Psychotropic Medication Use Is Associated With Greater 1-Year Incidence of Dementia After COVID-19 Hospitalization.

Background: COVID-19 has been associated with an increased risk of incident dementia (post-COVID dementia). Establishing additional risk markers may help identify at-risk individuals and guide clinical decision-making. Methods: We investigated pre-COVID psychotropic medication use (exposure) and 1-year incidence of dementia (outcome) in 1,755 patients (≥65 years) hospitalized with COVID-19. Logistic regression models were used to examine the association, adjusting for demographic and clinical variables. For further confirmation, we applied the Least Absolute Shrinkage and Selection Operator (LASSO) regression and a machine learning (Random Forest) algorithm. Results: One-year incidence rate of post-COVID dementia was 12.7% (N = 223). Pre-COVID psychotropic medications (OR = 2.7, 95% CI: 1.8-4.0, P < 0.001) and delirium (OR = 3.0, 95% CI: 1.9-4.6, P < 0.001) were significantly associated with greater 1-year incidence of post-COVID dementia. The association between psychotropic medications and incident dementia remained robust when the analysis was restricted to the 423 patients with at least one documented neurological or psychiatric diagnosis at the time of COVID-19 admission (OR = 3.09, 95% CI: 1.5-6.6, P = 0.002). Across different drug classes, antipsychotics (OR = 2.8, 95% CI: 1.7-4.4, P < 0.001) and mood stabilizers/anticonvulsants (OR = 2.4, 95% CI: 1.39-4.02, P = 0.001) displayed the greatest association with post-COVID dementia. The association of psychotropic medication with dementia was further confirmed with Random Forest and LASSO analysis. Conclusion: Confirming prior studies we observed a high dementia incidence in older patients after COVID-19 hospitalization. Pre-COVID psychotropic medications were associated with higher risk of incident dementia. Psychotropic medications may be risk markers that signify neuropsychiatric symptoms during prodromal dementia, and not mutually exclusive, contribute to post-COVID dementia.

Loneliness in Older Adults with Major Depression Across the COVID-19 Pandemic

Introduction Loneliness has emerged as a distinct clinical construct with detrimental physical and mental health effects. During the COVID-19 outbreak and aftermath, studies examining loneliness in older adults reported mixed results with increased, decreased, and static levels of loneliness. These inconsistent findings likely relate to pandemic-related phenomena of amplified social isolation (e.g., quarantines, social distancing, remote work) for some, and an increased sense of social connectedness (e.g., shared interests, challenges and experiences, greater media engagement) for others.  To our knowledge, only one study has examined the effect of the COVID-19 pandemic on older adults with pre-existing major depression.  Most were resilient, with no overall change in depression, anxiety, and suicidality scores, however loneliness was not explicitly considered.  As such, since loneliness and depression are interrelated in older adults, we sought to examine whether loneliness in non-remitted older depressed patients was impacted during the COVID-19 pandemic. Methods A brief survey instrument was developed that included relevant socio-demographic information, a modified Older Americans Resources and Services (OARS) scale for assessing perceived health status, a question on communication during the pandemic adapted from the Questionnaire for Assessing the Impact of the COVID-19 Pandemic in Older Adults (QAICPOA), a question on consumption of COVID-19 related news coverage, and the UCLA 3-item Loneliness Scale for three different time points:  prior to the pandemic (retrospective self-rating), during the height of the pandemic (defined as between the declaration of a formal pandemic in March 2020 until vaccinations began in December 2020) (retrospective self-rating), and currently at the time of survey administration in Fall 2021 (contemporaneous rating). To ensure a homogeneous patient population, eligibility criteria included a primary diagnosis of a major depressive disorder without psychosis, cognitive impairment, secondary psychiatric disorders, or a remitted state.  All patients were active registrants in the Zucker Hillside Hospital (ZHH) Geriatric Psychiatry Outpatient Clinic. A list of eligible patient names and contacts were generated through the IT department by ing information from the electronic health record.  As per Northwell's IRB review, this survey project met the criteria outlined in 45 CFR 46.101 for IRB exemption. Eligible patients were called and asked to complete the survey over the phone. Data for the current pilot sample were analyzed using a two-tailed paired t-test with a threshold of significance of p ≤0.05. Results 106 patients met eligibility criteria.  To date, 30 patients completed telephone surveys. The mean age of these respondents was 73.5 (SD ± 6.39) years. 73.3% (n = 22) were female and 26.1% (n = 8) were male.  63.3% of patients were white, 16.6% were Black, 13.3% were Hispanic, and 6.6% were Asian. 50% of patients were married, 26.6% were divorced, and 23.3% were widowed. 10% of patients were still working, while the remaining 90% were retired.  33.3% of patients had an associate, bachelor's, or graduate/advanced degree, 63.3% of patients completed high school, and 3.3% had not.  73% lived with at least one other person and 27% lived alone.  86.7% had one or more children and 13.3% were childless.  The mean OARS score was 3.16 (SD ± 1.88) (range 0-6, worse to best perceived health).  Compared to prior to the pandemic, 46.6 % of patients reported less communication with friends and family, 46.6 % reported they communicated the same, and 6.7% said they communicated more. Mean COVID-related news consumption rating (range 1-5, 5 = most) was 3.8 (SD ± 1.3).  Mean UCLA 3-item loneliness scale (range 3-9) scores were 4.97 (SD ± 1.85) prior to the pandemic, 6.47 (SD ± 1.89) during the height of the pandemic, and 5.37 (SD ± 2.11) in the Fall 2021 vaccination period.  A significant difference existed between loneliness scores prior to the pandemic and worsening loneliness during the height of the pandemic (p<0.0001). A significant difference also was found between loneliness scores during the height of the pandemic and improving loneliness during the less acute pandemic vaccination period (p < 0.005).  There was no significant difference between loneliness prior to and after the height of the pandemic. Conclusions In a representative pilot sample (expansion ongoing) of older depressed adults, loneliness increased significantly during the COVID-19 pandemic.  In the context of prior findings of largely stable mental health parameters and resilience during the COVID-19 outbreak in a similar population, this suggests that loneliness is a unique human experience not necessarily alleviated by effective coping strategies.  That loneliness significantly improved with a likely sense of incipient normalization reenforces that it is a dynamic psychological state subject to intervention. This research was funded by None.

Mortality in association with antipsychotic medication use and clinical outcomes among geriatric psychiatry outpatients with COVID-19.

OBJECTIVES: Older adults are particularly vulnerable to the negative consequences of antipsychotic exposure and are disproportionally affected by higher mortality from coronavirus disease 2019 (COVID-19). Our goal was to determine whether concurrent antipsychotic medication use was associated with increased COVID-19 mortality in older patients with preexisting behavioral health problems. We also report on findings from post-COVID follow-ups. DESIGN: Retrospective observational study. PARTICIPANTS: Outpatients at a geriatric psychiatric clinic in New York City. MEASUREMENTS: Demographic and clinical data including medication, diagnosis and Clinical Global Impression Severity (CGI-S) scales on outpatients who had COVID-19 between February 28th and October 1st 2020 were extracted from the electronic health records (EHR) from the hospital. RESULTS: A total of 56 patients were diagnosed with COVID-19 (mean age 76 years; median age 75 years) and 13 (23.2%) died. We found an increased mortality risk for patients who were prescribed at least one antipsychotic medication at the time of COVID-19 infection (Fisher's exact test P = 0.009, OR = 11.1, 95% confidence interval: 1.4-96.0). This result remains significant after adjusting for age, gender, housing context and dementia (Logistic regression P = 0.035, Beta = 2.4). Furthermore, we found that most patients who survived COVID-19 (88.4%) recovered to pre-COVID baseline in terms of psychiatric symptoms. Comparison of pre- and post-COVID assessments of CGI-S for 33 patients who recovered from COVID-19 were not significantly different. CONCLUSION: We observed a higher COVID-19 mortality associated with concurrent antipsychotics use in older patients receiving behavioral health services. The majority of patients in our geriatric clinic who recovered from COVID-19 appeared to return to their pre-COVID psychiatric function. More precise estimates of the risk associated with antipsychotic treatment in older patients with COVID-19 and other underlying factors will come from larger datasets and meta-analyses.

Presentation and Outcome of Coronavirus Disease (COVID-19) in Patients at a Geriatric Psychiatric Outpatient Clinic

Introduction The novel coronavirus disease 2019 (COVID-19) disproportionally affects elderly patients leading to particularly high morbidity and mortality rates in this population. Age, gender, comorbidities, and housing context have been reported to be among the risk factors for mortality. Exposure to antipsychotics have been discussed to potentially impact the immune response and may pose additional risks. Furthermore, neuropsychiatric presentations are common among older patients and it is unclear how geriatric patients with preexisting psychiatric and neuropsychiatric problems recover from COVID-19. Methods In this retrospective observational study, we describe demographic characteristics of patients at a large geriatric psychiatric outpatient clinic in the New York metropolitan area, who had COVID-19. Our aim is to identify factors that may be associated with increased mortality and to evaluate whether those who survived returned to pre-COVID baseline function. We combined information provided by the treating psychiatrists with data that could be extracted from the electronic health records. Results Between February and September 2020, we identified 56 patients who were diagnosed with COVID-19 (mean age 76 years old). Thirteen patients (23.2%) died and we found that antipsychotics use at the time of COVID-19 infection is associated with increased risk of death (Fisher's exact test P= 0.009, odds ratio = 11.5, 95% confidence interval: 1.4 – 96.0). The result remains significant after adjusting for age, gender, housing context and presence of neurocognitive disorder (Logistic regression P=0.037, Beta=2.4). Furthermore, we found that most patients who survived COVID-19 recovered to baseline (88.4%) as indicated by the ratio of pre- and post-COVID Clinical Global Impressions Severity scale (mean ratio= 0.98, median=1.0, One-sample t-test P=0.48) in 33 patients. Conclusions In conclusion, antipsychotics appear to be associated with higher mortality in our geriatric psychiatry outpatient cohort. However, it is encouraging to find that the majority of elderly patients who survived COVID-19 seems to recover to their baseline neuropsychiatric function. Future larger studies are needed to put these observations into a broader context as well as to explore underlying mechanisms of risk factors. Funding NIH K08 AG054727

Loneliness in the Elderly During the COVID-19 Pandemic: A Literature Review in Preparation for a Future Study

Introduction Loneliness, defined as “the subjective feeling of isolation, not belonging, or lacking companionship” has been found to have increasing prevalence in the United States. Elderly populations have a unique susceptibility to loneliness since aging is associated with many losses that can both provoke and amplify such feelings. Loneliness has been found to have detrimental effects on physical and mental health in the elderly, including increased rates of depression, cognitive impairment, and mortality. The COVID-19 pandemic has been associated with several factors that may contribute to feelings of isolation and loneliness. These include quarantine, social distancing, family and other significant relationship disruptions, interruption of regular vocation and avocational roles, illness, and death with associated grief. On the other hand, reports have also emerged about how older people have demonstrated greater resilience during the pandemic, with a sense of enhanced community emerging. As such, examining the pandemic's impact on loneliness in the elderly, especially in those older people with psychiatric illness, may illuminate new strategies to improve quality of life and clinical symptomatology. Methods PubMed searches were completed using the terms “loneliness,” “COVID-19,” and “elderly” up until December 6 2020. Media reports about loneliness during the COVID-19 pandemic were reviewed for any references to studies. Published, peer-reviewed studies were selected based upon their examination and measurement of loneliness prior to and during the COVID-19 pandemic in populations aged 65 and older. Additional eligible studies were obtained through reviewing the references of selected studies. Results Nine published studies were found that measured levels of loneliness in older adults at both any time point before the COVID-19 pandemic and during the COVID-19 pandemic. All studies examined a general older adult population without cognitive impairment. Loneliness was typically measured using the UCLA Loneliness Scale or the DeJong Gierveld Loneliness Scale. The majority of studies (seven out of nine) found increased levels of loneliness during the pandemic compared to after the pandemic. However, two of these studies found the increases to only be slight, although still significant. Two studies found the levels of loneliness pre-pandemic to remain stable during the pandemic. Conclusions Thus far, limited studies have looked at changes in loneliness in older adults during the COVID-19 pandemic. The results are mixed, although a majority of studies have found loneliness levels increase. The COVID-19 pandemic has led to associated stay-at-home orders, decreased in-person socialization, and increased death and loss, especially in older adults. All of these factors have the potential to exacerbate loneliness. On the other hand, some media reports have suggested that collective interest in and focus on the pandemic have been associated with a higher frequency of social interactions and greater engagement in current events. Hence, despite COVID-related isolation, quarantine and social distancing, a paradoxical enhanced sense of community may emerge for some that is not dissimilar to observed phenomena during other recent crises, leading to static levels of loneliness seen in two of the selected studies. As loneliness has many negative consequences for older adults it should continue to be studied within the context of COVID-19. Further research is needed to assess changes in loneliness during the pandemic and its aftermath within the subgroup of older, depressed adults living in the community as the relationship between loneliness and depression is well-established. This review has provided key background information for such a future study. Funding Not Applicable