COVID-19 mortality risk factors in older people in a long-term care center

Heras, Elena de las; Garibaldi, Pablo; Boix, Maite; Valero, Oliver; Castillo, Jorge J.; Curbelo, Yurisan; Gonzalez, Elso; Mendoza, Obilagilio; Anglada, María Isabel González; Miralles, Joan Carles; Llull, Petra; Llovera, Ricard; Piqué, Josep M.

doi:10.1007/s41999-020-00432-w

Cited by 54 publications

(49 citation statements)

References 31 publications

(34 reference statements)

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“…Incidence, demographic associations [ 20 ], transmission and symptom status [ 9 , 10 , 11 , 12 , 13 , 15 , 16 , 19 ], and atypical presentation [ 17 , 18 , 21 ] in LTCF residents are widely discussed in the literature [ 14 ]. Less attention was paid to the clinical patterns of COVID-19 in LTCF residents, as it relates to mortality outcomes, and those that did were not in exclusively outpatient settings [ 22 , 23 ]. The unique combination of a congregate outpatient setting, staff interaction, and resident characteristics suggests differences in exposure, illness course, and risk of sequelae like venous thromboembolisms, when compared to hospitalized or community-dwelling patients [ 35 ].…”

Section: Discussionmentioning

confidence: 99%

“…Existing studies on COVID-19 outbreaks in the institutionalized elderly largely focus on epidemiological characteristics [ 9 , 10 , 11 , 12 ] and clinical symptoms related to initial presentation and transmission [ 13 , 14 , 15 , 16 , 17 , 18 ]. Few studies assessed the clinical course and past initial symptom status of residents, as it relates to mortality outcomes [ 19 , 20 , 21 ], especially in a non-hospital setting [ 22 , 23 ], with an infection and mortality rate as high as those documented here. In this study, we report a COVID-19 outbreak among 116 residents of a nursing home with a very high infection and mortality rates, with a specific focus on the clinical presentation and characteristics associated with mortality.…”

Section: Introductionmentioning

confidence: 99%

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Clinical Presentation, Course, and Risk Factors Associated with Mortality in a Severe Outbreak of COVID-19 in Rhode Island, USA, April–June 2020

et al. 2020

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Long-term care facilities (LTCFs) have had a disproportionally high mortality rate due to COVID-19. We describe a rapidly escalating COVID-19 outbreak among 116 LTCF residents in Rhode Island, USA. Overall, 111 (95.6%) residents tested positive and, of these, 48 (43.2%) died. The most common comorbidities were hypertension (84.7%) and cardiovascular disease (84.7%). A small percentage (9%) of residents were asymptomatic, while 33.3% of residents were pre-symptomatic, with progression to symptoms within a median of three days following the positive test. While typical symptoms of fever (80.2%) and cough (43.2%) were prevalent, shortness of breath (14.4%) was rarely found despite common hypoxemia (95.5%). The majority of patients demonstrated atypical symptoms with the most common being loss of appetite (61.3%), lethargy (42.3%), diarrhea (37.8%), and fatigue (32.4%). Many residents had increased agitation (38.7%) and anxiety (5.4%), potentially due to the restriction measures or the underlying mental illness. The fever curve was characterized by an intermittent low-grade fever, often the first presenting symptom. Mortality was associated with a disease course beginning with a loss of appetite and lethargy, as well as one more often involving fever greater than 38 °C, loss of appetite, altered mental status, diarrhea, and respiratory distress. Interestingly, no differences in age or comorbidities were noted between survivors and non-survivors. Taking demographic factors into account, treatment with anticoagulation was still associated with reduced mortality (adjusted OR 0.16; 95% C.I. 0.06–0.39; p < 0.001). Overall, the clinical features of the disease in this population can be subtle and the symptoms are commonly atypical. However, clinical decline among those who did not survive was often rapid with patients expiring within 10 days from disease detection. Further studies are needed to better explain the variability in clinical course of COVID-19 among LTCF residents, specifically the factors affecting mortality, the differences observed in symptom presentation, and rate of clinical decline.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Clinical Presentation, Course, and Risk Factors Associated with Mortality in a Severe Outbreak of COVID-19 in Rhode Island, USA, April–June 2020

et al. 2020

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“…Several conditions are associated with increased virus susceptibility and worse outcomes, advanced age being the most important. In elderly patients, mortality associated with COVID-19 varies widely among different countries, but patients older than 65 consistently comprise the majority of total deaths [ 2 , 3 , 4 , 5 ]. Mortality, in this subset of the population, is reported to be 8–36%, depending on the country and age interval analyzed [ 2 , 3 , 4 , 5 , 6 ].…”

Section: Introductionmentioning

confidence: 99%

Impact of Chronic RAAS Use in Elderly COVID-19 Patients: A Retrospective Analysis

Oliveira

Gameiro

Bernardo

et al. 2021

JCM

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Corona Virus Disease-19 (COVID-19) recently emerged as a global pandemic. Advanced age is the most important risk factor for increased virus susceptibility and worse outcomes. Many older adults are currently treated with renin–angiotensin–aldosterone system (RAAS) inhibitors and there is concern that these medications might increase the risk of mortality by COVID-19. This is a retrospective cohort of 346 patients older than 65 years with COVID-19, at the Department of Medicine of the Centro Hospitalar Universitário Lisboa Norte, in Portugal, hospitalized between March 2020 and August 2020. Mean age was 80.9 ± 8.7 years old. Most patients had arterial hypertension (n = 279, 80.6%), almost half (n = 161, 46.5%) had cardiovascular disease and approximately one-third of patients had heart failure (n = 127, 36.7%) or diabetes Mellitus (n = 113, 32.7%). Ninety-eight patients (28.3%) had chronic kidney disease and almost half of the patients (49.4%) were chronically under renin–angiotensin–aldosterone system (RAAS) inhibitors. Twenty percent of patients died during hospitalization. In a multivariate analysis, older age (OR 1.11, 95% CI 1.04, 1.18, p = 0.002), absence of baseline medication with RAAS inhibitors (OR 0.27, 95% CI 0.10, 0.75, p = 0.011), higher serum ferritin (OR 1.00, 95% CI 1.00, 1.00, p = 0.003) and higher lactate levels (OR 1.08, 95% CI 1.02, 1.14, p = 0.006) were independent predictors of mortality. Older age, higher serum ferritin and lactate levels at admission were found to be independent predictors of mortality and might act as early predictors of worsening disease in clinical practice. Chronic treatment with RAAS inhibitors appeared to be protective, supporting guidelines in not discontinuing such drugs.

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“…Heras et al reported on COVID-19 patients from a single nursing home in Spain. 4 This was designed as a retrospective cohort case-controlled analysis. There were 100 confirmed cases and a medicalization approach to treatment had been carried out in 83 subjects.…”

Section: Resultsmentioning

confidence: 99%

Early Multidrug Outpatient Treatment of SARS-CoV-2 Infection (COVID-19) and Reduced Mortality Among Nursing Home Residents

Alexander

Armstrong²,

Fareed

et al. 2021

Preprint

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The outbreak of COVID-19 from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread all over the world with tremendous morbidity and mortality in the elderly. In-hospital treatment addresses the multifaceted nature of the illness including viral replication, cytokine storm, and endothelial injury with thrombosis. We identified nine reports of early treatment outcomes in COVID-19 nursing home patients. Multi-drug therapy including hydroxychloroquine with one or more anti-infectives, corticosteroids, and antithrombotic agents can be extended to seniors in the nursing home setting without hospitalization. Data from nine studies found multidrug regimens relying on the use of hydroxychloroquine as well as other agents including doxycycline were associated with a statistically significant and >60% reductions in mortality. Going forward, we theorize and based on the evidence, that early empiric treatment for the elderly with COVID-19 in the nursing home setting (or similar congregated settings with elderly residents/patients) has a genuine probability of success and acceptable safety. This group remains our highest at-risk group and warrants acute treatment focus that will prevent the development and/or worsening of problems associated with COVID-19, most particularly isolation, hospitalization, and death. In fact, with the rapidity and severity of SARS-CoV-2 outbreaks in nursing homes, in-center treatment of patients with acute COVID-19 is possibly the most rational and importantly feasible strategy to reduce the risks of hospitalization and death. If the approach remains ‘wait-and-see’ and elderly high-risk patients in such congregated nursing room type settings are allowed to worsen with no early treatment, they may be too sick and fragile to benefit from in-hospital therapeutics and are at risk for pulmonary failure, life-ending micro-thrombi of the lungs, kidneys etc. We put forth the notion that the most important factor in this regard, is making available early therapeutic intervention as described here. These drugs include and under supervision by skilled doctors, combination/sequenced ivermectin, hydroxychloroquine, colchicine, azithromycin, doxycycline, bromhexine hydrochloride, and favipiravir (outside the US), along with inhaled steroids such as budesonide and oral steroids including dexamethasone and prednisone, and anti-thrombotic anti-clotting drugs such as heparin). As the clinical trials data on treatments for COVID-19 mature, this early treatment therapeutic option deserves serious, urgent, and sober consideration by the medical establishment and respective decision-makers.

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COVID-19 mortality risk factors in older people in a long-term care center

Cited by 54 publications

References 31 publications

Clinical Presentation, Course, and Risk Factors Associated with Mortality in a Severe Outbreak of COVID-19 in Rhode Island, USA, April–June 2020

Clinical Presentation, Course, and Risk Factors Associated with Mortality in a Severe Outbreak of COVID-19 in Rhode Island, USA, April–June 2020

Impact of Chronic RAAS Use in Elderly COVID-19 Patients: A Retrospective Analysis

Early Multidrug Outpatient Treatment of SARS-CoV-2 Infection (COVID-19) and Reduced Mortality Among Nursing Home Residents

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