COVID-19 infection,  which is spreading at an alarming pace throughout the world, has already reached the majority of states in the USA. Updates and announcements are suggesting we all avoid exposure by minimizing travel and exposure to large groups of people, washing hands often and carefully, and self-quarantining if symptoms develop. Mortality risk for this coronavirus appears to be more than a hundred times as great as for the flu, so preventing spread is our best defense while we await more test kits and more definitive treatments. In children, the symptoms of infection are usually mild and the large majority of healthy adults will recover from infection as well. Older adults, though, are at risk for severe disease with this virus and we will need to be especially attentive to those who suffer from dementia.

Cognitive impairment is likely to make people with dementia an easier target for coronavirus infection. Hand hygiene, which is difficult enough for those of us with normal memory, will be a real problem for people with significant memory impairment. Covering coughs, too, requires alertness and executive function.  Judgment about exposure and keeping an adequate distance from others may be impaired in people with cognitive difficulties. Reporting symptoms, too, presents a potential hazard. People with dementia can manifest symptoms while remaining unaware of them, or they may experience discomfort without remembering to tell someone. Given that coronavirus is infectious for as long as 2 days to 2 weeks prior to symptoms, the close quarters in long term care facilities puts these institutions at significant risk for disease spread, much like the cruise ships where infection has been so difficult to contain. For the same reasons that persons with dementia are more vulnerable to catching coronavirus, they will be at greater risk for spreading the disease to others. In groups, the hygiene issues and diminished judgment about exposure will increase the risk for transmitting infection.

Once infected, people with dementia are likely to be at greater risk for complications such as pneumonia and respiratory distress. Amongst those infected, the average age of those who have died is in the mid-70’s. Those at greatest risk have pre-existing health problems such as chronic obstructive pulmonary disease or cardiovascular disease. Older adults and particularly those with dementia often live with chronic pulmonary and cardiac diseases which diminish their ability to recover from an acute illness. The aging immune system, too, is less able to fight off an infection. People with dementia may be compromised in their ability to cooperate with the care that helps restore an infected person to health.

Given these concerns, what can we do to protect our elders and especially those with dementia? Minimizing exposure, to begin with, is going to be very important. A person with dementia, at this risky time, should not be exposed unnecessarily to public transportation, large crowds, or unnecessary visitors who may be carrying the virus. Many older adults with dementia are cared for in their own homes or in the homes of family members and their caregivers will need to be scrupulous about avoiding their own exposure in the outside world, handwashing, covering coughs, self-quarantining if appropriate, and disinfecting surfaces on which the virus may be living (as it is capable of doing for at least a week in some cases). For those who reside in long term care settings, staff education and intervention will help to avoid unnecessary exposure from visitors and gatherings, to keep surfaces disinfected, to note the emergence of possible symptoms, and to isolate those with suggestive symptoms.

As our world faces this latest health crisis,  older adults and especially those with dementia will be at special risk. Their safety and survival can be protected by our awareness and attention to their protection.

Guest Blogger:James Ellison MD, MPH
James Ellison MD, MPH, is the Swank Foundation Endowed Chair in Memory Care and Geriatrics at Christiana Care, and a board member at the Mental Health Association in Delaware. He is a dedicated advocate for those with Alzheimer’s Disease and other forms of Dementia and their caregivers, and is an expert in geriatric psychiatry.