Diagnosis Problems of

COVID-19 and Influenza

in the Elderly
Kuntjoro Harimurti
Agenda
01 PATHOGENESIS COVID-19

CLINICAL MANIFESTATIONS
02 AND DIAGNOSIS of COVID-19
IN ELDERLY
INFLUENZA IN ELDERLY: A
03 REVIEW
CLINICAL DIAGNOSIS
04 COVID-19 AND INFLUENZA:
WHAT ARE IN COMMON?
Pathogenesis of COVID-19
Incubation Period
Within 14 days most cases occurring
following
exposures approximately four to five days
after exposure

Median between 2.5% will develop symptoms

4 and 5.1 days within 2.2 days and in 97.5%
within 11.5 days
Spectrum of illness

81% 14% 5%

Mild to Severe Critical

Moderate Dyspnea, Respiratory
No or mild hypoxia, or >50 failure, shock, or
pneumonia percent lung multiorgan
involvement on dysfunction
imaging within 24
to 48 hours

Overall
7% Case Fatality Rate
Severe illness
14%

Treated in ICU 88%

Mortality among
12% mechanical
ventilated
patients

Received mechanical ventilation

Risk factors for severe illness
• Advance age
• Comorbidities
• Cardiovascular disease
• Diabetes mellitus
• Hypertension
• Chronic lung disease
• Cancer (in particular hematologic
malignancies, lung cancer, and
metastatic disease)
• Chronic kidney disease
• Obesity
Impact of age on mortality

Case Fatality Rate (%) Mortality rate according to age and sex
70
60

60
50
50

Mortality (%)
40
40
30
30
20
20

10 10

0 0
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 >90
Overall Age >80 Age 70-80 Critical case
Male 0 0 7.1 4.6 8.2 12.2 18.7 35.8 60.6 63.6
Case Fatality Rate Female 0 0 1.8 2.5 2.5 6.9 12 27.4 48.1 46.4
Clinical Manifestations
Fever and Respiratory Symptoms

Fever (90%) Dry Cough (59%) Dyspnea (31%) Sputum

production (27%)
 Fatigue  Headache
 Anorexia  Rhinorrhea
Other symptoms  Myalgia  Conjunctivitis
 Anosmia and dysgeusia  Gastrointestinal
 Sore throat  Skin involvement
Clinical features of COVID-19:
Comparison of elderly and young-middle age

Sick and vomit

Nasal congestion, runny nose

Fatigue
Young and Middle-Age
Elderly
Fever

Chest tightness, Difficulty breathing

Cough and sputum

0 20 40 60 80 100
Atypical Covid-19 presentations
in older people
• Older people may not present with typical symptoms and it is apparent in
the case with Covid-19. Older people have also been recognised has
having a greater risk of infection and death from Covid-19.

• Covid-19 results in a massive cytokine storm which results in a variety of

symptoms including fever, fatigue, loss of appetite, myalgia and
arthralgia, nausea, vomiting, diarrhoea, rash, tachypnoea, tachycardia
seizures, headache, delirium, tremor and loss of coordination.

• Due to atypical presentation, patients may slip through the normal

screening process and may inadvertently be admitted to a general
medical ward rather than a Covid-19 cohort ward.
Atypical COVID 19 Presentations in Frail Older Adults

• Typical symptoms of COVID-19 such as fever, cough, and dyspnea may be

absent in the elderly despite respiratory disease
• Only 20-30% of geriatric patients with infection present with fever
• Atypical COVID-19 symptoms include delirium, falls, generalized weakness,
malaise, functional decline, and conjunctivitis, anorexia, increased sputum
production, dizziness, headache, rhinorrhea, chest pain, hemoptysis,
diarrhea, nausea/vomiting, abdominal pain, nasal congestion, and anosmia
• Tachypnea, delirium, unexplained tachycardia, or decrease in blood pressure
may be the presenting clinical presentation in older adults
Atypical COVID 19 Presentations in Frail Older Adults

• Threshold for diagnosing fever should be lower, i.e. 37.5°C or an increase of

>1.5°C from usual temperature
• Atypical presentation may be due to several factors, including physiologic
changes with age, comorbidities, and inability to provide an accurate history
• Older age, frailty, and increasing number of comorbidities increase the
probability of an atypical presentation
• Older adults may present with mild symptoms that are disproportionate to the
severity of their illness
CT and laboratory findings
CT Presentation According to Age Groups

• Study by Song et al.:

• GGO is more common in
younger (<50 yo) than older
(>50 yo) patients (77% vs 55%)
• Consolidative opacities is more
common in older (45%) vs.
younger patients (23%)
• Atypical findings were also most
commonly reported in older
Influenza infection: A review
Influenza in the elderly

• 5-15% population affected by influenza infection each

year, higher rates during epidemics resulting from
antigenic drift
• Considerable human suffering and economic burden
• Vulnerable populations: older adults, children, and those
with chronic diseases
• Among older adults, increasing age correlate with
increased risk hospitalization and all-cause mortality

Falsey et al. Clin Infect Dis. 2006;42:518-24

Harper et al. Clin Infect Dis. 2009;48:1003-32
Laboratory-Confirmed Influenza-Associated Hospitalizations,
Cumulative, 2016-2017, by Age Group

Source:
FluView Interactive
Clinical manifestation of influenza in elderly

Czaja CA, et al. Open Forum Infect Dis. 2019;6:ofz225

Diagnosis of influenza in elderly
Influenza should be considered in elderly patient with:
• Fever and acute onset of respiratory signs and
symptoms
• Fever and acute exacerbation of chronic lung disease
• New or worsening respiratory symptoms, including
exacerbation of congestive heart failure or altered mental
status, with or without fever
• Admitted without fever and acute respiratory symptoms
who subsequently develop febrile respiratory illness after
hospital admission

Harper et al. Clin Infect Dis. 2009;48:1003-32

How seasonal flu and Covid-19 compare
Covid-19 and
Flu: Identifying
the symptoms
Take Home Messages
• COVID-19 caused by SARS-CoV2 is new emerging disease that is now in
pandemic status
• Pathogenesis and clinical manifestations of COVID-19 are now have been
studying to understand how the SARS-CoV2 transmitted among people,
infected patients, and affected human body
• The spectrum of disease mostly mild, severe illness usually related to
advance age and comorbidities
• Clinical manifestations of COVID-19 in elderly relatively the same, but
atypical presentation should be always considered in frail elderly
• COVID-19 could have sign and symptoms which are in common with
influenza, both all affected respiratory organ
THANK YOU