Impact of COVID-19 on people living with dementia: emerging international evidence
Dear Editor,
High rates of COVID-19 related deaths in people living with dementia have been reported since the pandemic started. This is likely associated with the fact that many COVID-19 deaths correspond to care home residents, most of whom have dementia. People with dementia may be at increased risk of developing more severe COVID-19 infection (1) and die from it (2) according to studies conducted on hospital cohorts. Furthermore, carriers of ApoEε4/ε4 genotype, the strongest genetic risk factor for Alzheimer’s disease, are more likely to develop complications from COVID-19 (3). Although it remains unclear whether dementia is directly associated with the severity of COVID-19 or influenced by other factors (e.g. older age and associated comorbidity), growing evidence indicates that this population is extremely vulnerable to the effects of the virus. Not only that, but up to 5.7% of patients with severe presentation of COVID-19 have stroke, which can precipitate cognitive decline in people already living with progressive cognitive difficulties (4). To prevent infection, people with dementia have gone through confinement and isolation, both in the community and in care homes. These measures, also involving the removal of essential sources of support, care and meaningful contact with family members (including spouses and main partners in care), may have long-lasting deleterious effects. A survey conducted among patients attending an Italian memory clinic showed that up to 31% of people with dementia had experienced significant cognitive deterioration during the first month of lockdown and 54% a worsening of agitation, apathy and depression (5).
Mitigating the impact of COVID-19 on people with dementia should be a public health priority. The measures required include ensuring access to enough PPE and training on infection prevention and control for care workers, comprehensive testing policies, access to quarantine and step-down facilities, and implementation of guidance on compassionate isolation and person-centred care to lessen the psychological and cognitive detrimental effect of confinement. In many parts of the world, the rates of infection are beginning to decrease. We now have the opportunity to learn from these first experiences with COVID-19 and be better prepared so that, in future waves, people living with dementia are not left behind.
References
1. Atkins JL, Masoli JAH, Delgado J, et al. Preexisting comorbidities predicting severe COVID-19 in older adults in the UK Biobank community cohort. https://doi.org/10.1101/2020.05.06.20092700
2. Bianchetti A, Rozzini R, Guerini F., et al. Clinical presentation of COVID-19 in dementia patients. J Nutr Health Aging 24, 560-562 doi.org/10.1007/s12603-020-1389-1
3. Kuo CL, Pilling LC, Atkin JL, et al. APOE e4 Genotype predicts severe COVID-19 in the UK Biobank community cohort. The journals of Gerontology: series A, glaa131: https://doi.org/10.1093/gerona/glaa131
4. Mao L, Huijuna J, Wang M et al., Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020;77(6):683-690. doi:10.1001/jamaneurol.2020.1127
5. Canevelli m, Valleta M, Toccaceli M., et al. Facing dementia during the covid-19 outbreak. J Am Geriatr Soc. 2020 Jun 9. doi: 10.1111/jgs.16644.
Funding: ASG is supported by the ESRC/NIHR Dementia Research Initiative (ES/S010467/1). ACH is supported by the UK Research and Innovation’s Global Challenges Research Fund (ES/P010938/1).
Competing interests:
GL and ACH report no competing interests. ASG reports fees from MedAvante Pro-Phase. All reported financial activities are unrelated to this correspondence.
29 June 2020
Aida Suárez-González
Clinical Neuropsychologist and Senior Research Associate
Adelina Comas-Herrera (Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science), Gill Livingston (Division of Psychiatry, University College London, UK; Camden and Islington NHS Foundation Trust, London, UK)
Dementia Research Centre, UCL Institute of Neurology at Queen Square, University College London
Dementia Research Centre, box 16, 8-11 Queen Square, London WC1N 3BG
Rapid Response:
Impact of COVID-19 on people living with dementia: emerging international evidence
Dear Editor,
High rates of COVID-19 related deaths in people living with dementia have been reported since the pandemic started. This is likely associated with the fact that many COVID-19 deaths correspond to care home residents, most of whom have dementia. People with dementia may be at increased risk of developing more severe COVID-19 infection (1) and die from it (2) according to studies conducted on hospital cohorts. Furthermore, carriers of ApoEε4/ε4 genotype, the strongest genetic risk factor for Alzheimer’s disease, are more likely to develop complications from COVID-19 (3). Although it remains unclear whether dementia is directly associated with the severity of COVID-19 or influenced by other factors (e.g. older age and associated comorbidity), growing evidence indicates that this population is extremely vulnerable to the effects of the virus. Not only that, but up to 5.7% of patients with severe presentation of COVID-19 have stroke, which can precipitate cognitive decline in people already living with progressive cognitive difficulties (4). To prevent infection, people with dementia have gone through confinement and isolation, both in the community and in care homes. These measures, also involving the removal of essential sources of support, care and meaningful contact with family members (including spouses and main partners in care), may have long-lasting deleterious effects. A survey conducted among patients attending an Italian memory clinic showed that up to 31% of people with dementia had experienced significant cognitive deterioration during the first month of lockdown and 54% a worsening of agitation, apathy and depression (5).
Mitigating the impact of COVID-19 on people with dementia should be a public health priority. The measures required include ensuring access to enough PPE and training on infection prevention and control for care workers, comprehensive testing policies, access to quarantine and step-down facilities, and implementation of guidance on compassionate isolation and person-centred care to lessen the psychological and cognitive detrimental effect of confinement. In many parts of the world, the rates of infection are beginning to decrease. We now have the opportunity to learn from these first experiences with COVID-19 and be better prepared so that, in future waves, people living with dementia are not left behind.
References
1. Atkins JL, Masoli JAH, Delgado J, et al. Preexisting comorbidities predicting severe COVID-19 in older adults in the UK Biobank community cohort. https://doi.org/10.1101/2020.05.06.20092700
2. Bianchetti A, Rozzini R, Guerini F., et al. Clinical presentation of COVID-19 in dementia patients. J Nutr Health Aging 24, 560-562 doi.org/10.1007/s12603-020-1389-1
3. Kuo CL, Pilling LC, Atkin JL, et al. APOE e4 Genotype predicts severe COVID-19 in the UK Biobank community cohort. The journals of Gerontology: series A, glaa131: https://doi.org/10.1093/gerona/glaa131
4. Mao L, Huijuna J, Wang M et al., Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020;77(6):683-690. doi:10.1001/jamaneurol.2020.1127
5. Canevelli m, Valleta M, Toccaceli M., et al. Facing dementia during the covid-19 outbreak. J Am Geriatr Soc. 2020 Jun 9. doi: 10.1111/jgs.16644.
Funding: ASG is supported by the ESRC/NIHR Dementia Research Initiative (ES/S010467/1). ACH is supported by the UK Research and Innovation’s Global Challenges Research Fund (ES/P010938/1).
Competing interests: GL and ACH report no competing interests. ASG reports fees from MedAvante Pro-Phase. All reported financial activities are unrelated to this correspondence.