Treatment intensity and mortality among COVID‐19 patients with dementia: A retrospective observational study

Abstract

Background: We sought to determine whether dementia is associated with treatment intensity and mortality in patients hospitalized with COVID-19.Methods: This study includes review of the medical records for patients >60 years of age (n = 5394) hospitalized with COVID-19 from 132 community hospitals between March and June 2020. We examined the relationships between dementia and treatment intensity (including intensive care unit [ICU] admission and mechanical ventilation [MV] and care processes that may influence them, including advance care planning [ACP] billing and do-not-resuscitate [DNR] orders) and in-hospital mortality adjusting for age, sex, race/ethnicity, comorbidity, month of hospitalization, and clustering within hospital. We further explored the effect of ACP conversations on the relationship between dementia and outcomes, both at the individual patient level (effect of having ACP) and at the hospital level (effect of being treated at a hospital with low: <10%, medium 10%-20%, or high >20% ACP rates). Results: Ten percent (n = 522) of the patients had documented dementia. Dementia patients were older (>80 years: 60% vs. 27%, p < 0.0001), had a lower burden of comorbidity (3+ comorbidities: 31% vs. 38%, p = 0.003), were more likely to have ACP (28% vs. 17%, p < 0.0001) and a DNR order (52% vs. 22%, p < 0.0001), had similar rates of ICU admission (26% vs. 28%, p = 0.258), were less likely to receive MV (11% vs. 16%, p = 0.001), and more likely to die (22% vs. 14%, p < 0.0001). Differential treatment intensity among patients with dementia was concentrated in hospitals with low, dementiabiased ACP billing practices (risk-adjusted ICU use: 21% vs. 30%, odds ratio[OR] = 0.6, p = 0.016; risk-adjusted MV use: 6% vs. 16%, OR = 0.3, p < 0.001). Conclusions: Dementia was associated with lower treatment intensity and higher mortality in patients hospitalized with COVID-19. Differential treatment intensity was concentrated in low ACP billing hospitals suggesting an interplay between provider bias and "preference-sensitive" care for COVID-19.

Outcomes of COVID-19-Associated Hospitalizations in Geriatric Patients with Dementia in the United States: A Propensity Score Matched Analysis

“…Previous data on dementia and COVID-19 is consistent with our findings regarding increased in-hospital mortality [ 14 , 15 ]. The pathophysiology of dementia heightens COVID-19 mortality through impaired cognition, compromised respiratory function, and challenges in symptom recognition [ 14 ].…”

“…It is possible that the distinctive pathophysiology of COVID-19 in dementia patients underlies this observation. The altered immune response in dementia patients might counteract systemic inflammation from COVID-19 [ 14 , 15 ]. In the setting of COVID-19, the SARS-CoV-2 virus exploits ACE2 for cellular entry.…”

Characteristics Associated With Disparities Among Older Adults in Coronavirus Disease 2019 Outcomes in an Academic Health Care System

“…Other work has demonstrated dementia, a serious illness of older adults was associated with lower treatment intensity and higher mortality among patients hospitalized with COVID-19. Similar to our work, this association was attributed to a possible interplay between provider bias and treatment preference 36–41. Furthermore, after controlling for age, patients admitted from a SNF were also half as likely to be admitted to an ICU.…”

“…Similar to our work, this association was attributed to a possible interplay between provider bias and treatment preference. [36][37][38][39][40][41] Furthermore, after controlling for age, patients admitted from a SNF were also half as likely to be admitted to an ICU. Whereas these findings may be explained by the patient and/or family preferences, we cannot exclude the possibility that clinicians may have made informal triage decisions regarding scarce ICU beds based largely on patients' age.…”

Situation, Education, Innovation, and Recommendation: A Large-Scale Systematic Review of Advance Care Planning in the Age of COVID-19

“…The pandemic spurred an earlier initiation of ACP conversations, often influenced by media coverage and public awareness [ 45 ], but the quality of these discussions varied, with telemedicine emerging as a key but imperfect tool [ 43 , 44 ]. The variability in treatment intensity for patients with dementia [ 41 ] and the challenges in involving patients in shared decision-making [ 62 ] suggest that provider biases and systemic issues in healthcare communication persist.…”