4% of the older adults require supplementary oxygen, while invasive mechanical ventilation was required in almost a third of the reported hospitalized older individuals. In this review, death occurred in 20.0% of total patients with a recorded outcome (907/4531). Variability in confidence of findings is documented. Variety in symptom presentation is to be expected, and abnormalities in laboratory findings are present. Risk for mortality is evident, and attention to the need for supplementary oxygen and possible mechanical ventilation is advised. Further data is required isolating this age population. Presented literature may allow for the construction of better predictive models of COVID-19 in older populations.

Keywords COVID-19      SARS-CoV-2      elderly      older individuals      clinical features     
Corresponding Authors: Neumann-Podczaska Agnieszka   
About author:

These authors contributed equally to this work.

Just Accepted Date: 03 July 2020   Issue Date: 30 July 2020
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Neumann-Podczaska Agnieszka
Al-Saad Salwan R
Karbowski Lukasz M
Chojnicki Michal
Tobis Slawomir
Wieczorowska-Tobis Katarzyna
Cite this article:   
Neumann-Podczaska Agnieszka,Al-Saad Salwan R,Karbowski Lukasz M, et al. COVID 19 - Clinical Picture in the Elderly Population: A Qualitative Systematic Review[J]. Aging and disease, 2020, 11(4): 988-1008.
URL:  
http://www.aginganddisease.org/EN/10.14336/AD.2020.0620     OR
Figure 1.  Study Selection Diagram.
Wang L et al. [10]Zhu X et al. [11]Lian J et al.
[12]
*Cheng B et al.
[13]
*Cheng B et al. [13]Chen T et al. [14]Liu K et al. [15]Godaert L et al.
[16]
Liu Y et al.
[17]
Mi B et al.
[18]
Publication Month - 2020MarMarMarAprAprAprMarAprMarApr
CountryChinaChinaChinaChinaChinaChinaChinaFranceChinaChina
No. Patients ≥60 Years Old339114136675155181776
Age>60>70≥60≥60≥60≥65≥60>67>61>75
Male No.166675822313412842
Symptoms+ (%)
(92)
Fev
(82)
Fev
(85)
Fev
(74)
Cgh
(83)
Fev
(95)
Fev
(78)
Fev
(77)
Fev
(100)
Fev
(84)
Fev
(53)
Cgh
(60)
Cgh
(63)
Cgh
(60)
Fev
(64)
Cgh
(70)
Cgh
(33)
Cgh
(70)
Cgh
(100)
Cgh
(84)
Cgh
(41)
Dysp
(46)
Dysp
(36)
SP
(57)
CT
(64)
CT
(64)
CT
(33)
SP
(65)
Dysp
(58)
Chi
(67)
Dysp
(40)
Ft
(45)
Ft
(18)
Ft
(48) Ft/Mya(56) Ft/Mya(60)
Dysp
(17)
N/V
(59)
Ft/Mya
(43)
Ft/Mya
(67)
Ft/Mya
(28)
Anx
(33)
SP
(15)
Mya
(36)
SP
(48)
N/V
(20)
Mya
(11)
CT
(53)
Del
(14)
Dh
(50)
ST
(28)
SP
(9)
Dh
(13)
ST
(21)
N/V
(26)
SP
(10)
Ft
(11)
Dysp
(36)
Dh
(14)
N/V
(33)
Dizz
Others(26) CT
(13) Dh
-(13) Dysp (8) Dh
(6) Hdc
(14) Hdc (14) Diz(12) Hdc
(12) Diz (6) Dh (10) Con (6) AG
(10) Anx
(6) Hdc (6) Dh (6) AP
(11) Ft/Mya (6) NC(18) SP-(17) Hdc
(17) N/V (17) NC (17) CP (17) AP
≤5 %Mya, Hdc,
N/V, Diz, Pha
Mya, N, V, PhaNC, HpDh, AG-N/V, CP----
Comorbidities++ (%)
(41)
HTN
(54) CVD(39) HTN(59) HTN(50) HTN(39) HTN(46) Smo-(58) CVD(50)
OP
(16)
DM
(22) CLD(18) DM(17) DM(32) DM(22) DM(28) HTN-(43) HTN(33) HTN
(16)
CVD
(22)
PS
(6) Smo(17) CVD(24) CVD(20) CVD(17) DM-(29) CRD(17) DM
(7)
CLD
(20)
CBD
-(10) CLD(12) CLD(15)
CBD
(17) CVD-(14) DM(17) CLD
(7)
CBD
(19)
ED
-(6) CRD(13) CLD(6) CHD-(14) CLD(17) CVD
Others-----(10) Mal (6) CRD---(17) ND
(17) BI (100) fracture patients
≤5 %CHD,
CRD, Mal, AD
MalCLD, CVD, CRD, CHD, Mal, ICCRD, CHD, Mal-CHD,
TB
----
Radiological findings (%)
Description °--(43)
GGO
--(24)
PE
---(100)
GGO/ Cons
Single (S)/Multiple (M) lobe lesions--(42) M--(98) M(89) M
(11) S
--(100) M
Distribution
Unilateral (U)/ Bilateral (BI)--(42) Bi
(11) U
--(98)
Bi
(11)
U
---
Central (C) / Peripheral (P)/ Both----------
Outcome No. (%)
Healed/Discharged91 (27)87 (60)31 (23)67 (100)--17
(95)
---
Hospitalized183 (54)-13 (10) °°------2
(33)
Death65 (19)27 (24)--51 (100)19 (35)1
(6)
--4
(67)
Days of Hospital Stay Duration - Median (IQR)28 (15-28)----12 (1-45)----
Niu S et al. a
[19]
Kerpel A et al.
[20]
Graselli G et al.
[21]
Zhu T et al.
[22]
Chen Z et al.
[23]
Guo T et al. [24]**Sun H et al. [25]**Sun H et al. [25]Bruno G et al.
[26]
Gold J et al. [27]
Publication Month - 2020AprAprAprMarMarMayMayMayMayMay
CountryChinaIsraelItalyChinaChinaChinaChinaChinaItalyUSA
No. Patients ≥60 Years Old603961282010512312131117
Age≥6560-62≥61>60≥60≥ 60≥ 60≥ 60≥65≥65
Male No.34378316-48518219-
Symptoms+ (%)
(79)
Fev
(100) Fev-(86)
Fev
-(67) Fev(85)
Fev
(89)
Fev
(81)
Fev
-
(57)
Cgh
(67) Cgh-(47)
Cgh
-(65) Cgh(74)
Cgh
(73)
Cgh
(81)
Cgh
-
(30)
Dysp
(67) Ft/Mya-(33) Ft/Mya-(33)
Ft
(39)
GiS
(33)
GiS
(48)
Dysp
-
(24) Ft/Mya(33)
NC
-(29)
Dysp
-(30) Dysp(29)
Dh
(30)
Dh
(19)
Ft
-
(7)
Hdc
(33)
Syn
-(22)
Dh
-(10)
Dh
----
--(22)
AP
-(8)
Mya
----
Others-----(6)
N/V
----
≤5 %-----Hdc,
Anx
APAPGiS,
AP
-
Comorbidities++ (%)
(48) HTN(67) HTN(38) HTN--(44)
HTN
(55)
HTN
(63)
HTN
(87)
HTN
(86)
HTN
(29) CLD(67) Smo(18) CVD--(26)
DM
(20)
DM
(22)
DM
(26)
Smo
(47)
CVD
(16) CVD(33) DM(16)
HC
--(16)
CVD
(12)
CVD
(17)
CLD
(16)
CLD
(44)
DM
(10)
DM
(33) CVD(14) DM--(12)
Smo
-(17)
CVD
(16)
CVD
(21)
CKD
(6)
CBD
(33)
PS
(8) Mal--(9)
CLD
--(13)
DM
(19)
CLD
Others-(33)
DL
(15)
NS
-----(9)
CKD
-
≤5 %--CLD, CRD, CHD--CLD,
CKD
CLD,
CBD
-MalSmo,
Mal
Radiological findings (%)
Description °-(67)
Cons
-(89)
GGO/ Cons (54) GGO (22) Cons (7) PE
-(40)
GGO
--(65)
GGO/Cons (32) Cons
-
Single (S)/Multiple (M) lobe lesions-(100) M-(93)M
(7) S
(65)M(89)M----
Distribution
Unilateral (U)/ Bilateral (BI)-(100)
Bi
--(65)
Bi (35) U
(89)
Bi (1) U
--(96)
Bi (3) U
-
Central (C) / Peripheral (P)/ Both-(67) P-(60) P
(36) Both
------
Outcome No. (%)
Healed/Discharged23
(38)
1
(33)
111 (12)--90
(86)
123
(100)
-7
(23)
65
(56)
Hospitalized32
(53)
2
(67)
525 (55) °°--12
(11)
--18
(58)
16
Death5
(9)
-322 (34)--3
(3)
-121
(100)
6
(19)
36
(31)
Days of Hospital Stay Duration - Median (IQR)-----17
(13-23)
--23
(16-30)
10
(6-16)
Table 1  Symptoms, Comorbidities, Radiological Findings, and Outcome.
Wang L et al. [10]Zhu X et al. [11]Lian J et al. [12]*Cheng B et al. [13]*Cheng B et al. [13]Chen T et al. [14]Liu K et al.
[15]
Godaert L et al. [16]
Publication Month - 2020MarMarMarAprAprAprMarApr
CountryChinaChinaChinaChinaChinaChinaChinaFrance
No. Patients ≥60 Years Old3391141366751551817
Age>60>70≥60≥60≥60≥65≥60>67
Male1666758223134128
Symptoms No.Table 1Table 1Table 1Table 1Table 1Table 1Table 1Table 1
Comorbidities No.
Outcome No.
Laboratory Findings - Median (IQR)Cheng B. et al presented results as Mean with SD
WBC Count (x109/L)5.74 (4.37-8.29)6.67 (4.56-9.05)4.8
(3.9-6.4)
--6.1
(2-25.7)
5.38
(4.33-6.13)
-
Lymphocyte Proportion %------19.15 (10.58-26.93)-
Neutrophil Proportion %------68.3 (63.01-78.13)-
Neutrophil Count (x109/L)4.43 (2.76-6.62)5.19 (3.101-7.803)3.2
(2.5-4.4)
3.9+/-2.16.5+/-4.84.7
(1-21)
-4 x (<4.0)
Lymphocytes Count (x109/L)0.90 (0.59-1.29)0.805 (0.55-1.17)1.1
(0.7-1.4)
1.2+/-0.60.6+/-0.30.89
(0-6.0)
-13x (<1.5)
ESR (mm/h)---39.7+/-25.756.6+/-33.945
(9-96)
--
C-reactive Protein (CRP) (mg/L)49.6 (18.5-93.2)59.1 (20.2-110.6)19.0
(5.6-44.7)
30.8+/-37.1123.5+/-109.085.3
(2-284)
22.74 (13.33-34.82)16x(>10)
Interleukin-6 (IL-6) (pg/mL)10.9
(5.2-25.4)
----1.4
(0-200)
--
Procalcitonin (ng/mL)0.08 (0.04-0.17)0.104 (0.053-0.315)---0.48
(0-8)
0.04
(0.02-0.09)
-
Albumin (g/L)-33.85 (31.7-37)39.2 (36.0-42.0)38.6+/-4.933.1+/-5.033.3
(25-43)
33
(29-38)
-
Hemoglobin Hb (g/L)121
(109-130)
-129.0 (120.3-140.8)---107.35 (92.13-120.35)-
Platelet Count (x109/L)205
(151-259)
-169.5 (132.0-207.5)--162
(22-414)
207
(159-287)
7x(<15)
Lactate dehydrogenase (LDH) (U/L)301
(224-429)
328.5 (224-447)244.0 (206.0-311.0)262.0+/-249.8453.4+/-266.8395
(153-775)
--
APTT (s)28.5 (26.2-31.3)-------
PT (s)12.1 (11.6-12.7)-------
D-Dimer (mg/L)1.20 (0.62-3.25)1.5 (0.725-5.465)-0.95+/-1.354.59+/-7.131.35 (0.108-18.83)--
Cardiac Troponin (CtnI) (ng/mL)0.010 (0.006-0.030)-------
Creatine Kinase (CK) (U/L)63 (40-104)66.5
(42-130)
74.5 (52.3-123.0)88.6+/-56.7287.3+/-500.4141.2 (13-972)--
BUN (Blood Urea Nitrogen) (mmol/L)-7.2
(4.92-9.7)
4.4
(3.6-5.9)
6.4+/-6.19.1+/-5.2---
Creatinine (μmol/L)61
(50-76)
68
(57-96)
69.0 (58.6-79.6)123.0+/-218.8141.4+/-166.2104.2 (37-787)106.44 (79.83-150.79)-
Alanine aminotransferase (ALT) (U/L)27
(17-44)
32
(22-48)
21.0 (16.0-29.0)25.1+/-19.032.4+/-32.741.3
(8-279)
--
Aspartate aminotransferase (AST) (U/L)32
(23-46)
32
(22-48)
28.0 (22.0-36.0)--63.1 (18-209)--
Liu Y et al. [17]Mi B et al. [18]Guo T et al.
[24]
**Sun H et al. [25]**Sun H et al. [25]Bruno G et al.
[26]
Yuan Y et al. [28]
Publication Month - 2020MarAprMayMayMayMayMar
CountryChinaChinaChinaChinaChinaItalyChina
No. Patients ≥60 Years Old76105123121314
Age>61>75≥ 60≥ 60≥ 60≥6564-71
Male42485182192
Symptoms No.Table 1Table 1Table 1Table 1Table 1Table 14 Cough
2 Fever
2 Sputum
Production
1 Sore throat
Comorbidities No.4 <82 GNRI**
1 HTN
Outcome No.4 Discharged
Laboratory Findings - Median (IQR)
WBC Count (x109/L)5.24 (4.65-6.3)10.43 (7.61-12.10)4.9
(3.8-6.5)
5.37
(4.43-6.70)
10.15
(6.20-13.41)
6.43
(4.68-8.89)
5.37 (4.355-6.405)
Lymphocyte Proportion %19.8 (9.3-21)-----35.85 (25.43-44.75)
Neutrophil Proportion %74.8 (70-85.9)-----50.9 (46.175-58.25)
Neutrophil Count (x109/L)3.73 (3.33-5.39)8.77
(5.8-11.10)
3.6
(2.6-4.5)
---2.755 (2.02-3.76)
Lymphocytes Count (x109/L)0.8
(0.51-0.87)
0.70
(0.5-1.03)
1.1
(0.7-1.4)
0.95
(0.70-1.34)
0.51
(0.35-0.72)
0.83
(0.61-1.19)
1.76
(1.61-1.83)
ESR (mm/h)---36.0
(20.0-59.0)
37.0
(20.0-60.0
--
C-reactive Protein (CRP) (mg/L)52.95 (45.6-69.3)25.95 (17.8-48.75)33.6
(9.4-56.9)
39.8
(8.3-79.6)
105.4
(65.0-165.2)
79.2
(34.7-133.5)
4.7
(4.31-4.91)
Interleukin-6 (IL-6) (pg/mL)---12.7
(3.3-41.5)
75.2
(35.2-162.9)
--
Procalcitonin (ng/mL)0.077 (0.044-0.167)0.49 (0.22-1.95)-0.05
(0.03-0.09)
0.36
(0.14-1.01)
0.12
(0.07-0.18)
3x(<0.10) / 0.13
Albumin (g/L)38.3 (35.95-40.55)33.9 (33.5-36.33)36.2
(33.3-39.1)
----
Hemoglobin Hb (g/L)--125
(115-136)
--12.5
(11.7-14.2)
-
Platelet Count (x109/L)119
(118-141)
153
(144-178)
171.0
(135.8-228.8)
--193
(143-293)
-
Lactate dehydrogenase (LDH) (U/L)662 (551.5-708)-208.8
(173.1-239.4)
--268
(213.5-335)
180 (166.75-183.25)
APTT (s)-31.98 (31.34-34.68)33.9
(30.0-37.9)
----
PT (s)-13.18 (12.39-13.78)12.5
(11.4-13.1)
----
D-Dimer (mg/L)-12.45 (7.04-15.88)0.6
(0.3-1.9)
0.79
(0.47-1.63)
4.16
(1.49-21.00)
-73.5
(54.5-99.5)
Cardiac Troponin (CtnI) (ng/mL)0.012 (0.012-0.012)-----2 x (<0.010)
Creatine Kinase (CK) (U/L)107.5 (84.25-307.5)-84.5
(53.1-143.4)
---62
(50-66.5)
BUN (Blood Urea Nitrogen) (mmol/L)5.37 (4.64-6.2)8.74
(6.2-16.01)
5.5
(4.2-7.3)
--2.8
(2.1-4.1)
-
Creatinine (μmol/L)81.9 (50.3-113)96
(80.5-128)
66.9
(55.0-80.0)
66
(54-82)
90
(76-118)
89.3
(67.2-108.76)
-
Alanine aminotransferase (ALT) (U/L)26.6 (26.25-37.15)15
(15-17.25)
19.8
(15.0-28.3)
22
(14-36)
28
(19-42)
--
Aspartate aminotransferase (AST) (U/L)33.6 (26.45-47.05)32
(27.5-37.25)
26.0
(20.9-33.9)
28
(20-39)
45
(30-64)
-18.6 (16.675-23)
Table 2  Laboratory Findings.
Wang L et al. [10]Zhu X et al. [11]Lian J et al.
[12]
Chen T et al. [14]Liu K et al.
[15]
Godaert L et al.
[16]
Liu Y et al.
[17]
Mi B et al.
[18]
Graselli G et al.
[21]
Yuan Y et al. [28]Guo T et al.
[24]
Bruno G et al.
[26]
Gold J et al.
[27]
Richardson
S et al. [29]
Publication Month - 2020MarMarMarAprMarAprMarAprAprMarMayMayMayApr
CountryChinaChinaChinaChinaChinaFranceChinaChinaItalyChinaChinaItalyUSAUSA
No. Patients ≥60 Years Old339114136551817769614105311172582
Age>60>70≥60≥65≥60>67>61>75≥6164-71≥ 60≥65≥65>65
Male1666758341284278324819--
Symptoms No.Table 1Table 1Table 1Table 1Table 1Table 1Table 1Table 1Table 1Table 2Table 1Table 1Table 1-
Comorbidities No.-
Outcome No.676 Discharged
1487 (613 ICU) Hospitalized 419 Death
Hospital Stay duration (days) - Median (IQR)Discharged: 4.5 (2.7 - 7.2)
Still hospitalized: 4.4 (2.3-8.0) Dead: 4.4 (2.1 - 7.1)
Complications*(%)Most common complications of patients ≥60 years old
(42)
SI
-(17)
ARDS
-(39)
HI
(59)
RI
(100)
Pn
(33)
SI
--(10)
ARDS
(35)
ARDS
-(30)
RI
(29)
HI
-(10)
RI
-(39)
RI
(47)
HI
(86)
ARDS
---(5)
AHI
(29)
SI
--
(21)
ARDS
-(10)
HI
-(22)
SI
-(43)
RF
---(5)
RI
(10)
Sh
--
(21)
AHI
--(22)
ARDS
-(29)
RI
---(1)
HI
(1)
AHI
--
(17)
CI
---(17)
AHI
-(29)
HI
-------
Others(8) RI----(29) SI
(14) CI (14) Sh
-------
≤5 %ShShShHI
Treatment** (%)
-(97) AvT(86) AvT(62)
Ster
(89) LR-(100)
Rv
(100) AvT-(75)
LR
(93)
AvT
(68)
AbT
--
-(85)
AbT
(50) IFN(27) IFN(67)
AbT
-(100) IFN(100)
AbT
-(75)
Ig
(60)
AbT
(61)
LR
--
-(45) Ig(31) Um(18) LR(33) IFN-(57)
Ig
(50)
Ster
-(50) Um(49)
Ster
(55)
Ster
--
--(18) Ig(13) Um(22) Ig-(57)
Os
(33) Ig-(50)
Cef
(43)
Ig
---
--(9) LR(9)
Ig
-(43)
Ster
-(50) Moxi----
---------(25)
Os
----
------
-
--(25) IFN----
-----
-
-(25)
Lin
----
Supplementary Oxygen No. (%)-104 (91)-49 (89)17 (95)8
(47)
-6 (100)615
(64)
-89 (85)28 (90)104 (89)-
Mechanical Ventilation (MV) ° No. (%)---24 (44)--6 (86)-------
Invasive MV--6 (5)-4 (22)-3 (43)0709 (74)-8 (8)8 (26)48 (41)558 (22)
Non-Invasive MV--3 (2)-1 (6)--3 (50)80 (8)-7 (7)-5 (4)-
Other Treatments°° (%)-(70)
TCM (50) HT (28) VD (3) Hem
-(55)
MA (9) ThyF
(78)
ThyP (78) TCM (11) RRT (6) ECMO
----(75)
ThyF (75) Chlor (75) S
(64)
NCa (3) ECMO
(77)
HyC (74) Hep (13) Toc
(82)
NCa (11) RRT (43) VS (7) CPR
(4)
RRT
Table 3  Complications and Treatment.
No. Studies with reported resultsTotal patients
Symptoms161285No. Patients%
Fever1074/128583.6
Cough806/128562.7
Dyspnea328/128525.5
Fatigue256/128519.9
Sputum Production227/128517.7
Chest Tightness196/128515.3
Diarrhea167/128513.0
Anorexia108/12858.4
Fatigue & Myalgia103/12858.0
Myalgia59/12854.6
Nausea & Vomiting57/12854.4
Others*265/128520.6
Comorbidities162288No. Patients%
Hypertension979/228842.8
Cardiovascular Disease517/228822.6
Diabetes395/228817.3
Chronic Lung Disease188/22888.2
Hypercholesterolemia156/22886.8
Malignancy (Active or in Remission)108/22884.7
Chronic Renal Disease83/22883.6
Cerebrovascular Disease54/22882.4
Chronic Hepatic Disease38/22881.7
Not Specified145/22886.3
Others**156/22886.8
Radiological Findings9402DescriptionNo. Patients%
Ground Glass Opacity (GGO)115/40228.6
GGO + Consolidations52/40212.9
Pleural effusion15/4023.7
Consolidations18/4024.5
Normal11/4022.7
Distribution
Multiple Lobes250/40262.2
Single Lobe4/4021.0
Not Specified148/40236.8
Bilateral234/40258.2
Unilateral32/4028.0
Not Specified136/40233.8
Peripheral18/4024.5
Peripheral + Central10/4022.5
Central0/4020.0
Not Specified374/40293.0
Outcome144531No. Patients%
Hospitalized (As of date of publication)2290/453150.5
Discharged1203/453126.6
Death907/453120.0
Not Specified131/45312.9
Complications93241No. Patients%
Renal Impairment/ Injury832/324125.7
Secondary Infection160/32414.9
Hepatic Impairment/ Injury147/32414.5
ARDS126/32413.9
Acute Heart Injury79/32412.4
Cardiac insufficiency59/32411.8
Arrhythmia35/32411.1
Others +57/32411.8
Treatment (drugs)9476No. Patients%
Antiviral Therapy++330/47669.3
Antibiotic Therapy-199/47641.8
Immunoglobulin134/47628.2
Glucocorticoids107/47622.5
Interferon98/47620.6
Lopinavir & Ritonavir61/47612.8
Umifenovir49/47610.3
Oseltamivir5/4761.1
Ribavirin4/4760.8
Supplementary Oxygen914241020/142471.4
Treatment (Mechanical Ventilation)104018No. Patients%
Invasive MV1344/401833.4
Non-Invasive MV96/40182.4
MV - Not specified30/40180.7
Table 4  Summary Table.
Review FindingCERQual Assessment of Confidence in the EvidenceExplanation of CERQual AssessmentStudies Contributing to the Review Finding
Symptoms
Most Common: Hospitalized older COVID-19 patients were commonly reported to experience fever or cough, and to a lesser extent dyspnea, fatigue (with or without myalgia), sputum production, chest tightness, or diarrhea (in order from most to least commonly reported).Moderate6 studies with minor to moderate methodological limitations, of which selection bias due to admission of severe patients was noted. Relatively adequate data pertaining to 1285 older COVID-19 patients. 13 studies originating in China, which leads to moderate concerns of lack of geographic diversity in reported data. High coherence.10-18, 19, 20, 22, 24-26
Less Common: Less commonly observed symptoms in the elderly COVID-19 population included: headache, sore throat, GI symptoms, dizziness, delirium, nasal congestion, chills, chest pain, pharyngalgia, abnormal gait, syncope, nausea and vomiting (in no particular order).
Comorbidities
Most Common: Hypertension is the most commonly reported comorbidity in elderly COVID-19 patients, followed by cardiovascular disease, diabetes, chronic lung disease, and hypercholesterolemia.Moderate9 studies with minor to moderate methodological limitations. 2 studies had incomplete medical history of relevant patients, and 1 study revolved around COVID-19 presentation specifically in fracture patients. In total, adequate data, pertaining to 2288 patients, with reported comorbidities was present. Notably, smoking history was under-reported. Despite a predominance of studies from China, almost half of patients contributing to comorbidity conclusion stemmed from Italy, USA, and Israel. High coherence.10-15, 17- 21, 24-28
Less common: Minority of studies reported patients with chronic renal, hepatic, cerebrovascular disease or malignancy. Elderly COVID-19 patients with a variety of other immune, endocrine, nutritional, and neurological comorbidities were also occasionally reported.
Radiological Findings
Description: Ground Glass Opacities (GGO) was the most commonly reported observation in radiological imaging of older COVID-19 patients. Also, isolated consolidations or in combination with GGO were, to a lesser extent, documented with occasional cases of pleural effusion. Few patients demonstrate normal imaging findings.Low4 studies with minor to moderate methodological limitations. Gaps and inconsistency in reporting of radiological findings was observed. Inadequate data, pertaining to only 402 elderly COVID-19 patients. Moreover, only 2 studies originating from regions other than China (Israel and Italy), which raises concern for lack of geographic diversity. Insufficient reported radiological findings clouds coherency judgement, however reasonable coherence can be seen from preliminary data.12, 14, 15, 18, 20, 22-24, 26
Distribution: Adults ≥60 years old experience multiple lobe involvement in a bilateral distribution mainly. With primary data showing peripheral tendency of COVID-19.
Outcome
Almost half of total patients were still hospitalized as of date of individual study publication. However, hospitalized elderly COVID-19 patients with clear outcome show an evident risk for mortality. Majority of studies show an estimated mortality rate of >15%, with the total combined mortality rate being close to 20%. Hospital stay duration ranges from a few days to few weeks, with a common median of hospitalization being >10 days.Low14 studies with minor to significant methodological limitations. Possible selection bias due to hospital admission of mainly serious cases was noted in 7 studies, and in 1 study involvement of strictly ICU patients was observed. The dynamic nature of the situation led to short follow up time by majority of studies, which raises concerns for inadequacy of data. Reasonable coherence.10-12,14,15, 18 - 21, 24, 26-29
Laboratory findings
Lymphopenia (<1.1 x 109/L) and elevated inflammatory markers, CRP (>10 mg/L) and ESR (>35 mm/h), are commonly observed in the elderly COVID-19 patients. Occasionally, thrombocytopenia (<150x109/L), higher levels of LDH (>300 U/L), D-dimers (>1.0 mg/L), and renal markers (creatinine & BUN) can be seen. Other markers indicating organ damage, such as hepatic or cardiac, are mainly within normal range. IL-6 was an underreported biochemical variable.Moderate6 studies with minor to moderate methodological limitations. Minor concern for underlying comorbidities, baseline health, and associated medication use influence on results in 3 studies. Relatively adequate data pertaining to 1194 elderly COVID-19 patients. Overwhelming majority of data stemming from one geographic region (China), raises concern for lack of diversity. Moderate to high coherence.10-18, 24-26, 28
Complications
Besides a risk for secondary infection or ARDS, older COVID-19 patients are prone to renal injury over the course of the disease. Hepatic injury and cardiovascular related complications (including cardiac insufficiency or arrhythmia) can be observed to a lesser extent.Low7 studies with minor to significant methodological limitations. 3 studies admitted mainly severe cases of COVID-19, raising concern for potential selection bias. 6 studies had short observation time (<1 month), and large proportion of patients still hospitalized. Despite relatively adequate patient sample with reported complications (3241 patients), inconsistency in the documentation detail of complication is observed. Reasonable coherence.10, 12, 15-18, 24, 26, 29
Treatments
Drugs: Antiviral therapy is the main treatment approach for elderly COVID-19 patients, of which Lopinavir, Ritonavir, and Umifenovir are most commonly used. This is usually in combination with antibiotics, immunoglobulins, glucocorticoids, or interferon therapy.Very Low5 studies with minor to significant methodological limitations. Inadequate data, with detailed treatment plans and use of medication only pertaining to 476 patients. Moreover, all studies, except 1, originated from China raising substantial concerns regarding data reflectiveness of different international treatment approaches. Reasonable coherence11, 12, 14, 15, 17, 18, 24,26, 28
Supplementary Oxygen: Almost 4 in 5 hospitalized older COVID-19 patients require supplementary oxygen inhalation.Moderate6 studies with minor to moderate methodological limitations. 1 study revolved around ICU patients. Relatively adequate data pertaining to 1424 hospitalized elderly COVID-19 patients. Studies were predominantly from China, however considerable amount of total reported patients were from other regions such as Italy, USA, and France. Moderate to high coherence.11, 14, 15, 16, 18, 21, 24,26,27
Mechanical Ventilation: 20% to 50% of severely affected elderly patients may require invasive mechanical ventilation.Low4 studies with moderate methodological limitations. 4 studies admitting mainly severe cases. Concerns for restricted mechanical ventilation use due to limitations of available resources or overflow of patients. Relatively adequate data (4018 patients) from 3 geographic regions (USA, Italy, China). Generally low coherence, however reasonable coherence is observed amongst studies with mainly serious cases.12, 14, 15, 17, 18, 21, 29, 24,26,27
Table 5  CERQual assessment of Review Findings.
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