Medicare enrollees with Alzheimer disease and related dementias (ADRD) were more likely to die in 2020 than in 2019, even in regions with low rates of COVID-19 infection in the early days of the pandemic, according to a cross-sectional study published in JAMA Neurology.
Changes in health care delivery during the COVID-19 pandemic included decreased inpatient care and transition of outpatient care to telehealth. In nursing facilities, lockdowns and strict visitation procedures led to social isolation. This is the largest study of mortality trends among nursing home residents in the early phase of the COVID-19 pandemic.
Researchers evaluated mortality rates of 4 cohorts of 2019 and 2020 Medicare enrollees (26,952,752 enrollees, 26,688,136 enrollees, respectively), sorted based on whether they had ADRD and whether they were nursing home residents. The researchers compared mortality rates from March through December 2020 with those of March through December 2019.
Medicare enrollees with ADRD in 2019 (8.9% enrollees) and 2020 (8.6% enrollees) had similar gender and race makeup (2019: 63.5% women; 2.7% Asian, 9.2% Black, 5.7% Hispanic, and 80.7% White). In 2020, the nursing home population decreased 18.7%.
Community-dwelling Medicare beneficiaries without ADRD tended to be younger compared with those with ADRD (mean 74.1 years vs 82.6 years), while nursing home residents were more similarly aged (without ADRD aged mean 83.6 years vs with ADRD aged mean 79.7 years).
Compared with their peers who did not have these diseases, individuals with ADRD (25.8% vs 9.6%), lung disease (30.2% vs 18.2%), diabetes (33.9% vs 22.9%), and heart failure (50.8% vs 25.3%) were more likely to have Medicaid dual eligibility.
Excess mortality for Medicare enrollees without ADRD adjusted for age and sex was 12.4% higher in 2020 compared with 2019. Patients with ADRD experienced a 13.3% increased mortality risk compared with patients without ADRD in 2020. Nursing home residents without ADRD had a 24.2% increased mortality risk in 2020 compared with 2019. Nursing home residents with ADRD had 33.4% higher mortality risk in 2020 than in 2019.
Excess mortality was higher among Asian (36.0%), Black (36.7%), and Hispanic (40.1%) individuals both among enrollees with and enrollees without ADRD.
In the lowest quintile regions, mortality was 8.8% higher among patients with ADRD and 14.2% higher among nursing home residents.
Ridgewood, New Jersey (104.4% increase) and Bronx, New York (110.1%) were outliers for high excess mortality.
The researchers found that while rates of COVID-19 diagnosis tended to at least triple from the early to later periods of 2020, excess mortality among ADRD patients did not increase for COVID-19 exposure quintiles. They attributed that relative stability to improved hospital procedures, mask wearing, and social distancing rates in regions with higher COVID-19 infection rates.
Study limitations included possible exclusion of patients in alternative institutional settings, possible understating of COVID-19 infection rates in early 2020, decrease of nursing home occupancy in 2020, lack of national uniformity in pandemic waves, and inability to determine causation of variations in hospital referral regions (HRRs).
“The results of this cross-sectional study suggest that the COVID-19 pandemic may be associated with excess mortality among older adults with ADRD, especially for Asian, Black, and Hispanic populations and people living in nursing homes, even in areas with low COVID-19 prevalence,” the researchers concluded.
Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Gilstrap L, Zhou W, Alsan M, et al. 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