Findings from a new study, led by researchers at Dartmouth’s Geisel School of Medicine and published in JAMA Neurology, show that higher death rates have been associated with the COVID-19 pandemic among older adults with cognitive impairment—especially in racial and ethnic minority populations and those living in nursing homes.

In 2020, COVID-19 abruptly altered the delivery of healthcare and the daily operations of nursing facilities across the U.S. These changes included a decrease in inpatient care and a transition of outpatient care to telehealth platforms. In nursing facilities, operational changes included lockdowns and strict visitation procedures, resulting in social isolation for many residents.

But the associations between those changes related to the pandemic and patient outcomes, especially in vulnerable populations, are not yet well understood.

“When you think about adult populations that are potentially most at risk for bad outcomes when things change dramatically and abruptly in healthcare, older adults with cognitive issues—like Alzheimer’s disease and related dementias (ADRD)—are at or near the top of the list,” says Lauren Gilstrap, MD, MPH, an assistant professor of The Dartmouth Institute for Health Policy and Clinical Practice and of medicine at Dartmouth’s Geisel School of Medicine, who served as lead author on the study.

“During the pandemic, mortality rates increased across most if not all segments of society—we knew that going into the study,” she continues. “Our main question was whether the increase in mortality among these more vulnerable populations was proportional or disproportional.”

To find out, the researchers conducted a cross-sectional analysis using fee-for-service data on Medicare enrollees aged 65 and older. They compared mortality rates from 26.7 million enrollees in 2020 with those of 26.9 million enrollees in 2019 in four predetermined groups: people with ADRD; people without ADRD, those with ADRD living in nursing homes, and those without ADRD in nursing homes.

The investigators found that mortality was 24 percent higher among individuals with ADRD in 2020 compared to 2019, and 14 percent higher for people without ADRD. Among nursing home residents with ADRD, mortality was 36 percent higher in 2020 compared to 2019, versus 25 percent higher for those without ADRD.

The largest increases in mortality were observed among Asian, Black, and Hispanic ADRD populations.

When the researchers measured monthly COVID-19 infection rates across the country’s 306 hospital referral regions (or service areas), they found that the areas with the lowest COVID-19 prevalence had no excess mortality among enrollees without ADRD.

But they found eight percent higher mortality among community-dwelling enrollees with ADRD and 14 percent higher mortality among enrollees with ADRD living in nursing homes in those same areas where there was very low COVID-19.

“That was the most interesting finding in the study,” says Gilstrap. “I think what that tells us is that those deaths were probably related less to COVID and more to abrupt changes in the healthcare system and how those changes altered access to both acute and chronic care as well as community support services.

“Overall, I think our findings also highlight that as a healthcare system we really do have to think about people with cognitive limitations differently, and that more creative solutions are needed to better serve this highly vulnerable segment of society.”

The research was funded by the National Institute on Aging, the National Bureau of Economic Research, and the National Heart, Lung and Blood Institute.

The Dartmouth Institute for Health Policy and Clinical Practice is a world leader in studying and advancing models for disruptive change in healthcare delivery. The work of Dartmouth Institute faculty and researchers includes developing the concept of shared decision-making between patients and healthcare professionals, creating the model for Accountable Care Organizations (ACOs), and introducing the game-changing concept that more healthcare is not necessarily better care.