Excess Deaths Twice as High for Dementia Patients During Pandemic

Excess mortality was twice as high for older adults with dementia in the early phase of the COVID-19 pandemic than it was for those without dementia, an analysis of all Medicare enrollees showed.

From March through December 2020, adjusted mortality was 25.7% higher (95% CI 25.3-26.2) among older adults with Alzheimer’s disease and related dementias than it was during a similar period in 2019, reported Lauren Gilstrap, MD, MPH, of Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, and co-authors.

Among Medicare enrollees without Alzheimer’s and related dementias, adjusted mortality was 12.4% higher (95% CI 12.1-12.6) over the same periods, the researchers wrote in JAMA Neurology.

“We found that enrollees with Alzheimer’s disease and related dementias were at higher risk of dying in 2020 compared with 2019, either directly of COVID-19 or because of premature death owing to disruptions in health care,” Gilstrap and colleagues wrote.

“The elevated mortality risk was found early in the pandemic even in areas with very low COVID-19 infection rates, suggesting that older adults with Alzheimer’s disease and related dementias, especially those in racial and ethnic minority groups and those living in nursing homes, may be particularly susceptible to changes in health care delivery and nursing home care during the ‘lockdowns’ and other restrictions during the pandemic,” they added.

The pandemic has had far-reaching consequences on population health, noted Elan Guterman, MD, MAS, of the University of California San Francisco, in an accompanying editorial.

“The indirect effects of COVID-19, including increased adoption of telehealth, decreased access to community resources, and social isolation, carry their own health burden and disproportionately affect older adults with dementia who have consolidated social networks and increased functional dependence on communities and health systems,” Guterman wrote. “However, the actual impact of these changes on mortality has thus far been inadequately understood and recognized.”

Gilstrap and co-authors studied Medicare fee-for-service beneficiaries from Jan. 1, 2019, to Dec. 31, 2020, grouping participants into four categories: people with or without Alzheimer’s or dementia in general, and people with or without dementia in nursing homes.

The study included 26,952,752 people in 2019 and 26,688,136 people in 2020. In 2019, the mean age of community-dwelling beneficiaries without dementia was 74; for those with dementia, it was 83. In nursing homes, the mean age without dementia was 80; with dementia, it was 84.

Among people with a dementia diagnosis in 2019, 63.5% were women, 80.7% were white, 9.2% were Black, 5.7% were Hispanic, and 2.7% were Asian. These percentages were similar in 2020.

Comparing March through December data for 2020 versus 2019, mortality increased especially for dementia patients in Hispanic (40.1% increase), Black (36.7% increase), and Asian (36.0% increase) populations.

In 2020, mortality in nursing homes increased by 33.4% for residents with dementia and by 24.2% for those without dementia.

The U.S. hospital referral region in the lowest quintile for COVID-19 infections in 2020 had no excess mortality among older adults without dementia, but 8.8% higher mortality among community-dwelling dementia patients and 14.2% higher mortality among dementia patients in nursing homes.

“Although there has been widespread acceptance that dementia and nursing home care amplify the negative consequences of the COVID-19 pandemic, tying this observation to population-based estimates of excess mortality is crucial for establishing the importance of dementia as an independent risk factor for disparate health outcomes, including death,” Guterman noted.

There are several possible explanations for the rise in mortality, Gilstrap and co-authors said. Changes in healthcare delivery, including fewer inpatient admissions and shifts to telehealth for outpatient visits, may disproportionately affect people with dementia, they observed.

“Because older adults in general and older adults with cognitive impairments are less able to engage effectively with standard telehealth platforms, it is not difficult to imagine how the combination of less effective (or absent) outpatient care and lower inpatient admission rates led to higher mortality,” the researchers wrote.

The study had several limitations, Gilstrap and co-authors acknowledged. Some people in alternative institutional settings, like memory care units or group homes, may not have been included. SARS-CoV-2 infection rates likely were understated in early 2020 due to poor testing. In addition, nursing home occupancy rates fell during 2020, and spikes in COVID cases did not follow a uniform timeline across the U.S.