|Year : 2021 | Volume
| Issue : 1 | Page : 9-17
Clinicoepidemiological profile of COVID-19 in elderly patients of South-Eastern Rajasthan
Meenaxi Sharda, Prateek Jain, Sachin Shyoran, Bhimsain Goyal
Department of Medicine, Government Medical College, Kota, Rajasthan, India
|Date of Submission||09-Apr-2021|
|Date of Decision||07-Jul-2021|
|Date of Acceptance||10-Jul-2021|
|Date of Web Publication||17-Aug-2021|
Dr. Prateek Jain
Room No. 24, PG Hostel-1, Government Medical College, Kota - 324 010, Rajasthan
Source of Support: None, Conflict of Interest: None
Background and Objectives: COVID-19 pandemic took a significant toll on all, especially elderly individuals, who seem to have a higher risk for severe disease and mortality. We aim to study the clinicoepidemiological profile of COVID-19 in elderly patients of South-Eastern Rajasthan and to assess its severity and outcome. Methods: A retrospective analysis of 200 reverse transcription-polymerase chain reaction confirmed COVID-19 patients aged ≥60 years admitted between May and October 2020 in the dedicated COVID hospital of a tertiary care center of South-Eastern Rajasthan was done. Results: The median age of patients was 66 years (interquartile range [IQR]: 63–72 years). Twenty-five percent, 26.5%, and 48.5% cases fell under mild, moderate, and severe disease, respectively, with 52 nonsurvivors. The mean age of severe (68.78 ± 7.20 years) cases was significantly more than that of mild ones (65.96 ± 5.29 years, P = 0.048). Males (70.5%) and urban population (90%) were more affected than females (29.5%) and the rural ones (10%). 67.5% patients had comorbidities. The presence of multiple comorbidities was significantly associated with increased severity (P = 0.03). The median duration of symptoms was 4 days (IQR: 3–7 days). 19% presented asymptomatically. Complications included acute respiratory distress syndrome (47%), renal impairment (31%), hepatic dysfunction (30%), myocardial injury (30%), shock (10.5%), stroke (2%), encephalopathy (2%), acute STEMI (1.5%), deep vein thrombosis (1%), and heart failure (1%). The presence of dyspnea (P = 0.000), desaturation (P = 0.000), leukocytosis (P = 0.000), neutrophilia (P = 0.000), lymphopenia (P = 0.000), high neutrophil-to-lymphocyte ratio (P = 0.000), hyperglycemia (P = 0.015), renal impairment (P = 0.024), elevated creatine kinase-MB (P = 0.020), raised transaminases (P = 0.002), hypoproteinemia (P = 0.003), hypoalbuminemia (P = 0.000), A:G ratio reversal (P = 0.000), low high-density lipoprotein cholesterol (P = 0.000), and higher computed tomography severity score (P = 0.000), all were associated with both increased severity and mortality. Need of vasopressor support was significantly associated with older age (P = 0.022). Conclusion: Increasing age, multiple comorbidities, severe category, and complications are associated with poor prognosis in elderly patients.
Keywords: COVID-19, elderly, South-eastern Rajasthan
|How to cite this article:|
Sharda M, Jain P, Shyoran S, Goyal B. Clinicoepidemiological profile of COVID-19 in elderly patients of South-Eastern Rajasthan. J Indian Acad Geriatr 2021;17:9-17
|How to cite this URL:|
Sharda M, Jain P, Shyoran S, Goyal B. Clinicoepidemiological profile of COVID-19 in elderly patients of South-Eastern Rajasthan. J Indian Acad Geriatr [serial online] 2021 [cited 2021 Oct 24];17:9-17. Available from: http://www.jiag.com/text.asp?2021/17/1/9/323938
| Introduction|| |
COVID-19 crisis has affected millions of individuals. Elderly population seems to have a higher risk of acquiring severe COVID-19 illness with increased risk of mortality. Understanding the disease characteristics in the elderly population remains a special focus of interest since they are the most vulnerable ones, which forms the rationale for doing this study.
The aims of our study were:
- To study the clinicoepidemiological profile of COVID-19 in elderly patients of south-eastern Rajasthan
- To assess the severity and outcome of the elderly COVID-19 patients and determine the parameters associated with increased severity and mortality.
| Methods|| |
Study design and setting
An observational retrospective study was conducted in the dedicated COVID hospital of Government Medical College, Kota (Rajasthan) after an institutional ethical committee approval. Case sheets of 200 reverse transcription-polymerase chain reaction (RT-PCR)-positive COVID-19 patients aged ≥60 years who got admitted in the hospital between May and October 2020 were assessed, after taking approval from the hospital authority. Case sheets were reviewed for the sociodemographic profile which included age, sex, religion, and residential region and details of associated comorbid conditions, clinical manifestations at the time of admission, and their subsequent course during hospital stay. Reports of sequential laboratory, imaging investigations and treatment profile were noted to assess the organ dysfunction complications and final outcome.
All the records pertaining to the identity of the patient were kept confidential. Those patients who either left against medical advice in the middle of treatment or died within 2 h of hospitalization were not included. Those whose laboratory and imaging data were not available were also excluded to minimize the potential of missing data bias.
Patients were classified into mild, moderate, and severe categories defined as per the WHO clinical criteria [Table 1]. Based on outcome, they were labeled as “discharged”, who were discharged from the hospital after clinical recovery or RT-PCR negative, and “expired”, who succumbed to their illness in the hospital. Patients requiring mechanical ventilation support or fulfilling the Berlin criteria were labeled as having acute respiratory distress syndrome (ARDS). Hepatic dysfunction was defined as elevation in both alanine and aspartate aminotransferases above the upper normal reference limit. KDIGO criteria were used for the diagnosis of acute kidney injury. Patients requiring inotropic support to maintain systolic blood pressure above 90 mmHg were categorized for shock complication. Myocardial injury was defined as raised creatine kinase (CK)-MB levels (>25 IU/L) or with significant electrocardiographic changes.
Categorical and continuous variables were summarized as percentages and median (interquartile range [IQR]), respectively. Two subanalyses were done related to severity and outcome of patients. Means ± standard deviation of continuous variables was compared between two groups using independent student's t-test with unequal variances and between three groups using one-way ANOVA test. Categorical variables were compared using the Chi-square test. Pearson's correlation was used to assess correlation between two continuous variables. All statistical analyses were performed using the IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp. Released 2019. Test of significance was tested using P value. P < 0.05 was considered statistically significant.
| Results|| |
The age of 200 patients (141 males and 59 females) ranged from 60 to 90 years with a median age of 66 years (IQR: 63–72 years). The number of patients in the age groups 60–65, 66–70, 71–75, 76–80, and 80–90 years were 33%, 31.5%, 16.5%, 11.5%, and 7.5%, respectively. 161 patients were Hindu and 39 patients were Muslim. 180 cases were from urban areas. The number of patients under mild, moderate, and severe categories was 50, 53, and 97, respectively. 148 patients got discharged and 52 expired.
The most common comorbidity seen was hypertension (40%), followed by type-2 diabetes mellitus (33%). Fifty-six patients (28%) had multiple (2 or more) comorbidities [Table 2]. The duration of symptoms ranged from 1 to 15 days before getting hospitalized with a median duration of 4 days (IQR: 3–7 days). Fever was the most common symptom (67%), followed by breathlessness (61%) and dry cough (42%). 26.5% patients reported the onset of breathlessness along with fever and 22.5% reported breathlessness after fever with a mean gap of 3.66 days. 12% patients reported breathlessness without any history of fever. 19% presented asymptomatically [Figure 1]. ARDS (47%) was the most common complication, with 28.5% cases requiring ventilator support [Table 3] and [Table 4].
Laboratory profile predominantly showed eosinopenia (67%), lymphopenia (40.5%), thrombocytopenia (36%), raised SGOT (56.5%) and SGPT (34.5%), and hypoalbuminemia (31.5%) [Table 5]. Few investigations were not available in all the patients. CK-MB was elevated in 58 out of 78 patients (74.36%). D-dimer levels were elevated in 33 out of 39 patients (84.6%). C-reactive protein (CRP) was reactive in 56 out of 70 patients (80%). Blood group was available in only 117 patients. Patients getting affected were of blood group B+ (40.2%), O+ (24.85), A+ (14.5%), and AB+ (14.5%) in decreasing order.
54% patients had documented conversion from RT-PCR positive to RT-PCR negative within a median duration of 6 days (range: 1–21 days and IQR: 5–10 days). In rest of the patients, either the sampling was not repeated since they were discharged for home isolation or the patient expired. The virus was detectable for more than 15 days in 4 patients.
Chest X-ray showed bilateral predominantly peripheral patchy heterogeneous opacities in 75% patients mainly involving middle and lower zones. 75 patients had undergone HRCT chest. All of them had findings suggestive of atypical viral pneumonia which mainly included bilateral, peripheral based, patchy areas of ground-glass opacities with interlobular septal thickening (crazy-paving pattern) [Figure 2]. Three patients had mild pleural effusion. The CT severity score ranged from 2 to 24 out of 25 [Table 6].
|Figure 2: HRCT chest images of patients showing bilateral diffuse peripheral-based patchy areas of ground-glass opacities with interlobular septal thickening|
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No statistically significant association of gender, ABO blood group, and individual comorbidity, such as diabetes mellitus, hypertension, coronary artery disease, chronic obstructive pulmonary disease, or chronic kidney disease, was seen with either the severity or outcome [Table 7] and [Table 8]. The mean age of patients who required vasopressor support was more than those who did not [P = 0.022, [Table 9]].
|Table 9: Comparison of age with the need of oxygen/ventilator/vasopressor support|
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| Discussion|| |
We studied the clinicoepidemiological profile of 200 elderly COVID-19 cases. Our hospital was the sole dedicated COVID center in the Hadoti region of South-Eastern Rajasthan during our study period accessible to both urban and rural population equally. More of urban population getting affected than the rural reflects the high transmission rate in urban areas probably due to higher population density because of more crowded and lesser open spaces than the rural region. Males were more affected than females, probably due to their increased exposure to virus with more traveling outside home.
Fever remains the most common symptom reported by elderly COVID-19 patients, followed by breathlessness and cough. Guo et al. in his study on 105 elderly COVID-19 individuals found the most frequent symptoms as fever (66.7%) and cough (64.8%). Chen et al. also reported fever (83%), cough (82%), and breathlessness (31%) as the most common symptoms.
The high proportion of patients having dyspnea (61%) and low oxygen saturation (62.5%) on admission [Figure 3] and [Figure 4] suggests that most patients present to the hospital in ARDS or when significant lung involvement has occurred. Bradycardia was noted in 6% cases in our study [Figure 3]. Hu et al. also found sinus bradycardia in about one-third of severe COVID-19 cases and suggested a possible inhibitory influence of the virus on activity of cardiac conduction system including sinus node through angiotensin-converting enzyme 2.
Prominent laboratory abnormalities include eosinopenia, lymphopenia, leukocytosis, neutrophilia, anemia, thrombocytopenia, stress hyperglycemia, raised transaminases, deranged kidney function tests, hypoalbuminemia, A:G ratio reversal, elevated CKMB, and raised D-dimer and raised inflammatory markers such as CRP, interleukin-6 (IL-6), lactate dehydrogenase (LDH), and ferritin. The high proportion of anemia (21.5%) reflects the prevalence of anemia in the elderly population. Lymphopenia is a common finding encountered in COVID-19 patients as seen with other viral infections. The inflammatory markers were available mostly in moderate to severe cases and were elevated in most of them. The presence of raised transaminases, deranged renal parameters, and raised CKMB suggests that besides lung, COVID-19 also involves other organ systems and can cause hepatic, renal, and myocardial injury as well. Xu et al. have reported steatosis and liver injury in the liver biopsy of a patient with COVID-19. Cai et al. found abnormal liver function tests in 76.3% patients. Sharma et al. reported varying degrees of acute tubular necrosis in the kidney biopsies of COVID-19 patients. Karimian et al. found lymphopenia (51.6%), hyperglycemia (41.1%), reduced albumin (54.7%) and elevated CK-MB (14.7%), BUN (13.1%), creatinine (7.2%), LDH (53.1%), CRP (63.6%), IL-6 (59.9%), and ferritin (72.6%). Li et al. reported lymphopenia in 52.2%, eosinopenia in 74.7%, and elevated high-sensitivity-CRP in 86.7% cases.
Electrocardiographic abnormalities are commonly encountered which often gets missed or overlooked. Most of them include ST-T changes (7%), conduction blocks (6.5%), and arrhythmias (4%). Three patients in our study developed acute ST elevated myocardial infarction. One developed acute transient right bundle branch block and one patient presented to us with paroxysmal supraventricular tachycardia. Mehraeen et al. in his study reported ST-T abnormalities, which accounted for the most observed ECG finding in the patients with COVID-19. The underlying mechanisms of these ECG abnormalities in the severe stage of COVID-19 may be attributed to hypoxia and inflammatory damage incurred by the virus. Myocarditis is a relatively rare but potentially fatal complication reported in COVID-19 patients,, which may be caused by a combination of direct viral injury and cardiac damage due to host's immune response. These findings warrant the use of further investigations such as angiography and two-dimensional echocardiography in the acute and post-COVID management of patients.
Complications include ARDS (47%), acute kidney injury (31%), hepatic dysfunction (30%), myocardial injury (30%), shock (10.5%), stroke (2%), encephalopathy (2%), acute STEMI (1.5%), deep venous thrombosis of lower limbs (1%), precipitation of heart failure (1%), and pneumothorax (0.5%). Similar complications have been reported by Guo et al. and Li et al. in elderly COVID-19 patients. Besides lungs, the most commonly involved organs were the kidney, heart, and liver.
On comparing the epidemiological profile of the patients with the severity and outcome, the mean age of patients belonging to severe category is significantly more than those with mild severity (P = 0.048). The presence of single or multiple comorbidities is significantly associated with the severity of patients (P = 0.03). However, no single disease is found to be independently associated with either severity or outcome. Li et al. found that the presence of any comorbidities increases the mortality risk.
The presence of dyspnea (P = 0.000), tachypnea (P = 0.000), and low oxygen saturation (P = 0.000) on admission is independently found to be significantly associated with increased mortality [Table 8]. The onset of dyspnea may help physicians identify the patients with poor prognosis. Li et al. showed that the presence of dyspnea in elderly patients was independently associated with mortality.
Leukocytosis (P = 0.000), neutrophilia (P = 0.000), lymphopenia (P = 0.000), high neutrophil-to-lymphocyte ratio (NLR) (P = 0.000), hyperglycemia (P = 0.015), renal impairment (P = 0.024), elevated CK-MB (P = 0.020), raised transaminases (P = 0.002), hypoproteinemia (P = 0.003), hypoalbuminemia (P = 0.000), A: G ratio reversal (P = 0.000), low high-density lipoprotein cholesterol (HDL-C) (P = 0.000), all are significantly associated with both increased severity and mortality [Table 10] and [Table 11]. Rh positivity seems to be associated with severity of disease (P = 0.003). Li et al. also found that leukocytosis, neutrophilia, CKMB levels, albumin, and oxygen saturation were associated with mortality. Aggarwal et al. in his study found that higher CK-MB values, hypoalbuminemia, and acute kidney injury on admission were associated with poor outcome.
NLR is significantly associated with both severity and outcome of patients (P = 0.000). NLR of severe (15.020 ± 13.326) and expired patients (18.498 ± 15.74) are significantly higher than that of mild (2.596 ± 1.743) and discharged patients (6.208 ± 6.454), respectively (P = 0.000). NLR showed the largest area under the ROC curve of 0.781 (P = 0.000) with a sensitivity of 80.8% and specificity of 67.6% at a cut-off of 5.79 in predicting poor outcome [Figure 5]. Platelet-to-lymphocyte ratio (PLR) is found to be associated with severity of patients (P = 0.009) but not with the outcome (P = 0.097). Chan and Rout did a meta-analysis and found higher levels of NLR and PLR in patients with severe disease compared to nonsevere disease. NLR and PLR can be used as independent prognostic markers of disease severity in COVID-19. Yang et al. found that elevated NLR was significantly associated with illness severity and poor outcome. In his study, NLR exhibited the largest area under the curve at 0.841, with the highest specificity (63.6%) and sensitivity (88%).
The mean HDL-C is found to be significantly low in severe (36.61 ± 9.14 mg/dl) and expired cases (33.86 ± 8.35 mg/dl) as compared with mild (53.64 ± 9.48 mg/dl, P = 0.000) and discharged cases (45.00 ± 13.28 mg/dl, P = 0.000), respectively. Wang et al. found that patients with low HDL-C at admission showed a higher risk of developing severe events compared with those with high HDL-C. Kocar et al. provided an overview of cholesterol lipids in relation to COVID-19. HDL seems to have a variety of roles, from being itself a scavenger for viruses, an immune modulator and mediator of viral entry. The lipid metabolic pathways along with the composition of membranes could be targeted to selectively inhibit the life cycle of the virus as a basis for antiviral therapy.
CT severity score is found to be significantly associated with the outcome of patients (P = 0.000). Higher score is associated with increased mortality. This reflects that the proportion of lung involvement in COVID-19 has a direct and significant impact on the outcome of patients. Francone et al. in his study found that CT score of ≥18 was associated with an increased mortality risk.
Complications such as ARDS (P = 0.000), acute kidney injury (P = 0.000), myocardial injury (P = 0.000), hepatic dysfunction (P = 0.003), shock (P = 0.000), and encephalopathy (P = 0.024) are significantly associated with poor outcome. Requirement of oxygen therapy (P = 0.000), need for mechanical ventilator support (P = 0.000), and need for vasopressor support (P = 0.000) are significantly and independently associated with increased mortality. Need of oxygen therapy and ventilator support is significantly associated with the CT severity score (P = 0.000). Need of vasopressor support is significantly associated with older age.
The retrospective nature of the study resulted in lack of uniform data material and a few investigations such as inflammatory markers were not done in all the cases due to unavailability of tests in the institution and unaffordability by patients. Severity and outcome may be affected by various confounding factors or dynamic situations of a newly occurring pandemic such as varying virulence of different strains of virus, changing and newly emerging protocols of management with better understanding of the disease, and increased awareness of disease in the general population.
| Conclusion|| |
The presence of dyspnea, desaturation on admission, multiple co-morbidities, severe category and development of complications during the course of illness, significantly affects the outcome in elderly COVID-19 patients. Laboratory parameters such as leukocytosis, neutrophilia, lymphopenia, high neutrophil-to-lymphocyte ratio, hyperglycemia, elevated creatine kinase-MB, raised transaminases, hypoproteinemia, hypoalbuminemia, A:G ratio reversal and low high-density lipoprotein cholesterol all are associated with both increased severity and mortality.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]