Geriatric care facilities' concerns regarding hospital admission of infected residents with dementia or transport for admission in the COVID‐19 pandemic

Dear Editor,

Geriatric care facilities provide care for the most vulnerable people in our society, mostly older people with dementia (PWD). Since the outbreak of the COVID‐19 pandemic, aggressive infection prevention measures, including physical distancing, using personal protective equipment, conducting screening tests and vaccinations, have been implemented to prevent the residents' infection and outbreak of cluster infection.1, 2 However, issues related to the response to infected residents have been reported. The rise in ageism such as discriminatory practices based on age in access to medical treatment3, 4 has made it difficult for the residents to access specialized medical treatment including intensive care. A previous report showed that some facilities experienced refusal of hospitalization by COVID‐19 dedicated hospitals due to the infected residents having dementia, and difficulties in transporting them for hospitalization. ⁵ Understanding whether geriatric care facilities have concerns about these issues and the characteristics of facilities that are concerned will contribute to identifying the facilities that need support for responding to infected residents in cooperation with hospitals.

Therefore, an online self‐administered questionnaire of medical and long‐term care facilities for older people throughout Japan was conducted to investigate the impact of COVID‐19 on PWD conditions and lives from October to December 2021 by Hiroshima University and the Japan Geriatrics Society. ⁶ The participants were the representatives of facilities.

In this study, based on previous reports and a review with geriatricians and public health specialists, we hypothesized that the difficulty in admitting a resident to a COVID‐19‐dedicated hospital was related to overwhelmed local healthcare ⁴ and ageism,3, 4, 5 and the burden of institutional care for the infected residents ⁴ would affect the concerns of the facilities. Therefore, they were asked whether they were concerned about the refusal by hospitals to admit residents with dementia to the hospital and the difficulty of transporting them for admission, and about their characteristics. To identify characteristics of the facilities with concerns, a logistic regression analysis using a forced entry method was conducted with the presence or absence of facilities' concerns as the dependent variable, using the facilities' characteristics as the independent variables. The SPSS software ver. 27.0 (IBM, Armonk, NY, USA) was used for analysis, and the significance level was set at 5%.

Table 1 shows the facility attributes and results of the regression analysis. Of the 686 facilities that participated, 526 (76.7%) were concerned about the refusal by hospitals to admit residents with dementia to the hospital and the difficulty of transporting them for admission. From the logistic regression analysis, the strongest factor was that the percentage of residents with severe dementia among those with dementia was 75%–100% (odds ratio = 3.361, P = 0.027).

Table 1.

Attributes of facilities and related factors for facilities with concerns (logistic regression analysis)

Variables	Attributes of the facilities (n = 686)		Related factors for facilities with concerns (n = 680)
	Facilities with concerns (n = 526)	Facilities without concerns † (n = 160)	OR	(95% CI)	P‐value
Types of facility
Medical facility	12 (2.3%)	2 (1.2%)	Ref.
Long‐term care facility	514 (97.7%)	158 (98.8%)	0.442	(0.091–2.153)	0.312
Location of the facility (the local spread of infection was considered as the level of overwhelmed local healthcare)
Prefectures within the bottom 50% of places with the highest cumulative number of new positive COVID‐19 cases per population between January 2020 and November 2021 ‡	183 (34.8%)	83 (51.9%)	Ref.
Prefectures within the top 25%–50% of places ‡	134 (25.5%)	30 (18.8%)	2.211	(1.344–3.637)	0.002
Prefectures within the top 25% of places ‡	205 (39.0%)	46 (28.8%)	2.148	(1.390–3.320)	<0.001
No response	4 (0.7%)	1 (0.5%)
Number of residents	40.7 ± 40.3	37.7 ± 32.4	1.006	(0.999–1.013)	0.072
Percentage of residents with dementia
0%–25%	23 (4.4%)	14 (8.7%)	Ref.
25%–50%	39 (7.4%)	24 (15.0%)	0.830	(0.343–2.005)	0.678
50%–75%	57 (10.8%)	15 (9.4%)	2.281	(0.906–5.739)	0.080
75%–100%	407 (77.4%)	107 (66.9%)	3.159	(1.449–6.889)	0.004
Percentage of residents with severe dementia among residents with dementia
None	238 (45.2%)	100 (62.5%)	Ref.
1%–25%	89 (16.9%)	18 (11.3%)	2.330	(1.283–4.233)	0.005
25%–50%	76 (14.4%)	20 (12.5%)	1.348	(0.762–2.382)	0.305
50%–75%	83 (15.8%)	18 (11.3%)	1.541	(0.857–2.773)	0.149
75%–100%	40 (7.7%)	4 (2.4%)	3.361	(1.148–9.841)	0.027

Location of the 686 participating facilities included 46 of the 47 prefectures in Japan. Of the 686 facilities that participated in the study, 680 were included in the logistic regression analysis, excluding six facilities where independent variables were missing.

Regarding multicollinearity, variance inflation factor of all independent variables was <10. Cox and Snell R ² = 0.073; Nagelkerke R ² = 0.110; Hosmer–Lemeshow test χ² = 8.293, P = 0.405.

OR, odds ratio; CI, confidence interval.

^† Facilities that answered “‘not sure” were included.

^‡ At the time of the second survey (November 1, 2021), the cumulative number of new positive cases was calculated for each prefecture. Thereafter, the cumulative number of new positive cases per 100 000 population (the population was calculated using the population estimate as of October 1, 2021, based on the national statistics survey) was calculated. The prefectures were then listed in order of the number of cumulative new positive cases, and the quartiles were used to classify the prefectures as follows: (i) 12 prefectures within the top 25% (75th percentile or higher): Okinawa, Tokyo, Osaka, Kanagawa, Chiba, Saitama, Fukuoka, Hyogo, Aichi, Kyoto, Nara, and Hokkaido; (ii) 12 prefectures within the top 25%–50% (the 50th–75th percentile): Gifu, Shiga, Gunma, Ibaraki, Mie, Kumamoto, Okayama, Tochigi, Hiroshima, Shizuoka, Oita, and Saga; and (iii) other prefectures within the bottom 50% (≤50th percentile).

This study revealed the characteristics of facilities that were concerned about the refusal by hospitals to admit residents with dementia to the hospital and the difficulty in transporting them for admission. First, facilities with concerns were in prefectures with higher numbers of new positive cases and had a higher percentage of residents with dementia and higher percentage of residents with severe dementia. During the pandemic in Japan, some geriatric care facilities reported being forced to care for infected residents on‐site due to overwhelmed COVID‐19‐specialized hospitals. ⁵ Therefore, it is important for geriatric care facilities to consider and simulate in advance, whether an infected resident with dementia can be smoothly admitted or transported to a hospital, and whether the infection risk of other residents can be reduced within the facility or throughout the community. Second, our findings suggest to healthcare professions the need for efforts to prevent inequalities in the allocation of medical treatment to PWD. Unfortunately, ageism has become apparent in COVID‐19. ⁴ Discrimination based on age or dementia was not tolerated. Healthcare professionals and the government should discuss this ethical issue and ensure a service provision system to advocate for the rights of PWD to receive appropriate medical treatment.

Disclosure statement

The authors declare no conflict of interest.

Kazawa K, Kubo T, Akishita M, Ishii S. Geriatric care facilities' concerns regarding hospital admission of infected residents with dementia or transport for admission in the COVID‐19 pandemic. Geriatr. Gerontol. Int. 2022;22:1050–1052. 10.1111/ggi.14499

Data availability statement

The datasets analyzed in the present study are not publicly available. This study was conducted at the Hiroshima University in collaboration with the COVID‐19 Response Team of the Japan Geriatrics Society. Informed consent for the secondary use of the data was not obtained from the participants.