key: cord-0817427-jrzor57o authors: Miyashita, Satoshi; Yamada, Takayuki; Mikami, Takahisa; Miyashita, Hirotaka; Chopra, Nitin; Rizk, Dahlia title: Impact of dementia on clinical outcomes in elderly patients with coronavirus 2019 (COVID‐19): an experience in New York date: 2020-07-21 journal: Geriatr Gerontol Int DOI: 10.1111/ggi.13942 sha: 0633b37a52bf57395941d4fd22356e139de0e0f3 doc_id: 817427 cord_uid: jrzor57o nan There are many risk factors associated with a poor prognosis of COVID-19, including advanced age. 2 Dementia is common among elderly patients, affecting up to 7% of individuals ≥65 years worldwide. 3 However, it remains unclear whether dementia is associated with poor clinical outcomes in elderly patients infected with COVID-19. Therefore, our study, aimed to investigate associations between dementia and poor clinical outcomes in patients with COVID-19. Our study analyzed Mount Sinai Health System (MSHS) medical records from March 1 to April 2, 2020, using Epic SlicerDicer software. We extracted data from patients who had a positive result for the COVID-19 reverse transcription-polymerase chain reaction test during this period and continued to track them through April 11, 2020. We included patients aged ≥60 years old and compared clinical outcomes between patients with and without dementia. Our primary outcome was all-cause mortality. Secondary outcomes included the need for hospital admission, intubation or intensive care unit admission. We conducted subgroup analyses by age groups. P values were calculated using a two-tailed χ 2 test, and relative risk (RR) was calculated with a 95% Letters to the Editor -Research Studies confidence interval (CI). MSHS waived Institutional Review Board approval as this research used only de-identified, aggregate-level data. In total, 2071 COVID-19 cases were reported. Of these, 1099 (53.1%) patients were men, and 98 (4.7%) had dementia. In total, 429 (20.7%) patients died during the study period. Baseline characteristics and the primary and secondary outcomes are summarized in Table 1 . The proportions of those aged ≥80 years old (68.4% vs. 22.7%, P < 0.001) and those with hypertension (76.5% vs. 59.1%, P < 0.0059) were significantly higher in the dementia group. After adjusting by age group, we found a significantly increased risk of hospital admissions ( To the best of our knowledge, this is the first study to show that patients with dementia may be at high risk for poor clinical outcomes. After dividing our patients into two age groups, thereby reducing the effects of confounding, we found that patients with dementia who are infected with COVID-19 are at higher risk for both hospital admissions and death. Dementia is a common neurocognitive disease characterized by a decline in memory and multiple skills. 3 As suggested in our study, patients with dementia generally have multiple comorbidities as compared with others, and these afflictions increase their risk of hospitalizations and mortality from viral and bacterial infections. 4 COVID-19 is known to cause severe inflammation throughout the body via disruption of the renin-angiotensin system, which is one possible mechanism for increased hospital admissions and mortality in patients with dementia who are particularly susceptible to inflammation due to multiple comorbidities. 5 Our study revealed no difference in mortality in those aged ≥80 years old. In elderly patients, the mortality rate was remarkably high (35.6%), and we speculate that these patients are at risk for death regardless of the presence of dementia. One limitation of our study is an unclear causation between COVID-19 and clinical outcomes. In addition, the heterogeneity of dementia types may obscure the rationale of our findings. However, to our knowledge, this is the first report on the prognosis of COVID-19 in patients with dementia in the USA. The relatively large number of patients in the study allowed for the adjustment of age, which is one of the strongest prognostic factors. As the number of cases of COVID-19 is increasing rapidly, more studies of patients with dementia are possible and warranted in this pandemic. The authors declare no conflict of interest. This research did not receive any funding from agencies in the public, commercial or not-for-profit sectors. 1 One previous study showed that COVID-19 is more likely to affect older men with comorbidities;2 the highest mortality rate was observed among persons aged ≥85, ranging 10-27%, followed by 3-11% among those aged 65-84 years.3 Long-term care facilities (LTCF) are high-risk settings for severe outcomes of the COVID-19 outbreak, owing to both the advanced age and frequent chronic underlying health conditions of the residents.4 To prevent large-scale community transmission of COVID-19, Taiwan has taken advanced steps in terms of medical care planning (e.g. border control, identifying cases, quarantining suspicious cases, proactively searching for cases, allocating resources etc.).5 Thus far, just 395 COVID-19 patients have been confirmed, six of whom have died. Only one nursing home has been in lockdown, because one of its nursing staff became infected. In this article, we share our experiences regarding how we have responded to COVID-19 in our LTFC based on the management of visitors, residents and healthcare professionals (HCP), as well as government support and policies. The first policy we made was to limit the number of visitors when we learned that some infected individuals have no fever or respiratory symptoms. All visitors are required to: wear a mask; have their body temperature checked; voluntarily declare their history of travel, occupation, contacts and cluster; and register before entering the building. Visiting hours and the number of persons accompanying patients are gradually being reduced as the number of confirmed cases rises in Taiwan. Using big data technology, the government later makes the immigration data accessible on health insurance cards. All the visitors are required to present their health insurance card to make known if they have recently visited high-risk countries. Regarding management of HCP, we hold regular educational and training seminars to deal with COVID-19. We actively screen HCP for fever and respiratory symptoms at the beginning of their shifts, and implement sick leave policies that allow ill HCP to stay home. Traveling abroad is prohibited, and all employees must report their weekend and vacation activities every week. We now restrict all volunteers and nonessential HCP from entering the building. Later on, we decided to cancel all group activities, avoid communal dinners with colleagues, and to re-organize the groupings and schedules of nursing staff and attendants. One member of each group is confined to the same working place and accommodation area. To lower any risk of delayed diagnosis or misdiagnosis, if residents or HCPs have a fever or respiratory symptoms, they take a COVID-19 test. In terms of considerations for residents, they are not allowed to leave the facility. To avoid extra contact in the hospital, our staff regularly prescribe medication for them if they are in a stable condition. In addition, we increased the number of rehabilitation clinics in the facility for residents who require rehabilitation at the hospital. To decrease the burden and risks for HCPs, our facility has become temporarily unavailable to new residents. To prepare for surge capacity in staffing, equipment and supplies, we asked the residents and their families whether they would like to return home or stay in the facility while there is an outbreak occurring within it. International organizations have recognized the Taiwanese government for waging a successful battle against COVID-19. Just like its aggressive efforts toward border control, containment and proactive testing, the attempts to care for patients who require long-term care are not inferior to other aspects of Taiwan's overall endeavor. Initially, the government coordinated with manufacturers to help our LTFC purchase supplies, such as thermometers and ethyl alcohol. Later oneven though there has been no farreaching community transmissionthe government gave the order to keep all visitors from entering nursing homes or LTCF. To plan ahead of time and to mitigate supply shortages if outbreaks in the community were to occur, the government checks the vacancy of LTCF beds, coordinates with neighboring hospitals to satisfy the medical needs of LTFC and has requested a prepared plan from each facility. Although we are unable to predict whether there will be extensive community transmission of COVID-18 in Taiwan, most LTCF readily cooperate with the government's policies, try to plan ahead and minimize risks as best as they are able. * Cheng-Ren Chen and Hui-Chun Huang contributed equally to this work. Clinical characteristics of coronavirus disease 2019 in China Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China Pneumonia and influenza hospitalizations in elderly people with dementia Impact of dementia on clinical outcomes in elderly patients with coronavirus 2019 (COVID-19): an experience in New York We gratefully thank all residents and municipal staff in Higashiura for their helps and efforts. We would like to thank Editage (www. editage.com) for English language editing. This study was supported by grants from Research Funding for Longevity Sciences from the National Center for Geriatrics and Gerontology, Japan (no. 30-6).