Clinical neurological characteristics of geriatic patients with Coronavirus disease 2019 (COVID-19)

Background and objectives. Coronavirus Disease-2019 (COVID-19) is a respiratory infection caused by the severe acute respiratory syndrome coronavirus (SARS-CoV-2). The COVID-19 associates multi clinical symptoms such as neurological manifestations with mild to advanced progression. This study aimed to determine the clinical neurological characteristics of geriatric patients with COVID-19. Methods. The study was an observational and descriptive study on 27 geriatric patients with COVID-19. All patients’ age was over 60 years old who treated in the In-patient Department of Sanglah General Hospital, Denpasar, on July 2020 to January 2021. The data had taken from medical records. Outcomes. The mean age of all patients was 70.41 (± 8.902) years which dominated by the male (51.9%). The majority of manifestations in this study were fever in 13 people (48.1%), unconsciousness in 10 people (37%), and hemiparesis in 10 people (37%), and cough in 9 people (33.3%). Conclusion. The clinical neurology characteristics of geriatric patients with COVID-19 vary, which may involve general and neurological manifestations. Promptly accurate diagnosis is necessary for further management.

bACKGrOUND Coronavirus Disease-2019 (COVID-19) is a respiratory infection caused by the severe acute respiratory syndrome coronavirus (SARS-CoV-2) and first discovered in Wuhan, China. Clinical symptoms of COVID-19 vary from mild to advanced progression [1]. Neurological manifestations can be caused by infection of SARS-CoV-2 directly in the nervous system or indirectly through the immune response [2].
Appropriate treatment requires a proper diagnosis. Demographic data is necessary to consider the clinical diagnosis. Research on demographics data (including onset, age, gender, clinical symptoms and treatment durations) has not been establishing widely. Therefore, our study aimed to determine the clinical neurological characteristics of geriatric patients with COVID-19.

MEtHOD
This research was a retrospectively descriptive observational study. The data took from medical records of patients who were admitted in the inpatient department in Sanglah General Hospital, Den-pasar, from July 1, 2020 to January 31, 2021. Inclusion criteria were COVID-19 sufferers aged more than 60 years with neurological manifestations. The diagnosis of COVID-19 is based on World Health Organization clinical guidelines, which had been proven from the results of the history, physical examination and support tests. The exclusion criteria were COV-ID-19 sufferers whose data in their medical records were incomplete. The data includes age, gender, comorbid factors, clinical manifestations, patient outcomes and laboratory tests.
Sample selection used all COVID-19 patients who had met the inclusion and exclusion criteria during a predetermined period without a specific sample size. The ethical approval number 2021.02.1.0246 was taken from the ethics committee of Sanglah General Hospital Denpasar.
The data collected is then processed using the International Business Machine Statistical Package for the Social Sciences (IBM SPSS) Statistics version 20 software. The descriptive analysis had performed to determine the proportion and clinical neurological characteristics of geriatric patients with COVID-19 at Sanglah General Hospital Denpasar as a source for further research. rEsULt Twenty-seven geriatric patients (over 60 years) with COVID-19 and clinical neurological manifestations had treated at Sanglah Hospital from July 1, 2020, to January 31, 2021. The demographic and clinical characteristics of the research sample showed in Table 1.

DIsCUssION
This study used a descriptive design to show the proportion and mean of the sample. Twenty-seven samples were obtained, with a mean age of 70.41 (± 8.902) years old. This result is in line with Guo et al., study in 2020 that found an average age of 67 years [3].
The gender sample of this study dominated by the male (51.9%) to female (48.1%) is similar to a study conducted by Chen et al., in 2020 from Wuhan, which found that male results were 54.3-68% [3,4].
The dominant comorbid factors were hypertension as many as 19 people (70.4%) and diabetes mellitus as many as 11 people (40.7%). This is following a study that explained that geriatric patients (>60 years) had higher risk factors, including hypertension, diabetes mellitus, hyperlipidemia and vascular disease [2]. The risk factors for smoking were 3 people (11.1%) and alcohol consumption was 1 person (3.7%).
The general manifestations included fever in 13 people (48.1%) and cough in 9 people (33.3%). This result was similar with research conducted by Liu et al., in 2020, the main symptoms that are commonly found are fever and cough [5,6]. The upper respiratory tract is the entry point for SARS-Cov-2. The main target of SARS-CoV-2 is respiratory and digestive tract epithelial cells which have angiotensin converting enzyme 2 (ACE2). Decreased airway particle clearance function, and the number of cilia found in the elderly This causes factors that cause respiratory symptoms to be found more in the elderly [6]. Based on a retrospective study conducted by Mao et al., in 2020, it was found that COVID-19 predominantly affects the respiratory system, with common symptoms that are often found to be fever (61.7%), cough 50%, and decreased appetite (31.8%). Other common symptoms include fatigue, myalgia and shortness of breath [7].
The unconsciousness may be caused by encephalopathy related to hypoxia, drugs, toxins and metabolism. Consideration of the cause of encephalitis must be associated with the presence of brain inflammation characterized by other neurologic deficits [2].
In this study, headache manifested in only 7 (25.9%) of 27 patients. These differ from a study conducted by Rahman et al., in 2020, where reported headache as the most common neurological symptom. The underlying mechanism of headache is related to infection of the nervous system and other factors related to stress, fear and anxiety [9].
Cerebrovascular disease is associated with damage to blood vessels (specifically large blood vessels) accompanied by risk factors. Increased inflammatory response and hypercoagulable conditions characterized by increased levels of C-Reactive Protein (CRP) and D-dimer. The ischemic stroke resulted from a cytokine storm, which damage the vascular endothelium, disseminated intravascular coagulation and impair autoregulation. The binding of the virus to the ACE2 receptor found on the endothelium of blood vessels will cause extensive, which will increase the risk of thrombosis and cause ischemic stroke. In hemorrhagic stroke, the SARS-CoV-2 virus will reduce the expression and function of the ACE2 protein resulted in uncontrolled hypertension, rupture of artery walls and cerebral hemorrhage. Thrombocytopenia and hypercoagulation can also cause cerebral hemorrhage [10]. The dead clinical outcome obtained as many as 7 (25.9%) patients.
From the results of the study, there was an increase in CRP with an average of 48.5 mg/l (± 1. . This is in line with a meta-analysis study conducted by An et al. in 2020, from 14 studies an increase in CRP was found, with an average of 75.47 mg/dL. SARS-CoV-2 infection is an inflammatory response characterized by increased levels of interleukin (IL)-6, Granulocy Colony-Stimulating Factor (GCSF), Interferon gamma-induced protein 10