Mary Moore never felt the typical symptoms of COVID-19.

The 80-year-old resident of Toronto’s shelter system never came down with a fever, never felt her chest tighten or a cough tickle her throat. Despite sharing a room at an Etobicoke women’s shelter with three others, and despite the risk of her age, she hadn’t been scared of contracting the virus — reasoning that her only real exposure to the outside world was walking regularly, about a mile away then back.

But then, last month, she got sick — and fast. At first, it was hard to pinpoint precisely what was wrong.

“You know when you feel there’s something just not right?” Moore said. She asked staff to help her get to a nearby hospital. Then things started to deteriorate.

“I can remember being in the ambulance outside, and vaguely remember being in the emergency room,” Moore recalled.

A test confirmed that she’d contracted COVID-19. But for the next few weeks, as she battled the virus in hospital, her primary symptom still wasn’t one that she recognized from warnings. She was hallucinating — imagining small animals in her hospital room, or that she’d been discharged, and was sitting down to a meal in Toronto’s Chinatown neighbourhood.

That kind of delirium is one of the atypical ways that COVID-19 can show up, particularly in older adults, said Toronto geriatrician Dr. Nathan Stall. But because it doesn’t look like a typical case, it’s also the kind of situation where the virus can go undetected.

In Stall’s view, Moore’s case is evidence that the bar for older adults to get tested for COVID-19 should be “extremely low” as cases have risen this fall.

The risks are particularly high in the shelter system as a congregate environment that caters to vulnerable populations, he said. Symptoms like Moore’s may end up incorrectly attributed to other causes that show up more regularly among shelter users — addictions, mental illness or even dementia, he added.

That Moore’s case could have slipped through the cracks isn’t lost on her. “If I hadn’t gone to the hospital that day, God knows how long I would have been walking around with it,” she said.

Unknown to her, one of her roommates would later test positive for the virus as well, without showing any symptoms — prompting a Toronto shelter worker to call for broader-scale testing.

The most recent screening tool from Toronto’s Shelter, Support and Housing Administration asks staff to check if their adult clients have a fever; any new or worsening symptoms including a cough, difficulty breathing, sore throat, difficulty swallowing, runny nose, lost sense of taste or smell, nausea, vomiting or diarrhea; or fatigue, increased falls, chills or headaches.

The document includes a link to a longer , which includes delirium unrelated to “known causes or conditions” including alcohol withdrawal or other substance uses. But Dr. Stefan Baral, a physician with Toronto’s Inner City Health Associates, said they’ve been trying to stress that any unexplained change in a person is worth flagging.

That’s where shelter workers’ familiarity with their clients can play a major role, Baral said — and where assessing unfamiliar clients can present a challenge.

Anyone with atypical symptoms would be connected to “clinical partners,” said shelter system director Gord Tanner.

But street nurse Cathy Crowe worries about the task being assigned to shelter staff: “We know that shelter workers are swamped, so how much attention can really be paid properly to screening?”

Back in the hospital, Moore struggled to come to terms with her diagnosis. It didn’t seem to sink in, because she didn’t feel physically ill.

“I kept saying ‘No, there’s nothing wrong, there’s nothing wrong,’” she said.

The worst part of the experience was feeling like she was losing her mind. She was scared, but said the hospital nurses were attentive, and gently pointed out when she veered into hallucinations.

“’Honey, there’s nobody there. You’re talking and getting your own answers,’” she recalls one saying.

She tried not to panic or consider the grimmest outcomes, fearing it would make things worse.

Stall, who didn’t treat Moore, said auditory or visual hallucinations are consistent with delirium. Earlier in the pandemic, he and his colleagues at Mount Sinai hospital wrote a case report about an 83-year-old, who arrived in the emergency department after a fall at home.

The woman’s only complaint was a vague sense of dizziness. She was deemed a low risk for COVID-19 at triage, but diagnostic tests later revealed she was infected.

Atypical presentation of illness is actually common in older adults, the doctors wrote — with symptoms like falls, functional decline or delirium. For that reason, like Baral, Stall stressed that any change from a person’s baseline health should be cause for alarm, especially with seniors.

After being discharged from hospital, Moore spent several days at an isolation site for people with no fixed address. While she was lonely — “you have nobody to talk to, maybe your own walker or your walls,” she said — she had a comfortable bed, a TV and her own washroom.

Now back at the shelter, she’s urging more understanding about the different ways a COVID-19 infection can show up.

“Don’t take something for granted. If you think you have a sick stomach, or something like that, get it looked after right away, because there are different ways of feeling it,” she said.

“To me, I didn’t feel right. And after that, everything is a blur.”

Victoria Gibson is a Toronto-based reporter for the Star covering affordable housing. Her reporting is funded by the Canadian government through its Local Journalism Initiative. Reach her via email: