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      Recognition of the coronavirus disease 2019 pandemic and face mask wearing in patients with Alzheimer's disease: an investigation at a medical centre for dementia in Japan

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          Abstract

          COVID‐19 spreads from person to person through saliva droplets and aerosols from exhalation, talking, and a cough. 1 A systematic review and meta‐analysis on the management of severe viral respiratory infections, such as COVID‐19, showed that physical distancing of at least 1 m and wearing a face mask or eye protection reduce the risk of viral infections. 2 Among individuals who do become infected with COVID‐19, those with hypertension, cardiovascular diseases, and diabetes have a greater risk of having a more severe infection. 3 Furthermore, dementia has been shown to pose an increased risk for COVID‐19. 4 Therefore, preventing infection is of vital importance for patients with dementia. However, these patients may have difficulties understanding the risk of COVID‐19 and taking measures against infection either by themselves or with the help of others. The purpose of the present study was to examine recognition of the COVID‐19 pandemic and the status of face mask wearing in patients with Alzheimer's disease (AD). Patients with AD who visited the Medical Center for Dementia at Shinoda General Hospital in Yamagata, Japan, between May 2020 and July 2020 and who fulfilled the criteria for AD by McKhann et al. were enrolled in the study. 5 Patients with severe dementia who could not understand the question of examiner or with a severe reduction in activities of daily living such as eating or moving by themselves were excluded. In total, 55 patients (20 men, 35 women; mean age: 83.4 ± 5.4 years) and their caregivers (family members) participated in this study. The means ± SD of the Mini‐Mental State Examination and Clinical Dementia Rating (CDR) of these patients were 15.9 ± 5.4 and 1.5 ± 0.6, respectively. Semi‐structured interviews on face mask wearing as a preventive measure against COVID‐19 were conducted by a psychiatrist or clinical psychologist. The interview consisted of three questions. Question 1 was ‘Why are you, the examiner, the caregiver, and other patients wearing a face mask?’ If a patient's answer included words or expressions such as ‘coronavirus’, ‘new pneumonia’, and ‘to prevent transmission’, he or she was regarded as recognizing the COVID‐19 pandemic. This question was considered superior to direct questions such as ‘Do you know about the COVID‐19 pandemic?’, which could elicit an erroneous answer as an appearance‐saving response. 6 Question 2 was directed at the caregiver: ‘Does the patient wear a face mask properly or almost properly by himself or herself when necessary?’ If the patient did not wear a face mask properly or almost properly by himself or herself, we asked the caregiver question 3: ‘Can the patient wear a face mask properly or almost properly with your help?’ Statistical analyses were performed with Student's t‐test, Fisher's exact test, and χ2 test, where appropriate, using SPSS version 25 (IBM, Armonk, NY, USA). A P‐value <0.05 was considered statistically significant. The results of the semi‐structured interviews are shown in Table 1. Only 21 of the 55 patients (38.2%) recognized the COVID‐19 pandemic. These patients had a higher mean Mini‐Mental State Examination score and lower mean CDR score than those who did not recognize the COVID‐19 pandemic. Fourteen patients (25.5%) wore a face mask properly by themselves, but 41 patients (74.5%) did not. Patients who wore a face mask on their own had a lower mean CDR score (P = 0.004) and recognized the COVID‐19 pandemic at a higher rate (P = 0.028) than those who did not wear a face mask on their own. Of the 41 patients who did not wear a face mask on their own, 34 (82.9%) could wear one with a caregiver's help. There were no significant differences in mean Mini‐Mental State Examination score, CDR score, or rate of COVID‐19 pandemic recognition between those who could wear a face mask with help and those who could not. Table 1 Results of semi‐structured interviews with patients and their caregivers Recognizes COVID‐19 pandemic Does not recognize COVID‐19 pandemic P‐value Question 1 (n = 55) 21 (38.2%) 34 (61.8%) Age (years) 82.2 ± 5.4 84.1 ± 5.4 0.200 Men/women 7/14 13/21 0.779 Education (years) 11.3 ± 2.6 11.2 ± 2.7 0.946 MMSE 19.9 ± 3.4 13.5 ± 5.0 0.000 CDR 1.1 ± 0.5 1.8 ± 0.5 0.000 Distribution of CDR scores (0.5/1/2/3) 3/14/4/0 0/9/24/1 0.001 Wears a face mask by themselves Does not wear a face mask by themselves Question 2 (n = 55) 14 (25.5%) 41 (74.5%) Age (years) 85.0 ± 3.0 82.8 ± 6.0 0.081 Men/women 4/10 16/25 0.539 Education (years) 11.0 ± 2.5 11.3 ± 2.7 0.679 MMSE 18.4 ± 4.7 15.1 ± 5.5 0.054 CDR 1.1 ± 0.5 1.6 ± 0.6 0.004 Distribution of CDR scores (0.5/1/2/3) 2/9/3/0 1/14/25/1 0.037 Recognition of COVID‐19 pandemic 9 (64.3%) 12 (29.3%) 0.028 Wears a face mask with caregiver's help Does not wear a face mask with caregiver's help Question 3 (n = 41) 34 (82.9%) 7 (17.1%) Age (years) 83.5 ± 5.8 79.6 ± 6.1 0.124 Men/women 15/19 1/6 0.215 Education (years) 11.4 ± 2.7 11.1 ± 2.7 0.834 MMSE 15.4 ± 5.5 13.6 ± 5.4 0.417 CDR 1.6 ± 0.5 1.9 ± 0.7 0.271 Distribution of CDR scores (0.5/1/2/3) 1/12/21/0 0/2/4/1 0.160 Recognition of COVID‐19 pandemic 11 (32.4%) 1 (14.3%) 0.651 Values are presented as mean ± SD, frequency (percentage), or frequency. MMSE, Mini‐Mental State Examination; CDR, Clinical Dementia Rating; COVID‐19, coronavirus disease 2019. In our AD patients, the rate of recognition of the COVID‐19 pandemic was only 38.2%. It is reasonable to ascribe this low rate to amnesia, as those who did not recognize the pandemic had the poorestcognitive function scores. However, Mori et al. reported that 86.1% of AD patients were able to recall large earthquakes they experienced (e.g. the Kobe earthquake in 1995). The authors suggested that emotional arousal enhanced episodic memory through the amygdala. 7 It is possible that the COVID‐19 pandemic induces less emotional arousal and retention of episodic memory than large earthquakes experienced. Importantly, 74.5% of the patients did not wear face masks properly by themselves when necessary, most likely because of cognitive impairment, which also limited their pandemic recognition. However, 82.9% of these patients could wear a face mask with the help of their caregivers. This phenomenon was observed regardless of cognitive function score and recognition of the pandemic. It is suggested that instructing caregivers to help patients to wear a face mask is critical in preventing COVID‐19 infection. Last but not least, some of our patients (7/55, 12.7%) could not wear a face mask even with the help of caregivers. For these patients, different measures such as wearing of a face shield may be necessary. Disclosure The authors have no conflicts of interest to report. Ethics Statement This study was approved by the Ethics Committee of Shinoda General Hospital. Written informed consent was obtained from all patients and their families for inclusion in this study and for publication of this report.

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          Most cited references7

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          Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

          Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.
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            The diagnosis of dementia due to Alzheimer's disease: Recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease

            The National Institute on Aging and the Alzheimer's Association charged a workgroup with the task of revising the 1984 criteria for Alzheimer's disease (AD) dementia. The workgroup sought to ensure that the revised criteria would be flexible enough to be used by both general healthcare providers without access to neuropsychological testing, advanced imaging, and cerebrospinal fluid measures, and specialized investigators involved in research or in clinical trial studies who would have these tools available. We present criteria for all-cause dementia and for AD dementia. We retained the general framework of probable AD dementia from the 1984 criteria. On the basis of the past 27 years of experience, we made several changes in the clinical criteria for the diagnosis. We also retained the term possible AD dementia, but redefined it in a manner more focused than before. Biomarker evidence was also integrated into the diagnostic formulations for probable and possible AD dementia for use in research settings. The core clinical criteria for AD dementia will continue to be the cornerstone of the diagnosis in clinical practice, but biomarker evidence is expected to enhance the pathophysiological specificity of the diagnosis of AD dementia. Much work lies ahead for validating the biomarker diagnosis of AD dementia. Copyright © 2011. Published by Elsevier Inc.
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              Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis

              Summary Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19 and is spread person-to-person through close contact. We aimed to investigate the effects of physical distance, face masks, and eye protection on virus transmission in health-care and non-health-care (eg, community) settings. Methods We did a systematic review and meta-analysis to investigate the optimum distance for avoiding person-to-person virus transmission and to assess the use of face masks and eye protection to prevent transmission of viruses. We obtained data for SARS-CoV-2 and the betacoronaviruses that cause severe acute respiratory syndrome, and Middle East respiratory syndrome from 21 standard WHO-specific and COVID-19-specific sources. We searched these data sources from database inception to May 3, 2020, with no restriction by language, for comparative studies and for contextual factors of acceptability, feasibility, resource use, and equity. We screened records, extracted data, and assessed risk of bias in duplicate. We did frequentist and Bayesian meta-analyses and random-effects meta-regressions. We rated the certainty of evidence according to Cochrane methods and the GRADE approach. This study is registered with PROSPERO, CRD42020177047. Findings Our search identified 172 observational studies across 16 countries and six continents, with no randomised controlled trials and 44 relevant comparative studies in health-care and non-health-care settings (n=25 697 patients). Transmission of viruses was lower with physical distancing of 1 m or more, compared with a distance of less than 1 m (n=10 736, pooled adjusted odds ratio [aOR] 0·18, 95% CI 0·09 to 0·38; risk difference [RD] −10·2%, 95% CI −11·5 to −7·5; moderate certainty); protection was increased as distance was lengthened (change in relative risk [RR] 2·02 per m; p interaction=0·041; moderate certainty). Face mask use could result in a large reduction in risk of infection (n=2647; aOR 0·15, 95% CI 0·07 to 0·34, RD −14·3%, −15·9 to −10·7; low certainty), with stronger associations with N95 or similar respirators compared with disposable surgical masks or similar (eg, reusable 12–16-layer cotton masks; p interaction=0·090; posterior probability >95%, low certainty). Eye protection also was associated with less infection (n=3713; aOR 0·22, 95% CI 0·12 to 0·39, RD −10·6%, 95% CI −12·5 to −7·7; low certainty). Unadjusted studies and subgroup and sensitivity analyses showed similar findings. Interpretation The findings of this systematic review and meta-analysis support physical distancing of 1 m or more and provide quantitative estimates for models and contact tracing to inform policy. Optimum use of face masks, respirators, and eye protection in public and health-care settings should be informed by these findings and contextual factors. Robust randomised trials are needed to better inform the evidence for these interventions, but this systematic appraisal of currently best available evidence might inform interim guidance. Funding World Health Organization.
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                Author and article information

                Contributors
                ryo.kobayashi@med.id.yamagata-u.ac.jp
                Journal
                Psychogeriatrics
                Psychogeriatrics
                10.1111/(ISSN)1479-8301
                PSYG
                Psychogeriatrics
                John Wiley & Sons Australia, Ltd (Melbourne )
                1346-3500
                1479-8301
                01 October 2020
                : 10.1111/psyg.12617
                Affiliations
                [ 1 ] Department of Psychiatry Yamagata University School of Medicine Yamagata Japan
                [ 2 ] Medical Center for Dementia Shinoda General Hospital Yamagata Japan
                [ 3 ] Department of Neuropsychiatry, Aizu Medical Center Fukushima Medical University Aizuwakamatsu Japan
                Author notes
                [*] [* ] Correspondence: Dr. Ryota Kobayashi MD PhD, Department of Psychiatry, Yamagata University School of Medicine, 2‐2‐2 Iidanishi, Yamagata 990‐9585, Japan. Email: ryo.kobayashi@ 123456med.id.yamagata-u.ac.jp

                Author information
                https://orcid.org/0000-0002-4213-618X
                https://orcid.org/0000-0001-5855-491X
                Article
                PSYG12617
                10.1111/psyg.12617
                7536985
                33006226
                3cf722a8-336e-4f29-9dcf-bcd2f1908a05
                © 2020 Japanese Psychogeriatric Society

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

                History
                : 08 August 2020
                : 14 September 2020
                : 16 September 2020
                Page count
                Figures: 0, Tables: 1, Pages: 3, Words: 1456
                Categories
                Psychogeriatric Note
                Psychogeriatric Note
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