key: cord-255799-3j8axc4d authors: Isaia, Gianluca; Marinello, Renata; Tibaldi, Vittoria; Tamone, Cristina; Bo, Mario title: Atypical presentation of Covid-19 in an older adult with severe Alzheimer Disease date: 2020-04-22 journal: Am J Geriatr Psychiatry DOI: 10.1016/j.jagp.2020.04.018 sha: doc_id: 255799 cord_uid: 3j8axc4d nan We would like to report the case of an Alzheimer Disease patient affected by Covid-19 admitted to the Hospital at Home Service (HHS) of the University Teaching Hospital of Turin, Italy. HHS is a multidisciplinary service operating 7 days a week that can be directly activated by hospital wards to allow early and supported discharge from hospital. Four doctors and 14 nurses operate 7 days a week and look after 25 patients a day, on average. The HHS provides substitutive hospital-at-home care in a ''clinical unit'' model. Several examinations and treatments can be carried out at home, including blood tests, electrocardiogram, spirometry, pulse oximetry, ultrasonographic investigations, placement of peripherally inserted central catheters, oxygen and other respiratory therapies, intravenous fluids and drugs, blood transfusions, surgical treatment of pressure ulcers (1, 2, 3, 4, 5) . On march 15 th , an 83 year old woman was admitted to the emergency department (ED) from her private home with mild fever (100,4°F) and drowsiness. Her medical history included only a longstanding history of Alzheimer disease with dysphagia and total functional dependence, and a left arm fracture one month prior to hospitalization. In terms of her mental status, caregivers reported that she was aware of her surroundings at her home, while at hospital admission and during the hospital length of stay she was minimally conscious. She was not able to swallow food and drink, neither to swallow medications. Blood pressure at admission was 80/50 mmHg; she had low oxygen blood saturation (SpO2 90%) without dyspnea or cough. Other blood values were the following: WBC 15070 cells/mm 3 , hemoglobin 15.4 g/dL, creatinine 1.81 mg/dL, PCR 89 mg/L. Chest X-Ray was negative for pneumonia. While she did not have any history of exposure to COVID, she underwent nasopharyngeal swab which resulted negative. She was then moved to an Acute Medical Ward, where she was treated with cephalosporin and fluid supplementation with marginal improvement of clinical conditions (oxygen supplementation was stopped) and blood chemistries (creatinine 1.01 mg/dL, PCR 59 mg/L), but persistently high WBC count (14310 cells/mm 3 March 23rd, the patient returned home with the support of HHS program. On March 27th a new episode of blood oxygen saturation (SpO2 82-88%) occurred, associated with diarrhea but without fever. A second nasopharyngeal swab was done, which was positive for Covid-19 infection. According to recommendations from an infectious disease specialist, the patient was treated only with supportive measures, including oxygen supplementation, parenteral nutrition, low-dose heparin and corticosteroids (betamethasone 8 mg twice daily). It was not possible to administer hydroxicloroquine due to an inability to swallow, while the nasogastric tube was not considered appropriate. On April 10th, the patient is still alive and hemodynamically stable. Home care for demented subjects: new models of care and home-care allowance Substitutive "hospital at home" versus inpatient care for elderly patients with exacerbations of chronic obstructive pulmonary disease: a prospective randomized, controlled trial Hospital at home for elderly patients with acute decompensation of chronic heart failure: a prospective randomized controlled trial Delirium in elderly home-treated patients: a prospective study with 6-month follow-up The RAD-HOME project: a pilot study of home delivery of radiology services The authors report no funding to disclose or conflicts with any product mentioned or concept discussed in this article.