Study IDs factors influencing COVID-19 death risk in nursing home residents

Physical or cognitive impairment and certain comorbidities are among risk factors predicting mortality in nursing home residents with COVID-19, according to a study from the US.

“We identified several patient characteristics as being associated with mortality, including increased age, male sex, diabetes, chronic kidney disease (CKD), fever, hypoxia, shortness of breath, tachycardia, and cognitive and physical impairment,” said the authors.

“Considering all these risk factors jointly and aggregating their individual associations with risk will be important for identifying nursing home residents with COVID-19 who are at increased risk of death,” they said.

The risk of 30-day mortality increased with increasing age (odds ratio [OR], 1.46 [age 80–84 years]; OR, 1.59 [age 85–89 years], and OR, 2.14 [age ≥90 years] vs age 75–79 years). Conversely, mortality risk was lower in patients aged 70–74, 65–69, and <65 years (ORs, 0.74, 0.56, and 0.23, respectively). [JAMA Intern Med 2021;doi:10.1001/jamainternmed.2020.7968]

Thirty-day mortality risk was lower among women than men (OR, 0.69), and among Black residents (OR, 0.77) and those of other ethnicities* (OR, 0.60) vs White residents.

Mortality risk was elevated in residents with moderate or severe cognitive impairment** (ORs, 2.09 and 2.79, respectively) compared with cognitively intact residents. Physical function impairment*** was also associated with 30-day mortality with an elevated risk among patients with moderate (OR, 1.49) or severe (OR, 1.64) physical function impairment compared with none or limited impairment.

“Individuals with advanced dementia often have concurrent dysphagia, which is associated with increased risks of malnutrition, aspiration, bacterial pneumonia, and delirium, all of which complicate the course of COVID-19. These individuals generally require extensive assistance with [activities of daily living] … putting them in regular close proximity with many staff members who may be asymptomatically infected with viral strains from the community,” the authors pointed out.

“This increases not only the risk of SARS-CoV-2 transmission from staff to resident but also the risk of exposure to a higher viral load at the time of infection, which has been found to correlate with mortality risk,” they said.

Residents with diabetes (OR, 1.21) or CKD (OR, 1.33) also had an increased 30-day mortality risk. Certain COVID-19 symptoms, when included with other risk factors, were associated with an increased risk of 30-day mortality, specifically fever (OR, 1.66), shortness of breath (OR, 2.52), tachycardia (OR, 1.31), and hypoxia (OR, 2.05).

Cumulative mortality rates were increased in older residents and those with greater physical and cognitive impairment.

Using electronic medical data and nursing home infection logs, the authors identified 5,256 residents of 351 nursing homes in the US who had symptomatic (from 5 days pre- to 14 days post-testing) PCR-confirmed SARS-CoV-2 infection diagnosed between March 16 and September 15, 2020 (median age 79 years, 61 percent female, 71 percent White). There were 1,129 deaths (21 percent) within 30 days of the first positive SARS-CoV-2 test.

The authors cautioned that the findings may not be applicable to asymptomatic nursing home residents with COVID-19, in whom COVID-19 severity and clinical course may differ from symptomatic patients. Furthermore, follow-up data from more recent stages of the pandemic may be warranted to confirm the findings.