The Impact of Covid-19 on Future Higher-Age Mortality

Covid-19 has predominantly affected mortality at high ages. It kills by inflaming and clogging the air sacs in the lungs, depriving the body of oxygen ‒ inducing hypoxia ‒ which closes down essential organs, in particular the heart, kidneys and liver, and causes blood clots (which can lead to stroke or pulmonary embolism) and neurological malfunction. Evidence from different countries points to the fact that people who die from Covid-19 are often, but not always, much less healthy than the average for their age group. This is true for England & Wales – the two countries we focus on in this study. The implication is that the years of life lost through early death are less than the average for each age group, with how much less being a source of considerable debate. We argue that many of those who die from coronavirus would have died anyway in the relatively near future due to their existing frailties or co-morbidities. We demonstrate how to capture this link to poorer-than-average health using a model in which individual deaths are ‘accelerated’ ahead of schedule due to Covid-19. The model structure and its parameterization build on the observation that Covid-19 mortality by age is approximately proportional to all-cause mortality. This, in combination with current predictions of total deaths, results in the important conclusion that, everything else being equal, the impact of Covid-19 on the mortality rates of the surviving population will be very modest. Specifically, the degree of anti-selection is likely to be very small, since the life expectancy of survivors does not increase by a significant amount over pre-pandemic levels. We also analyze the degree to which Covid-19 mortality varies with socio-economic status. Headline statistics suggest that the most deprived groups have been disproportionately affected by Covid-19. However, once we control for regional differences in mortality rates, Covid-19 deaths in both the most and least deprived groups are also proportional to the all-cause mortality of these groups. However, the groups in between have approximately 10-15% lower Covid-19 deaths compared with their all-cause mortality. We argue that useful lessons about the potential pattern of accelerated deaths from Covid-19 can be drawn from examining deaths from respiratory diseases, especially at different age ranges. We also argue that it is possible to draw useful lessons about volatility spikes in Covid-19 deaths from examining past seasonal flu epidemics. However, there is an important difference. Whereas the spikes in seasonal flu increase with age, our finding that Covid-19 death rates are approximately proportional to all-cause mortality suggests that any spike in Covid-19 mortality in percentage terms would be similar across all age ranges. Finally, we discuss some of the indirect consequences for future mortality of the pandemic and the ‘lockdown’ measures governments have imposed to contain it. For example, there is evidence that some surviving patients at all ages who needed intensive care could end up with a new impairment, such as organ damage, which will reduce their life expectancy. There is also evidence that many people in lockdown did not seek a timely medical assessment for a potential new illness, such as cancer, or deferred seeking treatment for an existing serious illness, with the consequence that non-Covid-19-related mortality rates could increase in future. Self-isolation during lockdown has contributed to an increase in alcohol and drug consumption by some people which might, in turn, reduce their life expectancy. If another consequence of the pandemic is a recession and/or an acceleration in job automation, resulting in long-term unemployment, then this could lead to so-called ‘deaths of despair’ in future. Other people, by contrast, might permanently change their social behaviour or seek treatments that delay the impact or onset of age-related diseases, one of the primary factors that make people more susceptible to the virus – both of which could have the effect of increasing their life expectancy. It is, however, too early to quantify these possibilities, although it is conceivable that these indirect consequences could have a bigger impact on future average life expectancy than the direct consequences measured by the accelerated deaths model

Mobilization of Stroke Patients during the Covid-19 Pandemic: A Qualitative Research

Introduction: The Covid-19 pandemic has made it difficult for patients' families to access health services. This is because there is a feeling of fear and worry about being exposed to the COVID-19 virus. Objectives: explore family experiences in providing care mobilization for stroke patients at home. Methods: The design of this study was a qualitative study with a content analysis approach. The participants of this study were a family in rural Indonesia who cared for or one of their family members who suffered a stroke. There were three participants, namely the patient (P3), wife (P1), and children (P2). A purposive sampling technique was used in starting the interview. Data was collected using semi-structured interviews focusing on stroke survivors and their families. Results: There are two themes, namely exercise and taking care of food, which is family efforts to care for stroke patients during the Covid-19 pandemic, mobilization to prevent tissue damage, and do not require special facilities. Conclusions: Early mobilization is very important for early stroke sufferers through regular exercise such as walking around the house and light stretching every day, controlling the food eaten every day, and a high recovery rate

Neurological manifestations and neuro-invasive mechanisms of the severe acute respiratory syndrome coronavirus type 2

Background and purpose Infections with coronaviruses are not always confined to the respiratory tract and various neurological manifestations have been reported. The aim of this study was to perform a review to describe neurological manifestations in patients with COVID-19 and possible neuro-invasive mechanisms of Sars-CoV-2. Methods PubMed, Web of Science and COVID-dedicated databases were searched for the combination of COVID-19 terminology and neurology terminology up to 10 May 2020. Social media channels were followed up between 15 March and 10 May 2020 for postings with the same scope. Neurological manifestations were extracted from the identified papers and combined to provide a useful summary for the neurologist in clinical practice. Results Neurological manifestations potentially related to COVID-19 have been reported in large studies, case series and case reports and include acute cerebrovascular diseases, impaired consciousness, cranial nerve manifestations and autoimmune disorders such as the Guillain-Barre syndrome often present in patients with more severe COVID-19. Cranial nerve symptoms such as olfactory and gustatory dysfunctions are highly prevalent in patients with mild to moderate COVID-19 even without associated nasal symptoms and often present in an early stage of the disease. Conclusion Physicians should be aware of the neurological manifestations in patients with COVID-19, especially when rapid clinical deterioration occurs. The neurological symptoms in COVID-19 patients may be due to direct viral neurological injury or indirect neuroinflammatory and autoimmune mechanisms. No antiviral treatments against the virus or vaccines for its prevention are available and the long-term consequences of the infection on human health remain uncertain especially with regard to the neurological system

In-hospital and out-of-hospital stroke in patients with COVID-19: two different diseases?

Background: Ischemic stroke is a known complication of COVID-19. It may have a different pathogenesis and worse outcome compared to stroke in patients without COVID-19. Furthermore, patients with COVID-19 and out-of-hospital stroke onset might have different characteristics compared to patients with COVID-19 and in-hospital stroke onset. The aim of our study was to analyze the characteristics of patients with stroke with and without COVID-19 and of patients with COVID-19 with in-hospital and out-of-hospital stroke. Methods: We performed a retrospective study of all consecutive patients admitted to our hospital with ischemic stroke between October 2020 and February 2021. We compared functional outcome, lab test, demographic, and clinical characteristics between patients with or without COVID-19. We performed a sub-analysis comparing patients with COVID-19 and in-hospital and out-of-hospital stroke onset. Results: We included in the final analysis 137 patients of whom 26 with COVID-19. Half (13) had out-of-hospital stroke and half in-hospital stroke onset. Overall, patients with COVID-19 had higher mortality compared to the control group (27% vs 9%, p: 0.02), and non-significantly lower rate of good functional outcome (50% vs 63%, p: 0.22). Patients with COVID-19 and out-of-hospital stroke had higher rate of good functional outcome (69% vs 39%, p: 0.05), higher lymphocyte count, and lower D-dimer compared with patients with in-hospital stroke onset. Conclusions: Patients with stroke and COVID-19 had higher mortality compared to patients without COVID-19. Among patients with COVID-19 those with out-of-hospital stroke had better outcome and fewer blood test abnormalities compared to patients with in-hospital stroke

Exercise-Based Stroke Rehabilitation: Clinical Considerations Following the COVID-19 Pandemic

Background. The COVID-19 pandemic attributable to the severe acute respiratory syndrome virus (SARS-CoV-2) has had a significant and continuing impact across all areas of healthcare including stroke. Individuals post-stroke are at high risk for infection, disease severity, and mortality after COVID-19 infection. Exercise stroke rehabilitation programs remain critical for individuals recovering from stroke to mitigate risk factors and morbidity associated with the potential long-term consequences of COVID-19. There is currently no exercise rehabilitation guidance for people post-stroke with a history of COVID-19 infection. Purpose. To (1) review the multi-system pathophysiology of COVID-19 related to stroke and exercise; (2) discuss the multi-system benefits of exercise for individuals post-stroke with suspected or confirmed COVID-19 infection; and (3) provide clinical considerations related to COVID-19 for exercise during stroke rehabilitation. This article is intended for healthcare professionals involved in the implementation of exercise rehabilitation for individuals post-stroke who have suspected or confirmed COVID-19 infection and non-infected individuals who want to receive safe exercise rehabilitation. Results. Our clinical considerations integrate pre-COVID-19 stroke (n = 2) and COVID-19 exercise guidelines for non-stroke populations (athletic [n = 6], pulmonary [n = 1], cardiac [n = 2]), COVID-19 pathophysiology literature, considerations of stroke rehabilitation practices, and exercise physiology principles. A clinical decision-making tool for COVID-19 screening and eligibility for stroke exercise rehabilitation is provided, along with key subjective and physiological measures to guide exercise prescription. Conclusion. We propose that this framework promotes safe exercise programming within stroke rehabilitation for COVID-19 and future infectious disease outbreaks

Characteristics and Outcomes in Patients With COVID-19 and Acute Ischemic Stroke: The Global COVID-19 Stroke Registry

Recent case-series of small size implied a pathophysiological association between coronavirus disease 2019 (COVID-19) and severe large-vessel acute ischemic stroke. Given that severe strokes are typically associated with poor prognosis and can be very efficiently treated with recanalization techniques, confirmation of this putative association is urgently warranted in a large representative patient cohort to alert stroke clinicians, and inform pre- and in-hospital acute stroke patient pathways. We pooled all consecutive patients hospitalized with laboratory-confirmed COVID-19 and acute ischemic stroke in 28 sites from 16 countries. To assess whether stroke severity and outcomes (assessed at discharge or at the latest assessment for those patients still hospitalized) in patients with acute ischemic stroke are different between patients with COVID-19 and non-COVID-19, we performed 1:1 propensity score matching analyses of our COVID-19 patients with non-COVID-19 patients registered in the Acute Stroke Registry and Analysis of Lausanne Registry between 2003 and 2019. Between January 27, 2020, and May 19, 2020, 174 patients (median age 71.2 years; 37.9% females) with COVID-19 and acute ischemic stroke were hospitalized (median of 12 patients per site). The median National Institutes of Health Stroke Scale was 10 (interquartile range [IQR], 4-18). In the 1:1 matched sample of 336 patients with COVID-19 and non-COVID-19, the median National Institutes of Health Stroke Scale was higher in patients with COVID-19 (10 [IQR, 4-18] versus 6 [IQR, 3-14]), P=0.03; (odds ratio, 1.69 [95% CI, 1.08-2.65] for higher National Institutes of Health Stroke Scale score). There were 48 (27.6%) deaths, of which 22 were attributed to COVID-19 and 26 to stroke. Among 96 survivors with available information about disability status, 49 (51%) had severe disability at discharge. In the propensity score-matched population (n=330), patients with COVID-19 had higher risk for severe disability (median mRS 4 [IQR, 2-6] versus 2 [IQR, 1-4], P<0.001) and death (odds ratio, 4.3 [95% CI, 2.22-8.30]) compared with patients without COVID-19. Our findings suggest that COVID-19 associated ischemic strokes are more severe with worse functional outcome and higher mortality than non-COVID-19 ischemic strokes

Ischemic stroke and intracerebral hemorrhage in patients with COVID-19

Introduction. Patients with coronavirus disease 2019 (COVID-19) can exhibit neurological symptoms and diseases. A few studies have focused on cerebrovascular diseases in patients with COVID-19. In the present study, we as-sessed medical records of patients with COVID-19 with stroke. Material and methods. Forty-seven COVID-19 patients with stroke were consecutively selected and reviewed. Medical records of the patients including information on age, gender, severity of pulmonary involvement (intubation or non-intubation) in COVID, presence of ICH and ischemic stroke, localization of ICH, history of diabetes and hyper-tension were collected. Results. Twenty-three COVID-19 patients (49%) had ICH and 24 COVID-19 patients (51%) had ischemic stroke. Sixteen COVID-19 patients with ICH (69.6%) had lobar hemorrhage and 7 COVID-19 patients with ICH (30.4%) had non-lobar hemorrhage (p =0.093). Conclusions. In this study, ICH and ischemic stroke were present at roughly the same rate in COVID-19 patients with stroke. Lobar hemorrhage was seen more frequently in COVID-19 patients with ICH. Brain and cerebrovascular imaging can be a helpful component of the work-up in COVID-19 patients.</p

Characteristics and Outcomes in Patients With COVID-19 and Acute Ischemic Stroke: The Global COVID-19 Stroke Registry.

Recent case-series of small size implied a pathophysiological association between coronavirus disease 2019 (COVID-19) and severe large-vessel acute ischemic stroke. Given that severe strokes are typically associated with poor prognosis and can be very efficiently treated with recanalization techniques, confirmation of this putative association is urgently warranted in a large representative patient cohort to alert stroke clinicians, and inform pre- and in-hospital acute stroke patient pathways. We pooled all consecutive patients hospitalized with laboratory-confirmed COVID-19 and acute ischemic stroke in 28 sites from 16 countries. To assess whether stroke severity and outcomes (assessed at discharge or at the latest assessment for those patients still hospitalized) in patients with acute ischemic stroke are different between patients with COVID-19 and non-COVID-19, we performed 1:1 propensity score matching analyses of our COVID-19 patients with non-COVID-19 patients registered in the Acute Stroke Registry and Analysis of Lausanne Registry between 2003 and 2019. Between January 27, 2020, and May 19, 2020, 174 patients (median age 71.2 years; 37.9% females) with COVID-19 and acute ischemic stroke were hospitalized (median of 12 patients per site). The median National Institutes of Health Stroke Scale was 10 (interquartile range [IQR], 4-18). In the 1:1 matched sample of 336 patients with COVID-19 and non-COVID-19, the median National Institutes of Health Stroke Scale was higher in patients with COVID-19 (10 [IQR, 4-18] versus 6 [IQR, 3-14]), P=0.03; (odds ratio, 1.69 [95% CI, 1.08-2.65] for higher National Institutes of Health Stroke Scale score). There were 48 (27.6%) deaths, of which 22 were attributed to COVID-19 and 26 to stroke. Among 96 survivors with available information about disability status, 49 (51%) had severe disability at discharge. In the propensity score-matched population (n=330), patients with COVID-19 had higher risk for severe disability (median mRS 4 [IQR, 2-6] versus 2 [IQR, 1-4], P&lt;0.001) and death (odds ratio, 4.3 [95% CI, 2.22-8.30]) compared with patients without COVID-19. Our findings suggest that COVID-19 associated ischemic strokes are more severe with worse functional outcome and higher mortality than non-COVID-19 ischemic strokes

COVID-19 and stroke in sub-Saharan Africa: case series from Dar es Salaam

Low and middle-income countries including those in sub-Saharan (SSA) Africa are experiencing a steady increase in the number of COVID-19 cases. To the best of our knowledge, reports of COVID-19 related strokes are scarce in SSA. The peculiar situation of stroke care in SSA makes COVID-19 associated stroke a bothersome entity as it adds other dynamics that tilt the prognostic balance. We present a case series of COVID -19 related stroke in 3 patients from Tanzania. We emphasized protected code stroke protocol