key: cord-0936357-rnyezeo6 authors: Bielza, Rafael; Sanz, Juan; Zambrana, Francisco; Arias, Estefanía; Malmierca, Eduardo; Portillo, Laura; Thuissard, Israel J.; Lung, Ana; Neira, Marta; Moral, María; Andreu-Vázquez, Cristina; Esteban, Ana; Ramírez, Marcela Irma; González, Laura; Carretero, Guillermo; Moreno, Ricardo Vicente; Martínez, Pilar; López, Javier; Esteban-Ortega, Mar; García, Isabel; Vaquero, María Antonia; Linares, Ana; Gómez-Santana, Ana; Cerezo, Jorge Gómez title: Clinical Characteristics, Frailty, and Mortality of Residents With COVID-19 in Nursing Homes of a Region of Madrid date: 2020-12-11 journal: J Am Med Dir Assoc DOI: 10.1016/j.jamda.2020.12.003 sha: 370f9ce764568ea3f5943ac701f524859a7c5ff7 doc_id: 936357 cord_uid: rnyezeo6 OBJECTIVES: To describe the clinical characteristics, 30-day mortality, and associated factors of patients living in nursing homes (NH) with COVID-19, from March 20 to June 1, 2020. DESIGN: This is a retrospective study. A geriatric hospital-based team acted as a consultant and coordinated the care of older people living in NHs from the hospital. SETTING AND PARTICIPANTS: A total of 630 patients aged 70 and older with Coronavirus Disease 2019 COVID-19 living in 55 NHs. METHODS: A logistic regression was performed to analyze the factors associated with mortality. In addition, Kaplan-Meier curves were applied according to mortality and its associated factors using the log-rank Mantel-Cox test. RESULTS: The diagnosis of COVID-19 was mainly made by clinical compatibility (N = 430). Median age was 87 years, 64.6% were women and 45.9% were transferred to be cared for at the hospital. A total of 282 patients died (44.7%) within the 30 days of first attention by the team. A severe form of COVID-19 occurred in 473 patients, and the most frequent symptoms were dyspnea (n = 332) and altered level of consciousness (n = 301). According to multiple logistic regression, male sex (P = .019), the Clinical Frailty Score (CFS) ≥6 (P = .004), dementia (P = .012), dyspnea (P < .001), and having a severe form of COVID-19 (P = .001), were associated with mortality, whereas age and care setting were not. CONCLUSIONS AND IMPLICATIONS: Mortality of the residents living in NHs with COVID-19 was almost 45%. The altered level of consciousness as an atypical presentation of COVID-19 should be considered in this population. A severe form of the disease, present in more than three-quarters of patients, was associated with mortality, apart from the male sex, CFS ≥6, dementia, and dyspnea, whereas age and care setting were not. These findings may also help to recognize patients in which the Advance Care Planning process is especially urgent to assist in the decisions about their care. Conclusions and Implications: Mortality of the residents living in NHs with COVID-19 was almost 45%. The altered level of consciousness as an atypical presentation of COVID-19 should be considered in this population. A severe form of the disease, present in more than three-quarters of patients, was associated with mortality, apart from the male sex, CFS !6, dementia, and dyspnea, whereas age and care setting were not. These findings may also help to recognize patients in which the Advance Care Planning process is especially urgent to assist in the decisions about their care. Ó 2020 Published by Elsevier Inc. on behalf of AMDA e The Society for Post-Acute and Long-Term Care Medicine. The World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) a public health emergency of international concern on March 11, 2020. 1e3 The clinical range of this infectious disease varies from asymptomatic to critical cases, 4,5 the older population being the group with the highest risk of hospitalization and mortality. 6e8 In this regard, the impact of COVID-19 on older people living in nursing homes (NHs) has been particularly serious at national and international scales. 9 By June 23, it is estimated that a total of 19,553 people with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have died in NHs during the COVID-19 pandemic in Spain, representing 68.1% of all confirmed deaths from COVID-19 in our country. 9 Living in community, the lack of personal protective equipment for workers or the health vulnerability due to frequent conditions like frailty, dependence, dementia or high burden of comorbidities are some of the factors that have contributed to the expansion and lethality of the virus in this setting. 10 With respect to clinical symptoms in older individuals, they also present cough, dyspnea and fever as the most common, whereas delirium, lower temperature, and abdominal pain have been described as atypical presentations as compared with younger patients. 11 However, data in this particular group of patients living in NHs are still scarce and come from subgroup analysis in observational studies. 12 This research aims to describe the clinical characteristics, 30-day mortality, and risk factors for mortality in older patients with COVID-19 living in NHs in the area of influence of a hospital in the region of Madrid during the first wave of the COVID-19 pandemic, from March 20 to June 1, 2020. In March 2020, the Health Authorities of Madrid created the position of the geriatric hospital-based team to act as a consultant to the NH physicians and coordinate the care of older people living in these settings from the hospital, covering from 8 AM to 10 PM, 7 days a week. In this hospital, a working group was constituted, including 5 geriatricians and 14 other health care workers. The geriatric hospital-based team assessed residents at the request of the NH physicians, who provided a first description of the present illness, mainly by telephone. Additional information was obtained from the electronic health record (EHR) used in Madrid for primary and tertiary care integration. The decisions about the management of the patients had to take into account both the characteristics of the NH (whether that center had a qualified doctor, a 24-hour nurse, and the available material, mainly oxygen, drugs, and nursing equipment) and the situation of residents (the comprehensive geriatric assessment and the clinical presentation). If the patient could be adequately attended at the NH, it was recommended that he or she remained there, and if not, they were referred to the hospital. The transmission of information to patients and their relatives was carried out by the staff of the NH. After this initial evaluation, the necessary clinical procedures were carried out, that is, request for ambulances, the delivery of oxygen and hospital medications, the adjustment of oral treatments in the EHR and, when needed, the mobilization of human resources. The prescription included a treatment regimen for 5 days for each patient with the dosage, schedule, and form of administration: This individual package was delivered from the hospital to the NH and included (1) antibiotics, (2) fluid therapy, (3) enoxaparin, (4) hydroxychloroquine, (5) paracetamol, and (6) inhalers. In addition, frequent supplies of palliative drugs and steroids were also provided to be used when the patient suffered from distress or sepsis according to the WHO recommendation at that time. 13 The therapeutic protocol for COVID-19 in the NH was agreed with the Department of Infectious Diseases and was in common with that of the hospital. Updates to the protocol were communicated periodically to the NH physicians. Any changes in the clinical situation of a resident or members of the staff of the NH were evaluated and the appropriate clinical decisions were taken. The study population consisted of the residents attended by the geriatric hospital-based team of a public university hospital during the period of the COVID-19 pandemic, from March 20 to June 1, 2020. This hospital covers a population of 312,000 inhabitants in the north of Madrid, including 55 NHs with nearly 4200 older residents. This is a descriptive, observational, retrospective, and longitudinal study. We included only patients aged 70 and older with COVID-19 attended by the geriatric hospital-based team. We excluded those attended by the team with not enough data in the EHR to obtain a diagnosis of COVID-19. The study complied with good clinical practice standards set forth in the Declaration of Helsinki of 1975 and was approved by the relevant institutional review boards: Ethical and Research Committee of the hospital (reference, HULP4178). Mortality rate within 30 days after the first geriatric hospital-based team attention in patients diagnosed with COVID-19 was our main outcome. The diagnosis of COVID-19 was made based on positive SARS-CoV-2 polymerase chain reaction (PCR), positive serology, or clinical compatibility (at least 1 of the following symptoms at the initial evaluation: fever, arthromyalgia, headache, upper respiratory tract symptoms, dyspnea, epileptic seizures, chest pain, abdominal pain, cough, nausea or vomiting, diarrhea, hemoptysis, ageusia, or anosmia). We categorized a case as severe when any of the following were initially present: temperature >38 , systolic blood pressure <100 mm Hg, heart rate >100 beats per minute, basal saturation less than 90%, respiratory rate >30 per minute, or altered level of consciousness. 13, 14 We also recorded age, sex, previous intake of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and the presence of any of the following comorbidities: hypertension, cirrhosis, diabetes, chronic renal disease, obesity, chronic neurological disease, active smoking, heart failure, chronic inflammatory disease, ischemic heart disease, solid neoplasm, hematological neoplasm, chronic obstructive pulmonary disease (COPD), or sleep apnea syndrome. With respect to the comprehensive geriatric assessment, the previous Barthel Index (BI) 15 and the cognitive status according to the Global Deterioration Scale were collected. 16 Frailty was assessed through the Rockwood Clinical Frailty Scale (CFS), taking into account the preexisting level of function and mobility, considering the usual cutoff points, from (1) very fit to (9) terminally ill. 17 The treatments used were grouped into (1) antibiotics (ie, ceftriaxone 2 g intravenous, azithromycin 500 mg or cefixime 400 mg), (2) fluid therapy, (3) enoxaparin, (4) hydroxychloroquine, and (5) inhalers. Finally, we recorded whether the patient was being treated in the hospital or in the NH. If in the hospital, we additionally recorded length of stay and whether the patient was re-admitted within the first 30 days after their first care. Results for continuous and categorical variables are reported as median and interquartile range and number (percentage), respectively. Differences between survivors and nonsurvivors, patients admitted to the hospital and those who were not, and those classified as severe and mild cases were examined using the Mann-Whitney U test and the c 2 test for continuous and categorical variables, respectively. Multiple logistic regression was carried out to assess factors associated with mortality. We explored and found association between the tools that explore functional domains (ie, CFS and BI), through Spearman's rho correlation test, including only the CFS in the multiple logistic regression. Therefore in the model, the mortality was adjusted for age, sex, hospital admission, CFS !6, dementia, hypertension, COPD, sleep apnea syndrome, dyspnea, epileptic seizures, abdominal pain, cough, anosmia, and severe case. Finally, Kaplan-Meier curves were made for overall survival and for the main factors associated with mortality, applying a log-rank Mantel-Cox test. The existence of statistical significance was considered when the P value was less than .05. The analysis was performed with IBM SPSS Statistics program version 21.0 (IBM Corp., Armonk, NY). Of the 841 patients attended by the geriatric hospital-based team, 630 presented COVID-19 and complied with the criteria for inclusion in the study. Most of the diagnoses were based on clinical compatibility (n ¼ 430) with the disease (Figure 1 ). The median age was 87 years (82.9e91.1) and 407 were women (64.6%). As shown in Table 1 , the median of comorbidities per patient was 2 (1e3) and the most frequent were hypertension (n ¼ 408, 64.8%), chronic neurological disease (n ¼ 67, 10.6%), diabetes (n ¼ 110, 17.5%), heart failure (n ¼ 69, 11%), chronic renal disease (n ¼ 67, 10.6%), and ischemic heart disease (n ¼ 64, 10.2%). The most frequent symptoms at presentation were dyspnea (n ¼ 332, 52.7%), altered level of consciousness (n ¼ 301, 47.8%), fever (n ¼ 243, 38.6%), and cough (n ¼ 101, 16.3%). Regarding the treatment regimen, 354 patients (56.9%) received antibiotics, 296 fluid therapy (47%), 466 inhalers (74%), 502 enoxaparin (79.7%), and 91 hydroxychloroquine (14.4%). A total of 289 patients (45.9%) were transferred and treated at the hospital, and 341 (54.1%) remained in the NH. Table 2 shows that in the NH, the disease was less often diagnosed by PCR than in the hospital (13.5 vs 48.8, percentage). Patients attended at the NH were significantly older (88 vs 87, median age), frailer (CFS 7 vs CFS 6, median), presented a lower BI (30 vs 45, median), more frequently had dementia (57. 8 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 Results are expressed as n (%) or median (Q1eQ3). *Severe case if any of the following were present: temperature >38 , systolic blood pressure <100 mm Hg, heart rate >100 beats per minute, basal saturation less than 90%, respiratory rate >30 per minute, altered level of consciousness. Results are expressed as n (%) or median (Q1eQ3). *Severe case if any of the following were present: temperature >38 , systolic blood pressure <100 mm Hg, heart rate >100 beats per minute, basal saturation less than 90%, respiratory rate >30 breaths per minute, altered level of consciousness. 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 We identified 473 patients (75.08%) presenting with a severe form of the disease. In these cases, dementia was significantly more frequent (52. 2 Figure 2 ). There were no differences in any of the comorbidities between the groups. Nonsurvivors showed a higher temperature (37.7 vs 37.2 , median), higher respiratory rate (27 vs 21.5, median), and higher heart rate per minute (87 vs 84, median). Moreover, basal saturation (88% vs 92%, median) and systolic blood pressure were lower (110 mm Hg vs 120 mm Hg, median) in nonsurvivors. As expected, severe cases (87.2% vs 65.2%) were more frequent in nonsurvivors. However, there were no statistically significant differences in the mortality of patients attended at the NH or in the hospital. A Spearman correlation between BI and CFS scales was established with an r ¼ À0.974, and therefore we just include CFS in the logistic regression analyses as a measurement of functional status of the patient. According to logistic regression analyses (Figure 2 ), male sex, dementia, dyspnea, presenting a severe form of the illness, and the CFS !6 were factors significantly associated with mortality. No multiplicative interactions were found between CFS, dyspnea and severe case. In Figure 3 , survival curves according to overall survival and Kaplan-Meier curves were made with the main factors associated with mortality applying a log-rank Mantel-Cox test. To our knowledge, this is the first study that provides information about clinical characteristics and outcome of older residents of NHs with COVID-19 attended by a geriatric hospital-based team. Disappointingly, almost 45% of the patients died within 30 days of the first attendance. Fever, dyspnea, cough, and altered level of consciousness were the most frequent symptoms at presentation. Approximately three-quarters of the residents showed a severe form of COVID-19. Male sex, CFS score !6, dementia, dyspnea, and having a severe clinical form of COVID-19 were factors associated with mortality, whereas the age and the setting in which the resident was treated had no impact on mortality. The high number of deaths in the NH have been a critical piece of the worldwide pandemic numbers, with 19% to 72% of COVID-19 deaths occurring in these settings. 9, 18 Particularly in Madrid, from March 8 to April 19, 2020, 19% of older patients (n ¼ w8300 cases) living in these facilities died, a sixfold increase compared with the same period in previous years. 19 The high mortality we reported in our study (44.76%) is consistent with previous publications on hospitalized patients with COVID-19 aged 80 and older. 6, 20, 21 However, it contrasts with the 22.4% shown in a coordinated on-site medicalization program conducted in 4 care homes of Seville with 272 residents, where only 23.5% of patients were hospitalized, suggesting that the population did not present forms of COVID-19 as severe as ours. 22 Moreover, according to preliminary results, approximately 60% of the older population living in care facilities in Madrid have humoral immunity to SARS-CoV-2, implying that approximately 2500 residents in our area of influence would have been affected by COVID-19. 23 These data suggest that we may have attended more severe cases and, therefore, with worse prognosis. According to recent studies, and in line with our findings, delirium has been described as a clinical manifestation in older patients with COVID-19. 11, 24 In this regard, we did not evaluate the other items of the Confusion Assessment Method (ie, acute and fluctuating course, inattention, or disorganized thinking); however, we suspect that the incidence of delirium was high due to the large number of patients presenting altered level of consciousness and the prevalence of dementia in our sample. These data also reveal the importance of identifying atypical presentations of this disease in the older population. 25 According to the literature and in consonance with our results, frailty or dementia are factors associated with mortality more than age or comorbidities in older patients with COVID-19. 11, 26, 27 These are very common conditions in older residents in NHs, typically leading to frequent visits to emergency departments and admissions to hospital in a nonpandemic. 28 Several issues regarding how to better care for this population have become even more compelling during the pandemic, many related to adequately identifying which patients benefit from hospitalization. The risk/benefit of hospitalizations of older residents living in NHs, the medicalization of these facilities, and the screening tools for an adequate referral to the hospital are unresolved issues of paramount importance during the COVID-19 pandemic. 29 The similar mortality observed in residents treated with the same therapeutic protocol for SARS-CoV-2 in both settings suggests that the comprehensive and tailored intervention by the geriatric hospital-based team were appropriate. However, advance care planning was absent in most of the residents evaluated, a tool that should be included to improve the care and decision-making process. 30 In addition to being retrospective, our study is limited by the fact that the disclosure of the SARS-CoV-2 protocol in care facilities allowed the NH physicians to manage mild cases that are not included in our registry. Of note, the availability of a stock of palliative medicines and corticoids did not allow monitoring the end-of-life scenario in the NH, whose adequate management is essential in this lethal disease and in some cases may alter outcomes. 31 Almost 45% of the older patients with COVID-19 living in NHs died within 30 days of the first contact with the geriatric hospital-based team. Apart from the classical symptoms, altered level of consciousness is an atypical presentation of COVID-19 and should be taken into account for its diagnosis. Approximately three-quarters of the residents showed a severe form of COVID-19 that was associated with higher mortality. Sex, CFS score !6, dementia, and dyspnea were factors that contributed to increased mortality, whereas the age and whether the patient was treated in the hospital or in the NH had no impact on mortality. These findings may also help to recognize patients in which the advance care planning process is especially urgent to assist in the decisions about their care. 891 892 893 894 895 896 897 898 899 900 901 902 903 904 905 906 907 908 909 910 911 912 913 914 915 916 917 918 919 920 921 922 923 924 925 926 927 928 929 930 931 932 933 934 935 936 937 938 939 940 941 942 943 944 945 946 947 948 949 950 951 952 953 954 021 022 023 024 025 026 027 028 029 030 031 032 033 034 035 036 037 038 039 040 041 042 043 044 045 046 047 048 049 050 051 052 053 054 055 056 057 058 059 060 061 062 063 064 065 066 067 068 069 070 071 072 073 074 075 076 077 078 079 080 081 082 083 084 085 1086 1087 1088 1089 1090 1091 1092 1093 1094 1095 1096 1097 1098 1099 1100 1101 1102 1103 1104 1105 1106 1107 1108 1109 1110 1111 1112 1113 1114 1115 1116 1117 1118 1119 1120 1121 1122 1123 1124 1125 1126 1127 1128 1129 1130 1131 1132 1133 1134 1135 1136 1137 1138 1139 1140 1141 1142 1143 1144 1145 1146 1147 1148 1149 1150 Supplementary Results are expressed as n (%) or median (Q1-Q3). *Severe case if any of the following were present: temperature >38 , systolic blood pressure <100 mm Hg, heart rate >100 beats per minute, basal saturation less than 90%, respiratory rate >30 per minute, altered level of consciousness. 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 1211 1212 1213 1214 1215 1216 1217 1218 1219 1220 1221 1222 1223 1224 1225 1226 1227 1228 1229 1230 1231 1232 1233 1234 1235 1236 1237 1238 1239 1240 1241 1242 1243 1244 1245 1246 1247 1248 1249 1250 1251 1252 1253 1254 1255 1256 1257 1258 1259 1260 1261 1262 1263 1264 1265 1266 1267 1268 1269 1270 Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China Clinical characteristics of novel coronavirus cases in tertiary hospitals in Hubei Province Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study Clinical characteristics of coronavirus disease 2019 in China Clinical features of COVID-19 in elderly patients: A comparison with young and middle-aged patients Mortality in older patients with Covid-19 Risk factors for mortality in 244 older adults with COVID-19 in Wuhan, China: A retrospective study The effect of age on mortality in patients with COVID-19: A meta-analysis with 611,583 subjects Mortality associated with COVID-19 outbreaks in care homes: Early international evidence. 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A comparative cohort study in nursing homes outbreaks Prevalence and prognostic value of delirium as the initial presentation of COVID-19 in the elderly with dementia: An Italian retrospective study Typically atypical: COVID-19 presenting as a fall in an older adult Frailty and mortality in hospitalized older adults with COVID-19: Retrospective observational study The effect of frailty on survival in patients with COVID-19 (COPE): A multicentre, European, observational cohort study Assessment tools for determining appropriateness of admission to acute care of persons transferred from long-term care facilities: A systematic review Rationing limited healthcare resources in the COVID-19 era and beyond: Ethical considerations regarding older adults Commentary: COVID in care homes-challenges and dilemmas in healthcare delivery The role and response of primary healthcare services in the delivery of palliative care in epidemics and pandemics: A rapid review to inform practice and service delivery during the COVID-19 pandemic We thank all the staff of the Pharmacy, Palliative Care, Urology, General Surgery, Ophthalmology, Neurology, Orthopedics, Endocrinology, Dermatology, and Rehabilitation departments who participated in the geriatric hospital team. The authors also express their acknowledgment to Manuel Freire and the Admission Department of the Infanta Sofía University Hospital for the collection of the hospital discharge reports, and to the Department of Internal Medicine and Infectious Diseases for the design of the therapeutic protocols of COVID-19, to Cristina García for providing the results of the PCR-SARS-CoV-2 test of the sample, to José Manuel Bautista for making the laboratory of the Complutense University of Madrid available to the nursing homes for the performance of the PCR test, to Belén Ubach and Gonzalo Serralta for collaborating in the design of the assistance protocol, and to Álvaro Leal for the data collection work. Finally, we thank all the staff working in the nursing homes for their hard daily work with the elderly patients during the pandemic period. Characteristics of the Population According to the Severity of COVID-