Covid-19 and dementia: the health emergency within a daily and future emergency
The recent Covid-19 pandemic has had a particular impact on the elderly with dementia and in their families. In fact, these people, from one day to the next, found themselves totally isolated from their network of health, social and psychological support.
Worldwide, it is estimated that there are more than 50 million people with dementia with different diagnostic characteristics and that a new case is ascertained every 3 seconds (World Alzheimer’s report 2019). This pathology, due to syndromic peculiarities and pervasiveness of the different organic and psychic domains involved, requires a complex and articulated treatment process, aimed at welcoming and supporting medical, psychological and social needs. Having a neurodegenerative pathology means, for those affected, mostly older people over 65, to have an additional vulnerability to viral and systemic pathologies that makes these people particularly fragile.
Overall, the recent COVID-19 epidemic has caused serious threats to the physical health and life of people, but it has also been strongly impacting on the life of the elderly with dementia and their families. From one day to the next, these people found themselves totally isolated from all that health, social and psychological support network they usually received. The caregivers of these patients found themselves managing their loved ones throughout the day inside their home, when previously they had breathing moments guaranteed by home care or by attending specialist day centers. Likewise, family members of older people with dementia who resided in dedicated healthcare facilities no longer saw their relatives in person for months, if not in quick video calls or in exchanges of information conveyed by health personnel. Taken together, these elements have made elderly people with dementia subjects highly vulnerable to the Covid-19 pandemic, both for the social and welfare disadvantages due to measures of isolation and social distancing and for the high danger of possible iatrogenic outcomes in the event of viral contagion.
In a very recent Italian study, Bianchetti et al. 2020 analyzed the possible role of dementia as a mortality risk factor for the elderly affected by the virus. By adopting a retrospective study methodology, the authors used the clinical information from the registers of the COVID wards of the Brescia hospitals of 627 elderly patients hospitalized with SARS-CoV-2 pneumonia. Of the patients involved in the study, 82 had a diagnosis of dementia (13.1%). The authors used the Clinical Dementia Rating Scale (CDR) to distinguish patients in relation to the pervasiveness of cognitive impairment, identifying: 36 stage I patients ( 43.4%), 15 stage II patients (18.3%) and 31 stage III patients (37.8%). The results of this study documented a death rate of 62, 2% among patients with neurodegenerative pathology compared to 26.2% in the elderly with intact cognitive functioning. From a psychological and clinical point of view, it is interesting to note that for the elderly with Covid-19 there was a symptomatic pattern characterized by delirium (67%) especially in hypoactive form (50%) and by a general deterioration of the functional and of basic autonomies. It is also significant to report that for this particular population sample there was a lower presence of the medical symptoms usually associated with coronavirus. In fact, only 47% of patients had fever, 44% wheezing and 14% cough. The conclusive reflections of this pioneering study, within the medical and neuropsychological clinic for patients with dementia, have led to argue that the diagnosis of dementia, especially in the more advanced stages, represents an important risk factor for mortality and further reduction of functioning in COVID-19 patients. In addition, the configuration of symptoms for coronavirus dementia patients was atypical, further reducing the possibility of early recognition of symptoms in this complex population already characterized by important behavioral and communication difficulties that usually already delay the use of possible health care.
In addition to these current risk aspects, what could be the future consequences of the pandemic for people with cognitive impairment and for caregivers?
In our societies, in the last twenty years, social and economic systems have mobilized to design structures and services that at different levels help and support people with dementia and family members who take care of them. The sudden and pervasive spread of the pandemic, due to the spread of COVID-19, has led to a sudden crisis and a profound emergency situation throughout the social and welfare sector that deals with aging and in particular in professionals, structures and health care dealing with the management of older people with dementia. Many of the resources in the area have been converted for the emergency and also many of the home care and assistance, which benefited the dementia patients, have been suspended. From a psychological and well-being point of view, it is important to consider how people with dementia do not have and are not benefiting from all those non-pharmacological interventions that are promoted above all to limit the psychiatric and behavioral symptoms associated with dementia (delusions, hallucinations, depression, apathy, agitation, aggression, wandering, bustling, etc.), defined with the acronym BPSD (Behavioral and Psychological Symptoms of Dementia). As pointed out by Brown et al., 2020 in a recent work, the interventions usually proposed to manage BPSD involve physical and social contacts, impossible to exercise in these times of social distancing. The authors report that by the elderly with dementia, as a consequence of the interruption of the social stimulation network, short-term and long-term expections of BPSDs, in particular apathy and therefore an increase in the difficulties faced by caregivers, should be expected. A further risk according to Brown et al., 2020 is given by the abrupt and sudden interruption of the daily routine that this vulnerable population has suffered, like everyone else, due to the anti Covid measures. The authors highlight how, for patients with dementia, these rapid changes can lead to changes in delicate emotional balances, in particular for anxiety and anger, and in sleep-wake rhythms. As reported by Richards et al., 2005 in these patients, sleep difficulties may be further influenced by anxiety and limitations in social relationships. Feeding such vicious circles means creating a great difficulty for family caregivers. In such situations, it may be a wrong choice to insert hypnoid drugs as the latter, in addition to often creating metabolism problems due to frequent polypharmacotherapy, weaken the weak motivational system of the elderly with cognitive impairment, widening the states of apathy and further limiting the cognitive function. As reported by Ford et al., 2016, the combination of apathy and difficulty sleeping can lead to delusions, further helping to raise the morbidity and mortality index of the elderly with dementia. as well as often creating problems of metabolization due to frequent polypharmacotherapy, they weaken the weak motivational system of the elderly with cognitive impairment, widening the states of apathy and further limiting cognitive function. As reported by Ford et al., 2016, the combination of apathy and difficulty sleeping can lead to delusions, further helping to raise the morbidity and mortality index of the elderly with dementia. in addition to often creating problems of metabolization due to frequent polypharmacotherapy, they weaken the weak motivational system of the elderly with cognitive impairment, widening the states of apathy and further limiting cognitive function. As reported by Ford et al., 2016, the combination of apathy and difficulty sleeping can lead to developing delusions, further helping to raise the morbidity and mortality index of the elderly with dementia.
In conclusion, the emergency linked to the Covid-19 pandemic was and still is an important global challenge that affects every segment of the population, which must be faced with the economic, social and health resources that each society has. However, current research reports that the elderly with dementia represent a category highly at risk not only for the syndromic vulnerability that characterizes them and exposes them strongly to the iatrogenic outcomes of the virus, but also for the possible short and long-term consequences related to suspension of non-pharmacological and psychosocial management and support measures.