COVID-19-Associated Deaths in San Francisco: the Important Role of Dementia and Atypical Presentations in Long-term Care
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J Gen Intern Med DOI: 10.1007/s11606-020-06206-1 © Society of General Internal Medicine 2020
BACKGROUND
COVID-19 has caused significant mortality worldwide.1 Within the USA, marked geographic differences in incidence, hospitalization, and death have been reported.2 Better characterization of populations at increased risk for death from COVID-19 is needed, including from long-term care facilities (LTCF). We describe the demographic and clinical characteristics of the first 50 fatalities with COVID-19 in San Francisco.
METHODS
All San Francisco residents who die with laboratoryconfirmed COVID-19 infection are reported to the San Francisco Department of Public Health (SFDPH). We reviewed case report forms, medical records, and death certificate data for demographics, clinical presentation, and hospital course when applicable. Cause of death was not considered to be due to COVID-19 if not listed as the underlying cause of death on both the death certificate and medical record. These activities were public health surveillance, and not research; therefore, institutional review board review was not obtained.
RESULTS
From March 5 to July 14, 2020, 50 decedents with confirmed COVID-19 were reported. Of these, 46 had COVID-19 listed as the underlying cause of death and four were assessed as being unrelated to COVID-19; the non-COVID-19 causes of deaths were abdominal perforation, liver laceration, splenic laceration, and urosepsis. The remaining 46 fatalities are described in Table 1. The average age was 81 years (range 30–100), and the most common race-ethnicity was Asian (49%). The most common co-morbidities included dementia (46%), diabetes mellitus (43%), cardiac disease (41%), and chronic lung disease Received August 3, 2020 Accepted August 31, 2020
(28%). Common presenting symptoms included dyspnea (48%), fever ≥ 100.0 °F (46%), cough (30%), and altered mental status (25%). Thirty-nine (89%) were hospitalized, 24 (59%) required intensive care, and 19 (44%) were intubated. The mean time from symptom onset to death was 14.1 days (range 4 h–42 days). Twenty-one (46%) decedents resided in a LTCF; most (84%) were designated as DNR/DNI (do not resuscitate or intubate), comfort care, or hospice either preceding or at presentation. Ten (48%) LTCF decedents presented without any fever, cough, and/or dyspnea; in six, altered mental status (e.g., confusion or lethargy) was the sole presenting symptom. When compared to community decedents, LTCF decedents were more likely to have a dementia diagnosis and to present with altered mental status and were less likely to present with cough, be hospitalized, receive intensive care or intubation, or be diagnosed with sepsis or acute renal failure.
DISCUSSION
Consistent with other reports, older adults in San Francisco remain the most likely to die due to COVID-19.1, 2 In San Francisco, as of July 30, 2020, persons ≥ 60 years comprise 14% of COVID-19 infections, yet 90% of deaths.3 Asians accounted for nearly half of deaths, though they comprise only 10.2% of COVID19 infections in
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