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Addressing Vulnerability and Dementia in the Era of COVID-19

JAMA Neurol. Published online February 28, 2022. doi:10.1001/jamaneurol.2021.5330

he medical community was quick to recognize that dementia and other comorbidities of older age left older individuals prone to severe illness and death from COVID-19.1,2 Yet the impact of the COVID-19 pandemic has had far broader consequences to population health than can be attributed to the virus itself. 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. However, the actual impact of these changes on mortality has thus far been inadequately understood and recognized.

In this issue of JAMA Neurology, Gilstrap et al3 take an important step in quantifying the change in all-cause mortality among older adults with dementia in the US during the COVID-19 pandemic. The authors used a 100% sample of more than 53.6 million Medicare fee-for-service beneficiaries to examine the differences in mortality associated with the emergence of COVID-19. As expected, mortality increased for all individuals in 2020 compared with 2019; however, excess mortality was 2-fold higher among older adults with dementia, whose mortality increased 25.7% (95% CI, 25.3%-26.2%) in 2020, compared with 12.4% (95% CI, 12.1%-12.6%) among their peers without cognitive impairment. For nursing home residents with dementia, excess mortality was even higher, increasing 33.4% (95% CI, 32.8%-34.0%) in 2020. 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.

Could this finding merely represent the destructive force of COVID-19 infection among individuals with dementia? Although cause of death was not available in the cohort and the authors could not exclude a direct effect of COVID-19 on mortality, dementia was associated with excess mortality in 2020 irrespective of COVID-19 exposure. Specifically, regions with the lowest rates of COVID-19 infection experienced a decrease in mortality during 2020 among individuals without dementia yet still experienced increased mortality among individuals with dementia, strongly suggesting that downstream effects of COVID-19, rather than the virus itself, may have played a major role in driving mortality in this vulnerable population.

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