COVID-19 Pandemic Associated With Higher Mortality in Elderly With Alzheimer Disease and Related Dementias

Lauren Gilstrap, MD, MPH

Data from a recent cross-sectional study suggest the COVID-19 pandemic may be associated with excess mortality in older adults with Alzheimer disease and related dementias (ADRD). Even in areas with low COVID-19 prevalence, investigators concluded this excess mortality was particularly pronounced for Asian, Black, and Hispanic populations, as well as those in nursing homes.¹

Investigators included a total of 26,952,752 Medicare enrollees from 2019 and 26,688,136 from 2020, comparing mortality rates from March through Dec in 2019 with March through Dec in 2020. In 2019, patients without ADRD had a mean age of 74.1 years (SD, 8.8) and those with ADRD had a mean age of 82.6 years (AD, 8.4). Mean age of nursing home residents with ADRD, at 83.6 years (SD, 8.4), was similar to those without ADRD, at 79.7 years (SD, 8.8). For those diagnosed as having ADRD in 2019, 2.7% were Asian, 9.2% were Black, 5.7% were Hispanic, 80.7% were White, and 1.7% identified as other. Investigators noted that this composition did not change appreciably when compared with 2020.

Among all enrollees without ADRD, adjusted mortality in 2020 was 12.4% higher when compared with 2019 (95% CI, 12.1-12.6) and among those with ADRD, adjusted mortality in 2020 was 25.7% higher when compared with 2019 (95% CI, 25.3-26.2). These percentages were even greaterfor Asian patients with ADRD, at 36.0% higher in 2020 compared with 2019 (95% CI, 32.6-39.3), Black patients with ADRD, at 36.7% higher (95% CI, 35.2-38.2), and Hispanic patients with ADRD, at 40.1% higher (95% CI, 37.9-42.3). When evaluating the hospital referral region in the lowest quintile for COVID-19 infections in 2020, investigators found it had no excess mortality among those without ADRD, but there was 8.8% higher mortality among community-dwelling enrollees with ADRD (95% CI, 7.5-10.2) and a 14.2% higher mortality among those with ADRD living in nursing homes (95% CI, 12.2-16.2).

“To date, this study represents the largest examination of mortality trends among nursing home residents during the early phase of the COVID-19 pandemic,” lead author Lauren Gilstrap, MD, MPH, assistant professor of medicine, Geisel School of Medicine, Dartmouth, et al wrote. “The association between COVID-19 and mortality among nursing home residents, where COVID-19 is known to be prevalent, is complex.”

Data were collected from beneficiaries of Medicare Parts A and B, with patients being 65 years or older. Participants were then categorized into 4 prespecified cohorts: those with ADRD, those without ADRD, those with ADRD residing in nursing homes, and without ADRD residing in nursing homes.

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The study was limited due to the potential exclusion of patients in alternative institutional settings, aside from nursing homes, such as memory care units or group homes. Additionally, investigators noted the likelihood of the underreporting of COVID-19 infection rates due to poor detection rates early in the pandemic. Nursing home occupancy rates also decreased during 2020, which may have led to change in case mix, despite investigators’ assessment of demographic information and comorbidities suggesting little change. Other limitations included the varying waves of the pandemic, which may render the 2 periods in the study unable to fully capture the timing in local infection spikes, as well as investigators’ inability to determine why some hospital referral regions fared better than others, noting this as an area for additional research.

Gilstrap et al described the need to better adapt telehealth platforms to suit the needs of older adults, particularly those with ADRD and those living in nursing homes. This may have also affected the health of these populations due to the social isolation introduced by the pandemic and associated increased caregiver burden and stress.

“The consistently higher excess mortality within a given COVID-19 quintile underscored the vulnerability of patients with ADRD to abrupt changes in health care delivery, lockdowns, and social isolation, particularly for underserved groups, such as Asian, Black, and Hispanic populations,” Gilstrap et al wrote.

REFERENCE
1. Gilstrap L, Zhou W, Alsan M, Nanda A, Skinner JS. Trends in mortality rates among Medicare enrollees with Alzheimer disease and related dementias before and during the early phase of the COVID-19 pandemic. Jama Neurol. Published online February 28, 2022. doi:10.1001/jamaneurol.2022.0010