Looking at intra-hospital non COVID-19 mortality among elderly patients during COVID-19 pandemic.

Dear Editor,

An 83 years old man was admitted to our hospital for shortness of breath and fatigue, worsening in the previous seven days with impairment of his functional status during the pandemic of coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In the emergency department orthopnea and leg swelling were also observed. The patient underwent ECG detecting QS waves and ST-elevation in anterolateral derivations. A chest-CT revealed pleural effusion and ground-glass alterations. A SARS-CoV-2 nasopharingeal swab was performed and resulted negative. Patient had a history of rheumatoid arthritis, vascular Parkinsonism and recently diagnosed type 2 diabetes. He admitted typical intense chest pain 10 days earlier but he did not contact his primary care physician neither has gone to the emergency department because of the scare to contract coronavirus infection in the hospital. Echocardiography showed dyskinetic areas and aneurysmal dilatation of the left ventricle, right ventricle dilation, pulmonary arterial hypertension and biatrial dilatation. Sixteen days after admission, patient died for heart failure complications.

Starting from this clinical experience, we have retrospectively analyzed de-identified data from patients admitted to non-COVID wards of Geriatric Medicine, Internal Medicine and Neurology in 4 hospitals in the province of L’Aquila, Italy, in order to evaluate in-hospital mortality. Data collection occurred through automated extraction from the Local Health Authority registry. Our analysis included inpatients electronic health records relative to the time window from 8 March 2020, at the beginning of the quarantine measures imposed by government of Italy to limit COVID-19 diffusion, to 13 may 2020, ten after the end of lockdown period. In comparison to the same period of 2019, we observed a reduction of the hospitalization by 50.7 % (from 1406 patients in 2019 to 693 patients in 2020) while the intra-hospital mortality rate was nearly doubled (from 7.68 % in 2019 to 13.00 % in 2020) (Table 1 ). The hospital stay of deceased patients was tendentially shorter during the lockdown period in comparison of the same period in 2019 (Table 1). The large majority of deceased patients during the lockdown period were aged ≥ 70 years (91.1 %) and the main causes of death were the diseases and disorders of the nervous, respiratory and circulatory systems, globally accounting for more than 60 % of the deaths (Table 1). Worth mentioning, in our district the intra-hospital mortality for COVID-19 was 9.27 % (248 cases and 23 deaths). These data suggest an indirect impact of SARS-CoV-2 pandemic on general mortality that was even greater than the COVID-19-related mortality.

Table 1

Intra-hospital deaths during the quarantine in 4 hospitals of L’Aquila distric in comparison to the same period in 2019 (mean±SD).

Variables	2019	2020	P
Total admitted (n)	1406	693
Total deaths (n)	108	90
Age (years)	82.2±10.3	82.1±10.3	0.8322a
Gender (M/F)	56/52	42/48	0.467b
Mortality rate	7.68%	13.00%	0.0001b
Hospital stay (days)	8.2 ± 8.9	5.8 ± 7.2	0.065a
Deaths within 3 days	35.19%	44.44%	0.184b
Major Diagnostic Categories in deceased patients			P=0.798b
- Diseases and Disorders of the Respiratory System	44 (40.74%)	30 (33.33%)
- Diseases and Disorders of the Circulatory System	13 (12.04%)	15 (16.67%)
- Diseases and Disorders of the Nervous System	12 (11.11%)	15 (16.67%)
- Infectious and Parasitic DDs	15 (13.89%)	8 (8.89%)
- Others	24 (22.22%)	22 (24.44%)

Wilcoxon rank-sum test.

Chi-squared test.

Concerns that one possible consequence of efforts to contain COVID-19 could be an increase in deaths from other causes have been recently raised (Appleby, 2020). The clinical case we have presented demonstrates that the delay in hospitalization due to the fear of COVID-19 may have had significant health consequences for many clinical conditions requiring timely treatment (Baum & Schwartz, 2020). The evidence that the registered deaths mainly occurred during a short hospital-stay, suggesting a greater severity of clinical conditions at the time of hospitalization, further supports this perception. Undoubtedly, during the last few months we have received by mass media a constant bombardment with frightening statistics. Moreover, although isolating the elderly might reduce transmission, which is most important to delay the peak in cases, and minimise the spread to these subjects at high-risk for severe and fatal SARS-CoV-2 infections (Imam, Odish, & Gill, 2020; Niu, Tian, & Lou, 2020; Sun, Ning, & Tao, 2020), it is well known that social isolation among older adults is a serious public health concern because of their heightened risk of cardiovascular, autoimmune, neurocognitive problems (Armitage & Nellums, 2020; Galea, Merchant, & Lurie, 2020; Gerst-Emerson & Jayawardhana, 2015).

An unadequate home management of chronic diseases during the lockdown period should be also considered to explain our findings. Chronic respiratory and cardiovascular diseases, which accounted for a large amount of the deaths registered, usually require a tight physician-patient cooperation which was quite difficult to maintain during the spreading of COVID-19 pandemic. In this regards the COVID-19 pandemic is driving a rapid and radical transformation of care for older people based on a wide application of tele-communication technology, home-based programs of health-care and intervention strategies aiming to enhance the resilience of older adults to cope with stressing situations (Chen, 2020).

We would never know if a timely treatment at the time of chest pain could have prevented the death in our patient. Anyway, our experience suggest that the consequence of exaggerated fears and misplaced priorities could be relevant as much as the pandemic (Jones, 2020). Thus, meeting the care needs of older adults isolated at home (Steinman, Perry, & Perissinotto, 2020), struggling to secure safe lockdown for elderly residents (Logar, 2020) and making hospital access safe and feeling safe (Asch, 2020) is fundamental during pandemic since restrictive measures, although effective in limiting pandemic spreading, could have relevant health consequences, expecially for frail elderly population (Plagg, Engl, Piccoliori, & Eisendle, 2020). Futhermore, the communication strategies during emergencies should be mastered and employed in a responsible way without exceeding in sensationalisms or terrifying messages whose consequences on public health could be even greater than the emergency itself.

Author contributions

Concept and design: Giovambattista Desideri, Alessandro Rizzi, Claudio Ferri. Data collection: Leondino Mammarella, Stefano Necozione. Analysis and interpretation of data: Stefano Necozione, Davide Grassi, Raffaella Bocale. Manuscript preparation: all authors.

Declaration of Competing Interest

None.