Abstract
Coronavirus disease (COVID-19), an acute infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Older patients, especially those aged > 65 years, are very frail, primarily owing to comorbidities and physiological changes. This retrospective, observational, single-center cohort study included all unvaccinated patients admitted in the geriatric ward with a COVID-19 diagnosis confirmed by reverse transcription polymerase chain reaction during the first year of the pandemic. The study population was divided into survivors and deceased patients. We retrieved records of 1,906 patients. The average age of the participants was 74.7 ± 9.0 years, and the overall mortality rate was 32.8%. The most common symptoms were respiratory distress, fever, malaise, and cough; each of these occurred in >50% of the study population. The most frequent comorbidity was chronic hypertension, affecting 70.2% of the population, followed by diabetes mellitus (36.8%). Moreover, the deceased patients had a worse functional status according to the frailty scale and Barthel index scores compared to those who survived. One-third of the older population with COVID-19 died before the availability of the vaccine. It was confirmed that older adults with COVID-19 are highly vulnerable to falling ill and succumbing to respiratory diseases, especially unvaccinated individuals.
Introduction
Coronavirus disease (COVID-19), an acute infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), led to the most recent pandemic (Zheng, 2020). The virus is transmitted from person to person through respiratory droplets (Tana et al., 2023). COVID-19 has affected hundreds of millions of people worldwide. In Panama (Vigil-De Gracia et al., 2023), the first case of COVID-19 was reported on March 9, 2020; shortly after, the World Health Organization (WHO) declared the pandemic (García-Cabrera et al., 2021). Once the first cases of COVID-19 were reported, the Panamanian health authorities imposed several restrictions on the population to stop the spread of the virus. Schools, airports, and public meeting places were closed, and a continuous lockdown was enforced, allowing movement only with safe-conduct passes signed by authorities. Despite all these measures, the virus continued to spread rapidly. Two COVID-19 waves with clearly defined peaks of affected cases and deaths were recorded during the first year of the pandemic (Vigil-De Gracia et al., 2023).
COVID-19 is a heterogeneous disease with clinical findings ranging from asymptomatic cases to severe respiratory failure and death (Azami et al., 2022). Older patients, especially those aged > 65 years, are very frail, primarily owing to comorbidities and physiological changes. Hence, they are the population at the highest risk of contracting COVID-19 and succumbing to it (Azami et al., 2022; Landi et al., 2020; Shahid et al., 2020). Studies have reported that older adults account for 75% of all COVID-19-related deaths (Shahid et al., 2020; Zheng, 2020). Frailty is characterized by a decreased functional reserve and reduced ability to respond to stressful conditions; moreover, older adults are at an increased risk of falls, hospitalization, other traumatic events, and death (Ticinesi et al., 2022). Therefore, the symptoms and signs of COVID-19 must be identified early in patients infected with SARS-CoV-2 to control or stop the spread of the virus and to enable a timely treatment, especially in high-risk populations (Dent et al., 2019).
Vaccination programs and antiviral and monoclonal antibody therapies have dramatically changed the rates of severity, hospitalization, intensive care unit (ICU) admissions, and mortality associated with COVID-19 (Wynants et al., 2020).
This study aimed to identify the factors influencing survival in a population of unvaccinated older adults infected with SARS-CoV-2 and hospitalized in a tertiary referral hospital during the first year of the COVID-19 pandemic.
Methods
Type of Study
This retrospective, observational, single-center cohort study included patients with COVID-19 admitted to a geriatric ward and analyzed the characteristics of the survivors and deceased patients.
Study Population
This study included all unvaccinated patients admitted to the Department of Geriatric Medicine of the Dr. Arnulfo Arias Madrid Hospital Center, Panamanian Social Security Fund (Caja de Seguro Social—CSS), with a confirmed diagnosis of COVID-19 during the first year of the epidemic in Panama (from March 9, 2020, to March 1, 2021). In Panama, vaccination for this population began in March 2021. Therefore, the study population was not vaccinated against COVID-19 during the study period. Medical records of all hospitalized patients with COVID-19 diagnosis were reviewed.
Data
Data regarding the following variables were extracted: demographic data, symptoms on admission, vital signs, state of consciousness, comorbidities prior to SARS-CoV-2 infection, medications used during admission, medications added during hospitalization, results from blood and special tests performed during hospitalization, high-flow oxygen use, ICU admission, need for mechanical ventilation, frailty by clinical Frailty Scale (Mathieu et al., 2020), Barthel index score, hospitalization duration, and mortality.
The study population was divided into the survivors and deceased patients.
COVID-19 Diagnosis
COVID-19 was diagnosed by the positive reverse transcriptase-polymerase chain reaction test for SARS-CoV-2 using a nasopharyngeal swab sample. When the patient presented with clinical symptoms and signs of COVID-19, and the initial test was negative, the test was repeated within a reasonable time on the discretion of the attending physicians, which was usually between 24 and 72 hr. Only patients with a positive test in their records before hospital discharge or death were included in this study.
Ethical Statement
This study was approved by the Research Ethics. Due to the nature of being a retrospective study with patient records, need for informed consent to participate was waived by the Institutional Review Board. All ethical principles for medical research involving humans were followed as per the national and international guidelines.
Statistical Analysis
Continuous variables are expressed as means and standard deviations, whereas categorical and binary variables are expressed as absolute numbers and percentages. Categorical variables between the groups (survivors and deceased patients) were compared using the Pearson chi-square test with continuous correction or the Fisher exact test, where appropriate. The student’s t-test was used to compare differences in continuous variables between the two groups. Statistical significance was set at p < .05.
Results
We retrieved records of 1,906 patients admitted to the Department of Geriatric Medicine of the Dr. Arnulfo Arias Madrid Hospital Center, CSS, during the first year of the COVID-19 pandemic in Panama. The study population comprised 981 (51.5%) men. The average age of the participants was 74.7 ± 9.0 years (range 55–104); furthermore, 626 patients were deceased and the overall mortality rate was 32.8%. The most frequent symptoms were respiratory distress, fever, malaise, and cough, and each of these occurred in >50% of the study population (Table 1). The most frequent comorbidity was chronic hypertension, affecting 70.2% of the population, followed by diabetes mellitus (36.8%; Table 2).
Most Frequent Symptoms of the Study Population on Admission (N = 1,906).
Comorbidities Recorded on Admission in the Study Population (N = 1,906).
Note. COPD = chronic obstructive pulmonary disease.
Polypharmacy, which is common in this population, was recorded in 78.7% of the participants; antihypertensives were the most commonly used medications. During hospitalization, antibiotics and heparin were administered to more than 94% of the patients (Table 3).
Medications Used by the Study Population (N = 1,906).
Note. NSAIDs = nonsteroidal anti-inflammatory drugs.
The deceased patients were older adults and predominantly male. A history of cerebrovascular disease was associated with higher mortality, with no similar association observed for other conditions (Table 4). Moreover, the deceased patients had a worse functional status according to the clinical frailty scale and Barthel index scores compared to those who survived (Table 4). Medication use prior to admission was not associated with mortality. The deceased patients exhibited very low lymphocyte counts and albumin levels (Table 4).
Clinical Characteristics of the Study Groups (N = 1,906).
Note. OR = odds ratio; CI = confidence interval; COPD = chronic obstructive pulmonary disease.
Discussion
This study reported a high mortality rate (32.8%) among older adults with COVID-19 before the availability of the vaccine, correlating with previous findings (Chen et al., 2020; Mendes et al., 2020; Rockwood et al., 2005; H. Sun et al., 2020; P. Sun et al., 2020). Additionally, the following factors were significantly associated with a high mortality rate: age, sex (male), respiratory distress, cerebrovascular disease, severe lymphopenia, and albumin levels < 3%. A higher clinical frailty score and a lower Barthel index score were also associated with a higher mortality risk.
Fever is the most common symptom in the general population with COVID-19 (Simonsick et al., 2016; H. Sun et al., 2020; P. Sun et al., 2020; Verity et al., 2020). In our study, respiratory distress was the main symptom identified in patients (72.7%). Fever is less common in the geriatric population owing to changes in their immune status (H. Sun et al., 2020; P. Sun et al., 2020). Although fever was not the main symptom in our study population, 59.9% of the participants presented with fever. Therefore, respiratory distress was the main symptom in our population and a strong predictor of mortality.
A low lymphocyte count is associated with higher disease severity and, therefore, higher mortality (Ulugerger Avci et al., 2022), and our data corroborate these findings.
The WHO defines frailty as a condition characterized by an increased vulnerability associated with age resulting from decreased physiological reserve and systemic organ functions, making it difficult to perform activities of daily living (Friedman et al., 2019; Hirose et al., 2023; Qin et al., 2020; Sicsic & Rapp, 2019; Turner, 2014; WHO Clinical Consortium on Healthy Aging, 2016). In the geriatric population, frailty is an important parameter for the progression of COVID-19. Our study shows that the deceased patients had a higher clinical frailty score and a lower Barthel index score compared to the survivors. Previous studies have shown that a higher clinical frailty score is associated with a higher probability of ICU admission, mechanical ventilation use, prolonged hospital stay, and death (Dumitrascu et al., 2021; Jachymek et al., 2022; Ticinesi et al., 2019). In addition to frailty, other factors that adversely affect or worsen the outcomes of SARS-CoV-2 infection in older adults include malnutrition, long periods of bed rest, and comorbidities (Polverino et al., 2020; Tana et al., 2021; Yang et al., 2021).
In the initial months of the pandemic, most deaths in the geriatric population were attributed to poor or bad logistical and organizational plans and the shortcomings in primary care at home and hospitals.
The strengths of this study include its large cohort of patients with a confirmed COVID-19 diagnosis and the inclusion of multiple study variables. This could help us to assess the impact of COVID-19 on mortality in unvaccinated individuals and aid in the development of other therapies.
A limitation of this study is its retrospective design. Furthermore, the data were collected from a single hospital center, and the patients were not evaluated after vaccinations.
Conclusions
One-third of older patients died due to COVID-19 during the first year of the pandemic in Panama. COVID-19 highlights the fragility of older adults, which makes them more susceptible to falling ill and succumbing to respiratory diseases, especially if they are not vaccinated. These insights should be used to develop mortality prevention strategies for future pandemics.
