Excess Mortality Among Assisted Living Residents With Dementia During the COVID-19 Pandemic

Abstract

Objective: To evaluate whether assisted living (AL) residents with Alzheimer's disease and related dementias (ADRD) experienced a greater rate of excess all-cause mortality during the first several months of the COVID-19 pandemic compared to residents without ADRD, and to compare excess all-cause mortality rates in memory care vs general AL among residents with ADRD.

Design: Retrospective cohort study.

Setting and participants: Two cohorts of AL residents enrolled in Medicare Fee-For-Service who resided in 9-digit ZIP codes corresponding to US AL communities of ≥25 beds during calendar year 2019 or 2020.

Method: By linking Medicare claims and Vital Statistics data, we examined the weekly excess all-cause mortality rate, comparing the rate from March 12, 2020, to December 31, 2020, to the rate from January 1, 2019, to March 11, 2020. We adjusted for demographics, chronic conditions, AL community size, and county fixed effects.

Results: Of the 286,350 residents in 2019 and the 273,601 in 2020 identified in these cohorts, approximately 31% had a diagnosis of ADRD. Among all AL residents, the excess weekly mortality rate in 2020 was 49.1 per 100,000 overall during the pandemic. Compared to residents without ADRD, residents with ADRD experienced 33.4 more excess deaths per 100,000 during the pandemic. Among residents with ADRD, those who resided in memory care communities did not experience a statistically significant different mortality rate than residents who lived in general AL.

Conclusions and implications: AL residents with ADRD were more vulnerable to mortality during COVID-19 than residents without ADRD, a finding similar to those reported in other settings such as nursing homes. Additionally, the study provides important new information that residents with ADRD in memory care communities may not have been at differential risk of COVID-19 mortality when compared to residents with ADRD in general AL, despite prior research suggesting they have more advanced dementia.

Keywords: SARS-CoV-2; deaths; long-term care; memory care.

Fig. 1

The unadjusted weekly rate of excess all-cause mortality per 100,000 assisted living residents during COVID-19 comparing assisted living residents with diagnoses of ADRD to those without ADRD. Weekly unadjusted excess all-cause mortality was calculated using the Centers for Medicare & Medicaid Services Vital Status file. The calendar week began on January 1 of each year. Assisted living residents with Medicare Advantage and residents in small assisted living communities (<25 beds) were excluded. Minnesota and Connecticut were excluded because of their different licensing structures. Shaded areas represent CIs.

Fig. 2

The unadjusted weekly rate of excess mortality per 100,000 assisted living residents during COVID-19 comparing assisted living residents with ADRD in memory care and general assisted living communities. Weekly unadjusted excess all-cause mortality was calculated using the Centers for Medicare & Medicaid Services Vital Status file. The calendar week began on January 1 of each year. Assisted living residents with Medicare Advantage and residents in small assisted living communities (<25 beds) were excluded. The subsample includes 30 states in which we have information regarding whether they provide memory care. We define memory care as AL communities with a state license, designation, or certification specific to dementia care (Supplementary Table 1). Shaded areas represent CIs.

Supplementary Fig. 1

Sample selection flowchart for the analysis comparing residents with ADRD to residents without ADRD. (ADRD, Alzheimer’s disease and related dementias.)

Supplementary Fig. 2

Sample selection flowchart for subanalysis comparing residents with ADRD in memory care to residents with ADRD in general AL. (ADRD, Alzheimer’s disease and related dementias; AL, assisted living.)