Clinical frailty scale and mortality in COVID-19: A systematic review and dose-response meta-analysis

[Translation and validation of the Clinical Frailty Scale (CFS) into Spanish in Chile]

INTRODUCTION

The assessment of frailty is crucial for the management and care of older adults. The Clinical Frailty Scale (CFS) has been proposed as a useful and practical tool for this assessment, but its implementation requires translation and validation to the specific cultural context.

METHODS

A standardized process of translation and cultural adaptation of the CFS in its second version was carried out. Then, 44 participants were recruited, including geriatricians and geriatrics residents, who evaluated 11 clinical cases using the scale. The intraclass correlation coefficient (ICC) was used to assess the variability between the evaluators.

RESULTS

A total of 484 evaluations were obtained (11 cases, 44 evaluators) with an intraclass correlation coefficient of 0.98. The sensitivity analysis showed no differences between subgroups of evaluators separated by years of experience or specialty status (certified geriatricians or those in training).

CONCLUSIONS

The Spanish version of the CFS is reliable and practical for the assessment of frailty in older adults in Chile, constituting a valuable tool for this purpose in this context.

SARS-CoV-2 seroreversion and all-cause mortality in nursing home residents and staff post-primary course vaccination in Belgium between February and December 2021

BACKGROUND

During COVID-19 vaccine implementation, information on the persistence of antibody response and impact on mortality in nursing home residents was limited, as they were underrepresented in vaccine clinical trials and real-world data was lacking.

OBJECTIVES

(1) Measure the persistence of the SARS-CoV-2 antibody response and predictors for seroreversion after primary course COVID-19 vaccination in nursing home residents compared to staff and (2) assess all-cause mortality and predictors in nursing home residents after primary COVID-19 vaccination.

METHODS

Seroprevalence and mortality data were collected within a national serosurveillance study in 1640 residents and 1368 staff from 69 nursing homes proportionally spread across Belgium between February and December 2021. To assess the persistence of the antibody response, parametric exponential survival models with interval censoring were fitted, reported with the percentage of seroreverters 120 and 140 days post-primary course vaccination. Furthermore, all-cause mortality rate was calculated and COVID-19 mortality was descriptively reported. Predictors of seroreversion and all-cause mortality were estimated using Cox proportional hazards model.

RESULTS

Nursing home residents were 47 % more likely to serorevert in the 10 months after COVID-19 vaccination than staff. Infection naïvety, older age and high resident care dependency level were found as predictors for seroreversion. The all-cause mortality rate in vaccinated residents over 10 months was 14 % (95 % CI 13-16 %) (n = 229). In 2 % of cases, COVID-19 infection was the reported cause of death. Older age, being male, having severe renal, lung, or cardiac disease, or active cancer, and high care dependency level were identified as predictors for all-cause mortality, irrespective of history of SARS-CoV-2 or breakthrough infection.

CONCLUSION/PRACTICAL IMPLICATION

Future COVID-19 vaccination strategies should prioritize (infection naïve) nursing home residents, as they fail to mount a durable antibody response after primary course vaccination. Nevertheless, COVID-19 mortality remained low, representing only 2 % of the all-cause mortality rate. This study was registered on ClinicalTrials.gov (NCT04738695).

[Benefits of a pulmonary rehabilitation program for patients with long COVID: Impact of initial severity, disease duration, and presentation type on clinical outcomes]

INTRODUCTION

Two-thirds of patients infected with SARS-CoV-2 experience persistent symptoms after infection.

OBJECTIVES

To study the benefits of a respiratory rehabilitation program (RRP) in patients with long COVID and compare the results based on the time of evolution and clinical presentation.

METHODS

Post-hoc analysis of a prospective cohort of patients with long COVID. Changes were evaluated using the modified Medical Research Council (mMRC) dyspnea scale, the 6-minute walk test (6MWT), maximal inspiratory and expiratory pressures (maxIP and maxEP), and peripheral muscle strength. Statistical tests used: Chi-square, paired and independent t-Student tests, one-way ANOVA, and a general linear model.

RESULTS

Out of 158 patients referred to rehabilitation, 110 (mean age 58.1years; 57.3% women) started the RRP. After the intervention, significant improvements were observed: a reduction of 0.8 points (95%CI: -1.1 to -0.6) on the mMRC dyspnea scale, an increase of 19.6m (95%CI: -0.8 to 39.9) in the 6MWT, 16.8cmH2O (95%CI: 10.3 to 23.2) in maxIP, 22.5cmH2O (95%CI: 15.3 to 29.7) in maxEP, and 5.0kg (95%CI: 3.3 to 6.7) in quadriceps strength. Although these improvements were independent of infection onset and disease duration, patients from the first wave showed more modest improvements.

CONCLUSIONS

The RRP provides clinical and functional benefits for patients with long COVID, regardless of disease duration and initial severity of infection.

Consequences of COVID-19 for geriatric patients during a pandemic

To investigate the outcomes of geriatric COVID-19 patients in a German academic setting during the pandemic. This study included 468 consecutive geriatric patients (≥ 70 years) who tested positive for SARS-CoV-2 and were treated at the University of Duisburg-Essen from 2/2020 to 3/2021. 74 patients were transferred to a geriatric hospital and a 12-month follow-up (prospective study) was performed in 51 patients. Clinical assessments evaluated depression (GDS), apathy (AES), cognitive status (MMST), mobility (TUG), health status (EQ-5D-5 L), and daily living activities (Barthel Index). Demographic and clinical data were also analyzed. Results showed that the mortality in this vulnerable group was 52% (n = 209). Long-term survival was higher in patients who received comprehensive geriatric treatment (74.3% vs. 51.8%). The duration of inpatient stay at the primary hospital was 13.3 ± 3.6 days, with 28.8% (n = 135) requiring intensive care. At the 12-month mark more patients with geriatric treatment lived in nursing homes. Barthel-Index/Timed-Up-and-Go-Test/MMST/AES/GDS, and EQ-5D-5 L indicated worse outcomes in the group who received geriatric treatment. Specialized geriatric care may improve survival in geriatric COVID-19 patients despite decreased long-term outcomes. Further research, including international studies like NAPKON, are encouraged to confirm these findings and explore potential interventions for improved outcomes in this vulnerable population.

Age Differences and Prevalence of Comorbidities for Death and Survival in Patients with COVID-19: A Single-Center Observational Study in a Region of Southern Italy

The SARS-CoV-2 outbreak has resulted in a considerable number of deaths worldwide. The virus damages the pulmonary artery endothelium, leading to a condition known as microvascular pulmonary inflammatory thrombotic syndrome (MPITS), which can be fatal and cause multiple organ failure. The presence of preexisting comorbidities has been shown to significantly impact the severity and prognosis of patients with SARS-CoV-2 infection. The objective of this study was to compare the age groups of patients with coronavirus disease 2019 (COVID-19) and to identify the prevalence of comorbidities associated with death and survival in an area of southern Italy. The data set consisted of 1985 patients with confirmed cases of SARS-CoV-2 infection who were admitted to the A.O.U. San Giovanni di Dio e Ruggi d'Aragona Hospital in Salerno between January 2021 and December 2022. The results were presented for the overall population and stratified by outcome and age group. All analyses were performed using the XLSTAT (Lumivero, 2024, Paris, France) and STATA software (release 16.1, StataCorp LLG, College Station, TX, USA, 2019) packages. In the study, population, 636 cases (32%) resulted in death, with a higher prevalence in the 60-79 age group, followed by the ≥80 and 30-59 age groups. The most prevalent diseases among deceased and surviving patients with confirmed cases of SARS-CoV-2 infection were those affecting the circulatory system (61.5% vs. 55.5%), the respiratory system (55.8% vs. 26.2%), and the metabolic system (25.9% vs. 25.4%). In patients aged 30-79, respiratory diseases were the primary cause of mortality, whereas in those aged ≥80, circulatory system diseases were more prevalent. Among survivors, cardiovascular diseases were the most common comorbidities across all age groups, followed by respiratory diseases and endocrine, metabolic, and immune disorders. Moreover, these comorbidities were associated with an elevated risk of mortality. The study emphasizes the substantial influence of age and comorbidities on the mortality associated with SARS-CoV-2 infection. These findings highlight the necessity for targeted interventions to manage comorbid conditions in patients with SARS-CoV-2 infection, particularly in older adults.

Alpha-1 adrenergic antagonists and the risk of hospitalization or death in non-hospitalized patients with COVID-19: A population-based study

BACKGROUND

Alpha-1 receptor antagonists may interfere with IL-6 signaling and could therefore be a potential treatment for COVID-19. However, the effectiveness of these drugs in mitigating the risk of clinical deterioration among non-hospitalized patients with COVID-19 is unknown.

OBJECTIVES

The aim of this study is to examine the association between alpha-1 antagonist exposure and the 30-day risk of a hospital encounter or death in nonhospitalized patients with COVID-19.

METHODS

We conducted a population-based cohort study of Ontario residents aged 35 years and older who were eligible for public drug coverage and who had a positive test for SARS-CoV-2 between January 1, 2020, and March 1, 2021. We matched each individual receiving an alpha-1 antagonist at the time of their positive test with two non-exposed individuals using propensity scores. Our outcome was a composite of a hospital admission, emergency department visit, or death, 1 to 30 days following the positive test.

RESULTS

We matched 3289 alpha-1 antagonist exposed patients to 6189 unexposed patients. Overall, there was no difference in the 30-day risk of the primary outcome among patients exposed to alpha-1 antagonists at the time of their diagnosis relative to unexposed individuals (28.8% vs. 28.0%; OR 1.00, 95% CI 0.91 to 1.11). In a secondary analysis, individuals exposed to alpha-1 antagonists had a lower risk of death in the 30 days following a COVID diagnosis (OR 0.79; 95% CI 0.66 to 0.93).

CONCLUSION

Alpha-1 antagonists did not mitigate the 30-day risk of clinical deterioration in non-hospitalized patients with COVID-19. Our findings do not support the general repurposing of alpha-1 antagonists as a treatment for such patients, although there may be subgroups of patients in whom further research is warranted.

The impact of COVID-19 public health measures on the utilization of antipsychotics in schizophrenia in Manitoba - A population-based study

PURPOSE

During the COVID-19 pandemic, public health measures were implemented, yet it is unknown whether these measures affected medication access in those with schizophrenia (SCZ). This study aimed to assess whether the antipsychotic utilization in SCZ changed during the pandemic.

METHODS

We used dispensed prescription drug data from the Canadian province of Manitoba in individuals with SCZ using linked administrative data from the Manitoba Population Research Data Repository. The quarterly incident and prevalent dispensation of antipsychotics at two periods were compared with the expected trend (April 1, 2015 to April 1, 2020 and 2021) using linear autoregression. We stratified the primary results by age and sex and examined multiple subgroups.

RESULTS

There were 9045 individuals with SCZ in the first fiscal quarter of 2020. The prevalent use of the most common antipsychotics were: olanzapine (206.7/1000), risperidone (190.8/1000), quetiapine (174.4/1000), and clozapine (100.9/1000). The overall prevalent use of antipsychotics remained stable during the pandemic compared with the expected trend. A significant decrease in the incident use in April-June 2020 (estimate: -1.3, 95%CI:-2.2,-0.3) was noted compared with the expected. A significantly higher incidence of atypical antipsychotics (estimate: 1.4, 95%CI: 0.2,2.5) and risperidone separately (estimate: 1.8, 95%CI: 0.2,3.3) was noted in 2021 compared with expected.

CONCLUSION

This study found a decline in the receipt of antipsychotics for people with SCZ during the initial implementation of COVID-19 public health measures, particularly on the overall incidence. Future work on investigating the impact of these trends on SCZ outcomes is needed to inform future pandemic-related policies.

Ethical challenges causing moral distress: nursing home staff's experiences of working during the COVID-19 pandemic

OBJECTIVE

To investigate the experiences of healthcare staff in nursing homes during the COVID-19 pandemic.

DESIGN

Individual interviews. Latent qualitative content analysis.

SETTING

Ten nursing homes in Sweden.

SUBJECTS

Physicians, nurses and nurse assistants working in Swedish nursing homes.

MAIN OUTCOME MEASURES

Participants' experiences of working in nursing homes during the COVID-19 pandemic.

RESULTS

Four manifest categories were found, namely: Balancing restrictions and allocation of scarce resources with care needs; Prioritizing and acting against moral values in advance care planning; Distrust in cooperation and Leadership and staff turnover - a factor for moral distress. The latent theme Experiences of handling ethical challenges caused by the COVID-19 pandemic gave a deeper meaning to the categories.

CONCLUSION

During the pandemic, nursing home staff encountered ethical challenges that caused moral distress. Moral distress stemmed from not being given adequate conditions to perform their work properly, and thus not being able to give the residents adequate care. Another aspect of moral distress originated from feeling forced to act against their moral values when a course of action was considered to cause discomfort or harm to a resident. Alerting employers and policymakers to the harm and inequality experienced by staff and the difficulty in delivering appropriate care is essential. Making proposals for improvements and developing guidelines together with staff to recognize their role and to develop better guidance for good care is vital in order to support and sustain the nursing home workforce.

Clinical Manifestations and Outcomes of Older Patients with COVID-19: A Comprehensive Review

The consequences of coronavirus disease 2019 (COVID-19) are particularly severe in older adults with a disproportionate number of severe and fatal outcomes. Therefore, this integrative review aimed to provide a comprehensive overview of the clinical characteristics, management approaches, and prognosis of older patients diagnosed with COVID-19. Common clinical presentations in older patients include fever, cough, and dyspnea. Additionally, preexisting comorbidities, especially diabetes and pulmonary and cardiovascular diseases, were frequently observed and associated with adverse outcomes. Management strategies varied, however, early diagnosis, vigilant monitoring, and multidisciplinary care were identified as key factors for enhancing patient outcomes. Nonetheless, the prognosis remains guarded for older patients, with increased rates of hospitalization, mechanical ventilation, and mortality. However, timely therapeutic interventions, especially antiviral and supportive treatments, have demonstrated some efficacy in mitigating the severe consequences in this age group. In conclusion, while older adults remain highly susceptible to severe outcomes from COVID-19, early intervention, rigorous monitoring, and comprehensive care can play a pivotal role in improving their clinical outcomes.

Outpatient Antipsychotic Use and Severe COVID-19: Avoiding the Impact of Age in a Real-World Data Study

BACKGROUND

The association between use of antipsychotics and COVID-19 outcomes is inconsistent, which may be linked to use of these drugs in age-related diseases. Furthermore, there is little evidence regarding their effect in the nongeriatric population. We aim to assess the association between antipsychotic use and risk of disease progression and hospitalization due to COVID-19 among the general population, stratifying by age.

METHODS

We conducted a population-based, multiple case-control study to assess risk of hospitalization, with cases being patients with a PCR(+) test who required hospitalization and controls being individuals without a PCR(+) test; and risk of progression to hospitalization, with cases being the same as those used in the hospitalization substudy and controls being nonhospitalized PCR(+) patients. We calculated adjusted odds-ratios (aOR) and 95% confidence intervals (CI), both overall and stratified by age.

RESULTS

Antipsychotic treatment in patients younger than 65 years was not associated with a higher risk of hospitalization due to COVID-19 (aOR 0.94 [95%CI = 0.69-1.27]) and disease progression among PCR(+) patients (aOR 0.96 [95%CI = 0.70-1.33]). For patients aged 65 years or older, however, there was a significant, increased risk of hospitalization (aOR 1.58 [95% CI = 1.38-1.80]) and disease progression (aOR 1.31 [95% CI = 1.12-1.55]).

CONCLUSIONS

The results of our large-scale real-world data study suggest that antipsychotic use is not associated with a greater risk of hospitalization due to COVID-19 and progression to hospitalization among patients younger than 65 years. The effect found in the group aged 65 years or older might be associated with off-label use of antipsychotics.

The Impact of Frailty, Oropharyngeal Dysphagia and Malnutrition on Mortality in Older Patients Hospitalized for Covid-19

COVID-19 hospital mortality is higher among older patients through as yet little-known factors. We aimed to assess the effect of frailty (FR), oropharyngeal dysphagia (OD) and malnutrition (MN) on mortality in hospitalized COVID-19 older patients. Prospective cohort study of older patients (>70 years) with COVID-19 admitted to a general hospital from April 2020 to January 2021. Patients were evaluated on admission, discharge and at 1- and 3-months follow up. FR was assessed with FRAIL-VIG, OD with Volume-Viscosity Swallowing Test and MN with GLIM criteria. Clinical characteristics and outcomes, including intra-hospital, 1- and 3-month mortality, were analyzed. 258 patients were included (82.5±7.6 years; 58.9% women); 66.7% had FR (mild 28.7%, moderate 27.1% and severe 10.9%); 65.4%, OD and 50.6%, MN. OD prevalence increased from non-FR patients through the severity levels of FR: mild, moderate and severe (29.8%, 71.6%, 90.0%, 96.2%; p<0.0001, respectively), but not that of MN (50.6%, 47.1%, 52.5%, 56.0%). Mortality over the whole study significantly increased across FR categories (9.3% non-FR; 23.0% mild; 35.7% moderate; 75.0% severe; p<.001). Functionality (Barthel pre-admission, HR=0.983, CI-95%:0.973-0.993; p=0.001), OD (HR=2.953, CI-95%:0.970-8.989; p=0.057) and MN (HR=4.279, CI-95%:1.658-11.049; p=0.003) were independent risk factors for intra-hospital mortality. FR, OD and MN are highly prevalent conditions in older patients hospitalized with COVID-19. Functionality, OD and MN were independent risk factors for intra-hospital mortality.

Risk Factor Analysis and Nomogram for Early Progression of COVID-19 Pneumonia in Older Adult Patients in the Omicron Era

Background and Objective

Timely recognition of risk factors for early progression in older adult patients with COVID-19 is of great significance to the following clinical management. This study aims to analyze the risk factors and create a nomogram for early progression in older adult patients with COVID-19 in the Omicron era.

Methods

A total of 272 older adults infected with COVID-19 admitted from December 2022 to February 2023 were retrospectively recruited. Risk factor selection was determined using the logistic and the least absolute shrinkage and selection operator (LASSO) regression. A nomogram was then created to predict early progression, followed by the internal validation and assessment of its performance through plotting the receiver operating characteristic (ROC), calibration, and decision curves.

Results

A total of 83 (30.5%) older adult patients presented an early progression on chest CT after 3-5 days of admission under standard initiate therapy. Six independent predictive factors were incorporated into the nomogram to predict the early progression, including CRP > 10 mg/L, IL-6 > 6.6 pg/mL, LDH > 245 U/L, CD4+ T-lymphocyte count <400/µL, the Activities of Daily Living (ADL) score ≤40 points, and the Mini Nutritional Assessment Scale-Short Form (MNA-SF) score ≤7 points. The area under the curve (AUC) of the nomogram in discriminating older adult patients who had risk factors in the training and validation cohort was 0.857 (95% CI 0.798, 0.916) and 0.774 (95% CI 0.667, 0.881), respectively. The calibration and decision curves demonstrated a high agreement in the predicted and observed risks, and the acceptable net benefit in predicting the early progression, respectively.

Conclusion

We created a nomogram incorporating highly available laboratory data and the Comprehensive Geriatric Assessment (CGA) findings that effectively predict early-stage progression in older adult patients with COVID-19 in the Omicron era.

Multimorbidity and frailty are associated with poorer SARS-CoV-2-related outcomes: systematic review of population-based studies

BACKGROUND

Estimating the risks and impacts of COVID-19 for different health groups at the population level is essential for orienting public health measures. Adopting a population-based approach, we conducted a systematic review to explore: (1) the etiological role of multimorbidity and frailty in developing SARS-CoV-2 infection and COVID-19-related short-term outcomes; and (2) the prognostic role of multimorbidity and frailty in developing short- and long-term outcomes. This review presents the state of the evidence in the early years of the pandemic. It was conducted within the European Union Horizon 2020 program (No: 101018317); Prospero registration: CRD42021249444.

METHODS

PubMed, Embase, World Health Organisation COVID-19 Global literature on coronavirus disease, and PsycINFO were searched between January 2020 and 7 April 2021 for multimorbidity and 1 February 2022 for frailty. Quantitative peer-reviewed studies published in English with population-representative samples and validated multimorbidity and frailty tools were considered.

RESULTS

Overall, 9,701 records were screened by title/abstract and 267 with full text. Finally, 14 studies were retained for multimorbidity (etiological role, n = 2; prognostic, n = 13) and 5 for frailty (etiological role, n = 2; prognostic, n = 4). Only short-term outcomes, mainly mortality, were identified. An elevated likelihood of poorer outcomes was associated with an increasing number of diseases, a higher Charlson Comorbidity Index, different disease combinations, and an increasing frailty level.

DISCUSSION

Future studies, which include the effects of recent virus variants, repeated exposure and vaccination, will be useful for comparing the possible evolution of the associations observed in the earlier waves.

Predictors of outcomes of patients ≥ 80 years old admitted to intensive care units in Poland - a post-hoc analysis of the VIP2 prospective observational study

INTRODUCTION

Elderly patients pose a significant challenge to intensive care unit (ICU) clinicians. In this study we attempted to characterise the population of patients over 80 years old admitted to ICUs in Poland and identify associations between clinical features and short-term outcomes.

MATERIAL AND METHODS

The study is a post-hoc analysis of the Polish cohort of the VIP2 European prospective observational study enrolling patients > 80 years old admitted to ICUs over a 6-month period. Data including clinical features, clinical frailty scale (CFS), geriatric scales, interventions within the ICU, and outcomes (30-day and ICU mortality and length of stay) were gathered. Univariate analyses comparing frail (CFS > 4) to non-frail patients and survivors to non-survivors were performed. Multivariable models with CFS, activities of daily living score (ADL), and the cognitive decline questionnaire IQCODE as predictors and ICU or 30-day mortality as outcomes were formed.

RESULTS

A total of 371 patients from 27 ICUs were enrolled. Frail patients had significantly higher ICU (58% vs. 44.45%, P = 0.03) and 30-day (65.61% vs. 54.14%, P = 0.01) mortality compared to non-frail counterparts. The survivors had significantly lower SOFA score, CFS, ADL, and IQCODE than non-survivors. In multivariable analysis CFS (OR 1.15, 95% CI: 1.00-1.34) and SOFA score (OR 1.29, 95% CI: 1.19-1.41) were identified as significant predictors for ICU mortality; however, CFS was not a predictor for 30-day mortality ( P = 0.07). No statistical significance was found for ADL, IQCODE, polypharmacy, or comorbidities.

CONCLUSIONS

We found a positive correlation between CFS and ICU mortality, which might point to the value of assessing the score for every patient admitted to the ICU. The older Polish ICU patients were characterised by higher mortality compared to the other European countries.

Do-Not-ResuscitateDecision-Making during the COVID-19 Pandemic in a Teaching Hospital: Lessons Learned for the Future

Method

A cross-sectional survey study was conducted between February 2021 and April 2021 for all doctors and doctors in training, working in the Antwerp University Hospital during the COVID-19 pandemic.

Results

127 doctors participated in this study. The familiarity with the different scores used in the triage during the COVID-10 pandemic was 51% for the Clinical Frailty Scale (CFS) and 20% for the Charlson Comorbidity Index (CCI). Participants indicated that their DNR decision is based on various aspects such as clinical assessment, comorbidities, patient's wishes, age, prognosis, and functional state.

Conclusion

The familiarity with the different scores used during triage assessments is low. The total clinical picture of the patient is needed to make a considered decision, and this total picture of the patient seems to be well encompassed by frailty measurement (CFS). Although many participants indicated that the different scores do not offer much added value compared to their clinical assessment, it can help guide DNR decisions, especially for doctors in training.

Resilient Adaptation Strategies: Unveiling Older Adults' Coping Dynamics Amidst the COVID-19 Pandemic

Older adults, who are particularly vulnerable to coronavirus disease 2019 (COVID-19), exhibit less stress and greater well-being than their younger peers. However, there have been no in-depth explorations of adaptive coping strategies among this population, nor has the role of frailty status been addressed. The current study examined stress and coping in 30 U.S. older adults (mean age = 81 years, range = 68 to 95 years) amidst the COVID-19 pandemic, uncovering themes of: (1) Pandemic Stresses: stresses experienced during the pandemic centered around social isolation and concern for others' well-being; (2) Resilience: older adults proved highly adaptable, with lifetime experience as a stress buffer; and (3) Silver Linings: older adults reported positive by-products, such as reconnecting with and a renewed appreciation for life and nature. Motivation for change and change itself centered around creating value and meaning in the present, especially around social isolation. Findings challenge existing ageist stereotypes, give insight into interventional design, and highlight the importance of ensuring infrastructural and societal support. [Journal of Gerontological Nursing, 49(12), 32-39.].

Trends in frailty in brain tumor care during the COVID-19 pandemic in a nationwide hospital network in Germany

PURPOSE

Among brain tumor patients, frailty is associated with poor outcomes. The COVID-19 pandemic has led to increased frailty in the general population. To date, evidence on changes in frailty among brain tumor patients during the pandemic is lacking. We aimed to compare frailty among brain tumor patients in Germany during the COVID-19 pandemic to the pre-pandemic era and to assess potential effects on brain tumor care.

METHODS

In this retrospective observational study, we compared frailty among brain tumor patients hospitalized during the COVID-19 pandemic in years 2020 through 2022 to pre-pandemic years 2016 through 2019 based on administrative data from a nationwide network of 78 hospitals in Germany. Using the Hospital Frailty Risk Score (HFRS), frailty was categorized as low, intermediate, or high. We examined changes in frailty, patient demographics, the burden of comorbidity, rates of surgery, and mortality rates for different frailty groups during the pandemic and compared them to pre-pandemic levels.

RESULTS

Of the 20,005 included hospitalizations for brain tumors, 7979 were during the pandemic (mean age 60.0 years (± 18.4); females: 49.8%), and 12,026 in the pre-pandemic period (mean age: 59.0 years [± 18.4]; females: 49.2%). Average daily admissions decreased from 8.2 (± 5.1) during pre-pandemic years to 7.3 (± 4.5) during the pandemic (p < 0.01). The overall median HFRS decreased from 3.1 (IQR: 0.9-7.3) during the pre-pandemic years to 2.6 (IQR: 0.3-6.8) during the pandemic (p < 0.01). At the same time, the Elixhauser Comorbidity Index (ECI) decreased from 17.0 (± 12.4) to 16.1 (± 12.0; p < 0.01), but to a larger degree among high compared to low frailty cases (by 1.8 vs. 0.3 points; p = 0.04). In the entire cohort, the mean length of stay was significantly shorter in the pandemic period (9.5 days [± 10.7]) compared with pre-pandemic levels (10.2 days [± 11.8]; p < 0.01) with similar differences in the three frailty groups. Rates of brain tumor resection increased from 29.9% in pre-pandemic years to 36.6% during the pandemic (p < 0.001) without differences between frailty levels. Rates of in-hospital mortality did not change during the pandemic (6.1% vs. 6.7%, p = 0.07), and there was no interaction with frailty.

CONCLUSION

Even though our findings are limited in that the HFRS is validated only for patients ≥ 75 years of age, our study among patients of all ages hospitalized for brain tumors in Germany suggests a marked decrease in levels of frailty and in the burden of comorbidities during the COVID-19 pandemic.

Factors Affecting Mortality in Elderly Hypertensive Hospitalized Patients with COVID-19: A Retrospective Study

Purpose

Corona Virus Disease 2019 (COVID-19) endangers the health and survival of the elderly. We tried to explore factors especially kidney function which affected mortality in elderly hypertensive patients with COVID-19.

Methods

We conducted a retrospective research of 748 COVID-19 elderly patients (≥65 years old) at Zhejiang Hospital. This study compared demographic data, laboratory values, comorbidities, treatments, and clinical outcomes of hypertension and non-hypertension participants, and subgroup analysis of age and frailty was conducted in the hypertension population. Survival analysis was used to determine risk factors for death in elderly patients with COVID-19.

Results

Our study revealed that the elderly hypertensive patients with COVID-19 had higher blood urea nitrogen (BUN), serum uric acid (UA), serum creatinine (Scr), lower estimated glomerular filtration rate (eGFR), higher incidence of severity, admission to intensive care unit (ICU) and death, and longer in-hospital stay than non-hypertensive patients, which also occurred in the very elderly hypertensive patients compared with younger hypertensive patients and frail hypertensive patients compared with no-frail hypertensive patients. In addition, the prevalence of acute kidney injury (AKI) was higher in the oldest old hypertensive patients and frail hypertensive patients. Multivariate survival analysis indicated that the independent risk factors for death from COVID-19 were age ≥80 years, heart failure, antiviral therapy, calcium channel blocker (CCB) therapy, mechanical ventilation, AKI, and eGFR<60 mL/min per 1.73 m2.

Conclusion

The results of the present study suggested that the elderly hypertensive patients with COVID-19 would have more serious kidney injury, more serious disease progression and higher mortality, which also occurred in very elderly and frailty subgroup. Kidney dysfunction was closely related to mortality in elderly patients with COVID-19.

Reliability and validity of a frailty assessment tool in specialized burn care, a retrospective multicentre cohort study

BACKGROUND

Frailty is a predictor of adverse outcomes in elderly patients. The Canadian Study of Health and Aging Clinical Frailty Scale (CFS) is an often-used frailty assessment instrument. However, the CFS's reliability and validity in patients with burn injuries are unknown. This study aimed to assess the CFS's inter-rater reliability and validity (predictive validity, known group validity and convergent validity) in patients with burn injuries treated to specialized burn care.

METHODS

A retrospective multicentre cohort study was conducted in all three Dutch burn centres. Patients aged ≥ 50 years with burn injuries, with a primary admission in 2015-2018, were included. Based on information in the electronic patient files, a research team member scored the CFS retrospectively. Inter-rater reliability was calculated using Krippendorff's α. Validity was assessed using logistic regression analysis. Patients with a CFS ≥ 5 were considered frail.

RESULTS

In total, 540 patients were included, with a mean age of 65.8 years (SD 11.5) and a Total Body Surface Area (TBSA) burned of 8.5%. The CFS was used to assess frailty in 540 patients and the reliability of the CFS was scored for 212 patients. Mean CFS was 3.4(SD 2.0). Inter-rater reliability was adequate, Krippendorff's α 0.69 (95%CI 0.62-0.74). A positive frailty screening was predictive of a non-home discharge location (OR 3.57, 95%CI 2.16-5.93), a higher in-hospital mortality rate (OR 1.06-8.77), and a higher mortality rate within 12 months after discharge (OR 4.61, 95%CI 1.99-10.65) after adjustment for age, TBSA, and inhalation injury. Frail patients were more likely to be older (for<70 vs. ≥70 years odds ratio 2.88, 95%CI 1.95-4.25) and their comorbidities were more severe (ASA ≥3 vs 1-2 OR 6.43, 95%CI 4.26-9.70) (known group validity). The CFS was significantly related (rSpearman=0.55) to the Dutch Safety Management System (DSMS) frailty screening, reflecting a fair-good correlation between the CFS and DSMS frailty screening outcomes.

CONCLUSION

The Clinical Frailty scale is reliable and has shown its validity, including its association with adverse outcomes in patients with burn injury admitted to specialized burn care. Early frailty assessment with the CFS must be considered, to optimize early recognition and treatment of frailty.

What is the impact of a pre-hospital geriatrician led telephone 'Silver Triage' for older people living with frailty?

PURPOSE

Most older people are conveyed to hospital via ambulance, therefore presenting a focus to reduce hospitalisation. North Central London has introduced 'Silver Triage', a pre-hospital telephone support scheme where geriatricians support the London Ambulance Service with clinical decision-making.

METHODS

Data from the first 14 months was analysed descriptively.

RESULTS

There have been 452 Silver Triage cases (November 2021 to January 2023). 80% resulted in a decision to not convey. The mode clinical frailty scale (CFS) was 6. CFS did not influence conveyance rates. Prior to triage, paramedics thought hospitalisation was not required in 44% of cases (n = 72/165). All paramedics surveyed (n = 176) would use the service again. Most (66%, n = 108/164) felt they learnt something and 16% (n = 27/164) reported it changed their decision-making process.

CONCLUSION

Silver Triage has the potential to improve the care of older people by preventing unnecessary hospitalisation and has been well received by paramedics.

The impact of frailty on intra-hospital survival in older patients with COVID-19 infection: the importance of early identification. SEMI-COVID National Registry

BACKGROUND

Emerging evidence suggests that frailty may be a significant predictor of poor outcomes in older individuals hospitalized due to COVID-19. This study aims to determine the prognostic value of frailty on intrahospital patient survival.

METHODS

This observational, multicenter, nationwide study included patients aged 70 years and older who were hospitalized due to COVID-19 in Spain between March 1 and December 31, 2020. Patient data were obtained from the SEMI-COVID-19 Registry of the Spanish Society of Internal Medicine. Frailty was assessed using the Clinical Frailty Scale. The primary outcome was hospital survival. Cox proportional hazards models were used to assess predictors of survival.

RESULTS

A total of 1,878 participants (52% men and 48% women) were included, with 1,351 (71.9%) survivors and 527 (28.1%) non-survivors. The non-survivor group had higher mean age (83.5 vs. 81 years), comorbidities (6.3 vs. 5.3 points on the Charlson index), degree of dependency (26.8% vs. 12.4% severely dependent patients), and frailty (34.5% vs. 14.7% severely frail patients) compared to survivors. However, there were no differences in terms of sex. Our results demonstrate that a moderate-severe degree of frailty is the primary factor independently associated with shorter survival [HR 2.344 (1.437-3.823; p<0.001) for CFS 5-6 and 3.694 (2.155-6.330; p<0.001) for CFS 7-9].

CONCLUSION

Frailty is the main predictor of adverse outcomes in older patients with COVID-19. The utilization of tools such as the Clinical Frailty Scale is crucial for early detection in this population.

Variables Associated with 30-Day Mortality in Very Elderly COVID-19 Patients

BACKGROUND

Advanced age increases the risk for severe COVID-19. However, the risk factors for mortality from COVID-19 in very elderly patients (≥80-years-old) are unknown.

OBJECTIVE

Investigate the relationship of mortality with the clinical characteristics of very elderly COVID-19 patients.

MATERIALS AND METHODS

Very elderly patients who were hospitalized with COVID-19 from December 3, 2022 to January 1, 2023 were retrospectively examined. Sociodemographic and clinical variables were recorded and survival was recorded after 30 days.

RESULTS

We examined 181 patients (median age: 90.84 years; 114 older than 90 years). The median Barthel index was 30.69, and 55.8% of patients had severe or critical COVID-19 pneumonia. Forty-two patients (33.2%) received a high-flow nasal cannula or non-invasive ventilation, and only 4.4% received mechanical ventilation. The overall mortality was 35.9%, and there was no significant difference in mortality for the 80 to 90-year-old group and the over 90-year-old group (37.7% vs 32.8%, P=0.508). A multivariate analysis showed that the Barthel index (OR, 0.975; 95% CI, 0.962-0.989), serum creatinine (SCr) level (OR, 1.003; 95% CI, 1.000-1.006), white blood cell (WBC) count (OR, 1.160; 95% CI, 1.056-1.276), D-dimer level (OR, 1.060; 95% CI, 1.009-1.113), and corticosteroid use (OR, 0.268; 95% CI, 0.124-0.582) were significantly and independently related to 30-day mortality. A binary classification model based on the multivariate analysis had good predictive value (area under the curve, 0.794).

CONCLUSION

Very elderly COVID-19 patients have a high risk for mortality. The Barthel index, SCr, WBC count, D-dimer level, and corticosteroid use were independently associated with mortality.

Clinical frailty scale is useful in predicting return-to-home in patients admitted due to coronavirus disease

BACKGROUND

The spread of the novel severe acute respiratory syndrome coronavirus 2 infection has been prolonged, with the highly contagious Omicron variant becoming the predominant variant by 2022. Many patients admitted to dedicated coronavirus disease 2019 (COVID-19) wards (COVID-19 treatment units) develop disuse syndrome while being treated in the hospital, and their ability to perform activities of daily living declines, making it difficult for hospitals to discharge them. This study aimed to investigate the relationship between the degree of frailty and home discharge of patients admitted to a COVID-19 treatment units.

METHODS

This study retrospectively examined the in-patient medical records of 138 patients (82.7 ± 7.6 years old) admitted to a COVID-19 treatment unit from January to December 2022. The end-point was to determine the patients' ability to be discharged from the unit directly to home; such patients were classified into the 'Home discharge' group and compared with those in the 'Difficulty in discharge' group. The degree of frailty was determined based on the Clinical Frailty Scale (CFS), and the relationship with the endpoint was analysed. A receiver operating characteristic (ROC) curve was created and the cut-off value was calculated with the possibility of home discharge as the state variable and CFS as the test variable. Logistic regression analysis was conducted with the possibility of home discharge as the dependent variable and CFS as the independent variable.

RESULTS

There were 75 patients in the Home discharge group and 63 in the Difficulty in discharge group. ROC analysis showed a CFS cut-off value of 6 or more, with a sensitivity of 70.7% and a specificity of 84.1%. The results of the logistic regression analysis showed a significant correlation between possibility of home discharge and CFS even after adjusting for covariates, with an odds ratio of 13.44.

CONCLUSIONS

Based on the evaluation of the degree of frailty conducted in the COVID-19 treatment unit, it was possible to accurately predict whether a patient could be discharged directly to home after treatment CFS could be an effective screening tool to easily detect patients requiring ongoing hospitalisation even after the acute phase of treatment.

Ethical conflicts associated with COVID-19 pandemic, triage and frailty-unexpected positive disease progression in a 90-year-old patient: A case report

During the COVID 19 pandemic, advanced age, scoring systems, and a shortage of ICU beds were used as cut-offs for ICU admission. This case report describes the epicrisis of an elderly patient who was almost mistakenly not treated in an ICU.

Expert Consensus: Main Risk Factors for Poor Prognosis in COVID-19 and the Implications for Targeted Measures against SARS-CoV-2

The clinical evolution of patients infected with the Severe Acute Respiratory Coronavirus type 2 (SARS-CoV-2) depends on the complex interplay between viral and host factors. The evolution to less aggressive but better-transmitted viral variants, and the presence of immune memory responses in a growing number of vaccinated and/or virus-exposed individuals, has caused the pandemic to slowly wane in virulence. However, there are still patients with risk factors or comorbidities that put them at risk of poor outcomes in the event of having the coronavirus infectious disease 2019 (COVID-19). Among the different treatment options for patients with COVID-19, virus-targeted measures include antiviral drugs or monoclonal antibodies that may be provided in the early days of infection. The present expert consensus is based on a review of all the literature published between 1 July 2021 and 15 February 2022 that was carried out to establish the characteristics of patients, in terms of presence of risk factors or comorbidities, that may make them candidates for receiving any of the virus-targeted measures available in order to prevent a fatal outcome, such as severe disease or death. A total of 119 studies were included from the review of the literature and 159 were from the additional independent review carried out by the panelists a posteriori. Conditions found related to strong recommendation of the use of virus-targeted measures in the first days of COVID-19 were age above 80 years, or above 65 years with another risk factor; antineoplastic chemotherapy or active malignancy; HIV infection with CD4+ cell counts < 200/mm³; and treatment with anti-CD20 immunosuppressive drugs. There is also a strong recommendation against using the studied interventions in HIV-infected patients with a CD4+ nadir <200/mm³ or treatment with other immunosuppressants. Indications of therapies against SARS-CoV-2, regardless of vaccination status or history of infection, may still exist for some populations, even after COVID-19 has been declared to no longer be a global health emergency by the WHO.

The Clinical Frailty Scale for mortality prediction of old acutely admitted intensive care patients: a meta-analysis of individual patient-level data

BACKGROUND

This large-scale analysis pools individual data about the Clinical Frailty Scale (CFS) to predict outcome in the intensive care unit (ICU).

METHODS

A systematic search identified all clinical trials that used the CFS in the ICU (PubMed searched until 24th June 2020). All patients who were electively admitted were excluded. The primary outcome was ICU mortality. Regression models were estimated on the complete data set, and for missing data, multiple imputations were utilised. Cox models were adjusted for age, sex, and illness acuity score (SOFA, SAPS II or APACHE II).

RESULTS

12 studies from 30 countries with anonymised individualised patient data were included (n = 23,989 patients). In the univariate analysis for all patients, being frail (CFS ≥ 5) was associated with an increased risk of ICU mortality, but not after adjustment. In older patients (≥ 65 years) there was an independent association with ICU mortality both in the complete case analysis (HR 1.34 (95% CI 1.25-1.44), p < 0.0001) and in the multiple imputation analysis (HR 1.35 (95% CI 1.26-1.45), p < 0.0001, adjusted for SOFA). In older patients, being vulnerable (CFS 4) alone did not significantly differ from being frail. After adjustment, a CFS of 4-5, 6, and ≥ 7 was associated with a significantly worse outcome compared to CFS of 1-3.

CONCLUSIONS

Being frail is associated with a significantly increased risk for ICU mortality in older patients, while being vulnerable alone did not significantly differ. New Frailty categories might reflect its "continuum" better and predict ICU outcome more accurately.

TRIAL REGISTRATION

Open Science Framework (OSF: https://osf.io/8buwk/ ).

Mortality in COVID-19 older patients hospitalized in a geriatric ward: Is obesity protective?

BACKGROUNDS

To investigate the relationship between obesity and 30-day mortality in a cohort of older hospitalized COVID-19 inpatients.

METHODS

Included patients were aged 70 years or more; hospitalized in acute geriatric wards between March and December 2020; with a positive PCR for COVID-19; not candidate to intensive care unit admission. Clinical data were collected from patients electronic medical records. Data on 30-day mortality were retrieved from the hospital administrative database.

RESULTS

Patients included (N = 294) were on average 83.4 ± 6.7 years old, 50.7% were women, and 21.7% were obese (BMI > 30 kg/m²). At 30-day, 85 (28.9%) patients were deceased. Compared to survivors in bivariable analysis, deceased patients were older (84.6 ± 7.6 vs 83.0 ± 6.3 years), more frequently with very complex health status (63.5% vs 39.7%, P < .001), but less frequently obese (13.4% vs 24.9%, P = .033) at admission. Over their stay, deceased patients more frequently (all P < .001) developed radiologic signs of COVID-19 (84.7% vs 58.9%), anorexia (84.7% vs 59.8%), hypernatremia (40.0% vs 10.5%), delirium (74.1% vs 30.1%), and need for oxygen (87.1% vs 46.4%) compared to survivors. In multivariable analysis that controlled for all markers of poor prognosis identified in bivariable analysis, obese patients remain with 64% (adjOR 0.36, 95%CI 0.14-0.95, P = .038) lower odds to be deceased at 30-day than non-obese patients.

CONCLUSIONS

In this population of older COVID-19 inpatients, an inverse association between obesity and 30-day mortality was observed even after adjusting for all already-known markers of poor prognosis. This result challenges previous observations in younger cohorts and would need to be replicated.

Long COVID and hypertension-related disorders: a report from the Japanese Society of Hypertension Project Team on COVID-19

The coronavirus disease 2019 (COVID-19) affects infected patients even after the acute phase and impairs their health and quality of life by causing a wide variety of symptoms, referred to as long COVID. Although the evidence is still insufficient, hypertension is suspected to be a potential risk factor for long COVID, and the occurrence of cardiovascular diseases seems to be a key facet of multiple conditions observed in long COVID. Nonetheless, there are few reports that comprehensively review the impacts of long COVID on hypertension and related disorders. As a sequel to our previous report in 2020 which reviewed the association of COVID-19 and hypertension, we summarize the possible influences of long COVID on hypertension-related organs, including the cardiovascular system, kidney, and endocrine system, as well as the pathophysiological mechanisms associated with the disorders in this review. Given that the clinical course of COVID-19 is highly affected by age and sex, we also review the impacts of these factors on long COVID. Lastly, we discuss areas of uncertainty and future directions, which may lead to better understanding and improved prognosis of clinical problems associated with COVID-19.

Inflammatory Biomarkers Differ among Hospitalized Veterans Infected with Alpha, Delta, and Omicron SARS-CoV-2 Variants

Mortality due to COVID-19 has been correlated with laboratory markers of inflammation, such as C-reactive protein (CRP). The lower mortality during Omicron variant infections could be explained by variant-specific immune responses or host factors, such as vaccination status. We hypothesized that infections due to Omicron variant cause less inflammation compared to Alpha and Delta, correlating with lower mortality. This was a retrospective cohort study of veterans hospitalized for COVID-19 at the Veterans Health Administration. We compared inflammatory markers among patients hospitalized during Omicron infection with those of Alpha and Delta. We reported the adjusted odds ratio (aOR) of the first laboratory results during hospitalization and in-hospital mortality, stratified by vaccination status. Of 2,075,564 Veterans tested for COVID-19, 29,075 Veterans met the criteria: Alpha (45.1%), Delta (23.9%), Omicron (31.0%). Odds of abnormal CRP in Delta (aOR = 1.85, 95% CI:1.64-2.09) and Alpha (aOR = 1.94, 95% CI:1.75-2.15) were significantly higher compared to Omicron. The same trend was observed for Ferritin, Alanine aminotransferase, Aspartate aminotransferase, Lactate dehydrogenase, and Albumin. The mortality in Delta (aOR = 1.92, 95% CI:1.73-2.12) and Alpha (aOR = 1.68, 95% CI:1.47-1.91) were higher than Omicron. The results remained significant after stratifying the outcomes based on vaccination status. Veterans infected with Omicron showed milder inflammatory responses and lower mortality than other variants.

Atypical presentation of COVID-19 in older patients is associated with frailty but not with adverse outcomes

PURPOSE

Older patients with COVID-19 can present with atypical complaints, such as falls or delirium. In other diseases, such an atypical presentation is associated with worse clinical outcomes. However, it is not known whether this extends to COVID-19. We aimed to study the association between atypical presentation of COVID-19, frailty and adverse outcomes, as well as the incidence of atypical presentation.

METHODS

We conducted a retrospective observational multi-center cohort study in eight hospitals in the Netherlands. We included patients aged ≥ 70 years hospitalized with COVID-19 between February 2020 until May 2020. Atypical presentation of COVID-19 was defined as presentation without fever, cough and/or dyspnea. We collected data concerning symptoms on admission, demographics and frailty parameters [e.g., Charlson Comorbidity Index (CCI) and Clinical Frailty Scale (CFS)]. Outcome data included Intensive Care Unit (ICU) admission, discharge destination and 30-day mortality.

RESULTS

We included 780 patients, 9.5% (n = 74) of those patients had an atypical presentation. Patients with an atypical presentation were older (80 years, IQR 76-86 years; versus 79 years, IQR 74-84, p = 0.044) and were more often classified as severely frail (CFS 6-9) compared to patients with a typical presentation (47.6% vs 28.7%, p = 0.004). Overall, there was no significant difference in 30-day mortality between the two groups in univariate analysis (32.4% vs 41.5%; p = 0.173) or in multivariate analysis [OR 0.59 (95% CI 0.34-1.0); p = 0.058].

CONCLUSIONS

In this study, patients with an atypical presentation of COVID-19 were more frail compared to patients with a typical presentation. Contrary to our expectations, an atypical presentation was not associated with worse outcomes.

A multidimensional approach to older patients during COVID-19 pandemic: a position paper of the Special Interest Group on Comprehensive Geriatric Assessment of the European Geriatric Medicine Society (EuGMS)

PURPOSE

The COVID-19 pandemic has been a dramatic trigger that has challenged the intrinsic capacity of older adults and of society. Due to the consequences for the older population worldwide, the Special Interest Group on Comprehensive Geriatric Assessment (CGA) of the European Geriatric Medicine Society (EuGMS) took the initiative of collecting evidence on the usefulness of the CGA-based multidimensional approach to older people during the COVID-19 pandemic.

METHODS

A narrative review of the most relevant articles published between January 2020 and November 2022 that focused on the multidimensional assessment of older adults during the COVID-19 pandemic.

RESULTS

Current evidence supports the critical role of the multidimensional approach to identify older adults hospitalized with COVID-19 at higher risk of longer hospitalization, functional decline, and short-term mortality. This approach appears to also be pivotal for the adequate stratification and management of the post-COVID condition as well as for the adoption of preventive measures (e.g., vaccinations, healthy lifestyle) among non-infected individuals.

CONCLUSION

Collecting information on multiple health domains (e.g., functional, cognitive, nutritional, social status, mobility, comorbidities, and polypharmacy) provides a better understanding of the intrinsic capacities and resilience of older adults affected by SARS-CoV-2 infection. The EuGMS SIG on CGA endorses the adoption of the multidimensional approach to guide the clinical management of older adults during the COVID-19 pandemic.

Frailty impacts immune responses to Moderna COVID-19 mRNA vaccine in older adults

BACKGROUND

Immune responses to COVID-19 mRNA vaccines have not been well characterized in frail older adults. We postulated that frailty is associated with impaired antibody and cellular mRNA vaccine responses.

METHODS

We followed older adults in a retirement facility with longitudinal clinical and serological samples from the first Moderna mRNA-1273 vaccine dose starting in February 2021 through their 3rd (booster) vaccine dose. Outcomes were antibody titers, antibody avidity, and AIM+ T cell function and phenotype. Statistical analysis used linear regression with clustered error for antibody titers over multiple timepoints with clinical predictors including, age, sex, prior infection status, and clinical frailty scale (CFS) score. T cell function analysis used linear regression models with clinical predictors and cellular memory phenotype variables.

RESULTS

Participants (n = 15) had median age of 90 years and mild, moderate, or severe frailty scores (n = 3, 7, or 5 respectively). Over the study time course, anti-spike antibody titers were 10-fold higher in individuals with lower frailty status (p = 0.001 and p = 0.005, unadjusted and adjusted for prior COVID-19 infection). Following the booster, titers to spike protein improved regardless of COVID-19 infection or degree of frailty (p = 0.82 and p = 0.29, respectively). Antibody avidity significantly declined over 6 months in all participants following 2 vaccine doses (p < 0.001), which was further impaired with higher frailty (p = 0.001). Notably, avidity increased to peak levels after the booster (p < 0.001). Overall antibody response was inversely correlated with a phenotype of immune-senescent T cells, CD8 + CD28- TEMRA cells (p = 0.036, adjusted for COVID-19 infection). Furthermore, there was increased detection of CD8 + CD28- TEMRA cells in individuals with greater frailty (p = 0.056, adjusted for COVID-19).

CONCLUSIONS

We evaluated the immune responses to the Moderna COVID-19 mRNA vaccine in frail older adults in a retirement community. A higher degree of frailty was associated with diminished antibody quantity and quality. However, a booster vaccine dose at 6 months overcame these effects. Frailty was associated with an increased immune-senescence phenotype that may contribute to the observed changes in the vaccine response. While the strength of our conclusions was limited by a small cohort, these results are important for guiding further investigation of vaccine responses in frail older adults.

Prevalence and association of frailty with SARS-CoV-2 infection in older adults in Southern Switzerland-Findings from the Corona Immunitas Ticino Study

BACKGROUND

Frailty is an age-associated state of increased vulnerability to stressors that strongly predicts poor health outcomes. Epidemiological evidence on frailty is limited during the COVID-19 pandemic, and whether frailty is associated with the risk of infection is unknown.

OBJECTIVES

We derived a robust Frailty Index (FI) to measure the prevalence of frailty and its risk factors in community-dwelling older adults in Southern Switzerland (Ticino), and we explored the association between frailty and serologically confirmed SARS-CoV-2 infection.

METHODS

In September 2020, we recruited a random sample of community-dwelling older adults (65 +) in the Corona Immunitas Ticino prospective cohort study (CIT) and assessed a variety of lifestyle and health characteristics. We selected 30 health-related variables, computed the Rockwood FI, and applied standard thresholds for robust (FI < 0.1), pre-frail (0.1 ≤ FI < 0.21), and frail (FI ≥ 0.21).

RESULTS

Complete data for the FI was available for 660 older adults. The FI score ranged between zero (no frailty) and 0.59. The prevalence of frailty and pre-frailty were 10.3% and 48.2% respectively. The log-transformed FI score increased by age similarly in males and females, on average by 2.8% (p < 0.001) per one-year increase in age. Out of 481 participants with a valid serological test, 11.2% were seropositive to either anti-SARS-CoV-2 IgA or IgG. The frailty status and seropositivity were not statistically associated (p = 0.236).

CONCLUSION

Advanced age increases the risk of frailty. The risk of COVID-19 infection in older adults may not differ by frailty status.

Risk Factors of Severe COVID-19: A Review of Host, Viral and Environmental Factors

The clinical course and outcome of COVID-19 are highly variable, ranging from asymptomatic infections to severe disease and death. Understanding the risk factors of severe COVID-19 is relevant both in the clinical setting and at the epidemiological level. Here, we provide an overview of host, viral and environmental factors that have been shown or (in some cases) hypothesized to be associated with severe clinical outcomes. The factors considered in detail include the age and frailty, genetic polymorphisms, biological sex (and pregnancy), co- and superinfections, non-communicable comorbidities, immunological history, microbiota, and lifestyle of the patient; viral genetic variation and infecting dose; socioeconomic factors; and air pollution. For each category, we compile (sometimes conflicting) evidence for the association of the factor with COVID-19 outcomes (including the strength of the effect) and outline possible action mechanisms. We also discuss the complex interactions between the various risk factors.

Association between Clinical Frailty Scale (CFS) and clinical presentation and outcomes in older inpatients with COVID-19

BACKGROUND

Frailty is a physiological condition characterized by a decreased reserve to stressors. In patients with COVID-19, frailty is a risk factor for in-hospital mortality. The aim of this study was to assess the relationship between clinical presentation, analytical and radiological parameters at admission, and clinical outcomes according to frailty, as defined by the Clinical Frailty Scale (CFS), in old people hospitalized with COVID-19.

MATERIALS AND METHODS

This retrospective cohort study included people aged 65 years and older and admitted with community-acquired COVID-19 from 3 March 2020 to 31 April 2021. Patients were categorized using the CFS. Primary outcomes were symptoms of COVID-19 prior to admission, mortality, readmission, admission in intensive care unit (ICU), and need for invasive mechanical ventilation. Analysis of clinical symptoms, clinical outcomes, and CFS was performed using multivariable logistic regression, and results were expressed as odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Of the 785 included patients, 326 (41.5%, 95% CI 38.1%-45.0%) were defined as frail (CFS ≥ 5 points): 208 (26.5%, 95% CI 23.5%-29.7%) presented mild-moderate frailty (CFS 5-6 points) and 118 (15.0%, 95% CI 12.7%-17.7%), severe frailty (7-9 points). After adjusting for epidemiological variables (age, gender, residence in a nursing home, and Charlson comorbidity index), frail patients were significantly less likely to present dry cough (OR 0.58, 95% CI 0.40-0.83), myalgia-arthralgia (OR 0.46, 95% CI 0.29-0.75), and anosmia-dysgeusia (OR 0.46, 95% CI 0.23-0.94). Confusion was more common in severely frail patients (OR 3.14; 95% CI 1.64-5.97). After adjusting for epidemiological variables, the risk of in-hospital mortality was higher in frail patients (OR 2.79, 95% CI 1.79-4.25), including both those with mild-moderate frailty (OR 1.98, 95% CI 1.23-3.19) and severe frailty (OR 5.44, 95% CI 3.14-9.42). Readmission was higher in frail patients (OR 2.11, 95% CI 1.07-4.16), but only in mild-moderate frailty (OR 2.35, 95% CI 1.17-4.75)..

CONCLUSION

Frail patients presented atypical symptoms (less dry cough, myalgia-arthralgia, and anosmia-dysgeusia, and more confusion). Frailty was an independent predictor for death, regardless of severity, and mild-moderate frailty was associated with readmission.

Cytokine absorption in critically ill old COVID-19 patients with renal failure: A retrospective analysis of 503 intensive care unit patients

BACKGROUND

COVID-19 is associated with cytokine release in critical disease states. Thus, cytokine absorption has been proposed as a therapeutic option. This study investigated the influence of cytokine absorption on mortality in old critical patients with COVID-19 and renal failure admitted to intensive care units (ICU).

METHODS

This retrospective analysis of a prospective international observation study (the COVIP study) analysed ICU patients≥70 years with COVID-19. Data on Sequential Organ Failure Assessment (SOFA) score, clinical frailty scale (CFS), ICU therapy details including renal replacement therapy (RRT) with/without cytokine absorption were collected. The cytokine absorption group was compared to patients receiving RRT without cytokine absorptionRESULTS:Among 3927 patients, 503 received RRT; among them 47 patients were treated with cytokine absorption. Mortality rates were high in both groups with increased rates in the cytokine group for ICU mortality and 30-day mortality, but not for 3-month mortality. Logistic regression analysis indicated that SOFA-score, but not cytokine absorption was associated with mortality.

CONCLUSIONS

Critical COVID-19 patients with renal failure treated with cytokine absorption showed higher short term mortality rates when compared to patients with renal replacement therapy alone. Mortality is associated with disease severity, but not cytokine absorption in a multivariate analysis.

Frailty Reduces Vaccine Effectiveness Against SARS-CoV-2 Infection: A Test-Negative Case Control Study Using National VA Data

OBJECTIVES

To assess the variation of vaccine effectiveness against SARS-CoV-2 infection during the Delta wave according to frailty status among U.S. veterans.

DESIGN

Test-negative case-control study of SARS-CoV-2 mRNA vaccine effectiveness.

SETTING

Veterans Health Administration (VHA) medical centers.

PARTICIPANTS

Veterans 19 years and older who had at least one COVID-19/Flu like symptoms and received a SARS-CoV-2 PCR or antigen test at VHA medical centers between July 25 to September 30, 2021.

INTERVENTION

mRNA vaccination.

MEASUREMENTS

New SARS-CoV-2 infection. Vaccine effectiveness was defined as 1-odds of vaccination in cases/odds of vaccination in controls, where cases were patients who had a COVID-19 test and tested positive for SARS-CoV-2, and controls were those who tested negative. Frailty was measured using the VA frailty index, categorized as robust (0-<0.1), pre-frail (≥0.1-<0.21) and frail (≥0.21).

RESULTS

A total of 58,604 patients (age:58.9±17.0, median:61, IQR:45-72; 87.5%men; 68.1%white; 1.3%African American, 8.3%Hispanic) were included in the study. Of these, 27,733 (47.3%) were robust, 16,276 (27.8%) were prefrail, and 14,595 (24.9%) were frail. mRNA vaccine effectiveness against the Delta variant symptomatic infection was lower in patients with frailty, 62.8 %(95%CI:59.8-65.7), versus prefrail 73.9%(95%CI:72.0-75.7), and robust, 77.0 %(95%CI:75.7-78.3).

CONCLUSIONS

This test-negative case control study showed that mRNA vaccine effectiveness against infection declined in veterans with frailty. Frailty status is a factor to consider when designing, developing, and evaluating COVID-19 vaccines.

Reliability and validity of the post COVID-19 condition stigma questionnaire: A prospective cohort study

BACKGROUND

Many of the 10-20% percent of COVID-19 survivors who develop Post COVID-19 Condition (PCC, or Long COVID) describe experiences suggestive of stigmatization, a known social determinant of health. Our objective was to develop an instrument, the Post COVID-19 Condition Stigma Questionnaire (PCCSQ), with which to quantify and characterise PCC-related stigma.

METHODS

We conducted a prospective cohort study to assess the reliability and validity of the PCCSQ. Patients referred to our Post COVID-19 Clinic in the Canadian City of Edmonton, Alberta between May 29, 2021 and May 24, 2022 who met inclusion criteria (attending an academic post COVID-19 clinic; age ≥18 years; persistent symptoms and impairment at ≥ 12 weeks since PCR positive acute COVID-19 infection; English-speaking; internet access; consenting) were invited to complete online questionnaires, including the PCCSQ. Analyses were conducted to estimate the instrument's reliability, construct validity, and association with relevant instruments and defined health outcomes.

FINDINGS

Of the 198 patients invited, 145 (73%) met inclusion criteria and completed usable questionnaires. Total Stigma Score (TSS) on the PCCSQ ranged from 40 to 174/200. The mean (SD) was 103.9 (31.3). Cronbach's alpha was 0.97. Test-retest reliability was 0.92. Factor analysis supported a 6-factor latent construct. Subtest reliabilities were >0.75. Individuals reporting increased TSS occurred across all demographic groups. Increased risk categories included women, white ethnicity, and limited educational opportunities. TSS was positively correlated with symptoms, depression, anxiety, loneliness, reduced self-esteem, thoughts of self-harm, post-COVID functional status, frailty, EQ5D5L score, and number of ED visits. It was negatively correlated with perceived social support, 6-min walk distance, and EQ5D5L global rating. Stigma scores were significantly increased among participants reporting employment status as disabled.

INTERPRETATION

Our findings suggested that the PCCSQ is a valid, reliable tool with which to estimate PCC-related stigma. It allows for the identification of patients reporting increased stigma and offers insights into their experiences.

FUNDING

The Edmonton Post COVID-19 Clinic is supported by the University of Alberta and Alberta Health Services. No additional sources of funding were involved in the execution of this research study.

Frailty and the impacts of the COVID-19 pandemic on community-living middle-aged and older adults: an analysis of data from the Canadian Longitudinal Study on Aging (CLSA)

BACKGROUND

frailty imparts a higher risk for hospitalisation, mortality and morbidity due to COVID-19 infection, but the broader impacts of the pandemic and associated public health measures on community-living people with frailty are less known.

METHODS

we used cross-sectional data from 23,974 Canadian Longitudinal Study on Aging participants who completed a COVID-19 interview (Sept-Dec 2020). Participants were included regardless of whether they had COVID-19 or not. They were asked about health, resource, relationship and health care access impacts experienced during the pandemic. Unadjusted and adjusted prevalence of impacts was estimated by frailty index quartile. We further examined if the relationship with frailty was modified by sex, age or household income.

RESULTS

community-living adults (50-90 years) with greater pre-pandemic frailty reported more negative impacts during the first year of the pandemic. The frailty gradient was not explained by socio-demographic or health behaviour factors. The largest absolute difference in adjusted prevalence between the most and least frail quartiles was 15.1% (challenges accessing healthcare), 13.3% (being ill) and 7.4% (increased verbal/physical conflict). The association between frailty and healthcare access differed by age where the youngest age group tended to experience the most challenges, especially for those categorised as most frail.

CONCLUSION

although frailty has been endorsed as a tool to inform estimates of COVID-19 risk, our data suggest it may have a broader role in primary care and public health by identifying people who may benefit from interventions to reduce health and social impacts of COVID-19 and future pandemics.

Validating the Centre of Excellence on Longevity Self-AdMinistered (CESAM) Questionnaire: An Online Self-Reported Tool for Frailty Assessment of Older Adults

OBJECTIVES

Subjective health measures are often used to assess frailty, but the validity of self-reported online tools to identify frailty remains to be established. We aimed to assess concurrent, known-groups, convergent and predictive validity of the Centre of Excellence on Longevity Self-AdMinistered (CESAM) questionnaire for frailty assessment of older adults in an outpatient setting.

DESIGN

Cross-sectional analysis of 120 participants.

SETTING AND PARTICIPANTS

Participants of age ≥65 were recruited from an outpatient geriatric clinic. Individuals who had severe neurological, cognitive, or motor deficits were excluded.

METHODS

We assessed concurrent validity with area under receiver operating characteristic curve (AUC) against the Frailty Index (FI) and Clinical Frailty Scale (CFS). We analyzed known-groups validity between CESAM scores with frailty status (CFS and FI), Modified Barthel Index (MBI), and modified Chinese Mini-Mental State Examination (mCMMSE) using 1-way analysis of variance. We evaluated convergent validity using correlations with MBI, the Lawton index, mCMMSE, and Geriatric Depression Scale (GDS). Associations between CESAM-identified frailty for clinician-diagnosed geriatric syndromes, and health-related quality of life (HRQoL) was analyzed using regression analysis.

RESULTS

The CESAM questionnaire demonstrated excellent diagnostic performance for frailty using FI ≥0.25 (AUC = 0.88; 95% CI: 0.82-0.94; P < .001) and CFS ≥4 (AUC = 0.78; 95% CI: 0.68-0.88; P < .001). CESAM scores increased significantly with increasing frailty (both CFS and FI), lower MBI, and lower mCMMSE scores (all P < .001), indicating concurrent validity. The moderate-good correlation of CESAM scores with MBI (r = -0.61; P < 0.001), Lawton Index (r = -0.54; P < .001), mCMMSE (r = -0.53; P < .001) and GDS (r = 0.58; P < .001) supports convergent validity. Using a cutoff of ≥8 for frailty identification, CESAM-identified frailty was associated with cognitive impairment (OR = 3.7; 95% CI: 1.7-8.2; P = .001) depression (OR = 4.0; 95% CI: 1.7-9.6; P = .002), falls (OR = 3.1; 95% CI: 1.2-8.2; P = .021) and poorer HRQoL (β = -0.1; 95% CI: -0.2 to -0.02; P = .017).

CONCLUSION AND IMPLICATIONS

Our results support the validity of an online self-reported tool to identify frailty and geriatric syndromes in an outpatient setting, an approach that is potentially applicable for remote screening of frailty.

Two Years with COVID-19: The Electronic Frailty Index Identifies High-Risk Patients in the Stockholm GeroCovid Study

INTRODUCTION

Frailty, a measure of biological aging, has been linked to worse COVID-19 outcomes. However, as the mortality differs across the COVID-19 waves, it is less clear whether a medical record-based electronic frailty index (eFI) that we have previously developed for older adults could be used for risk stratification in hospitalized COVID-19 patients.

OBJECTIVES

The aim of the study was to examine the association of frailty with mortality, readmission, and length of stay in older COVID-19 patients and to compare the predictive accuracy of the eFI to other frailty and comorbidity measures.

METHODS

This was a retrospective cohort study using electronic health records (EHRs) from nine geriatric clinics in Stockholm, Sweden, comprising 3,980 COVID-19 patients (mean age 81.6 years) admitted between March 2020 and March 2022. Frailty was assessed using a 48-item eFI developed for Swedish geriatric patients, the Clinical Frailty Scale, and the Hospital Frailty Risk Score. Comorbidity was measured using the Charlson Comorbidity Index. We analyzed in-hospital mortality and 30-day readmission using logistic regression, 30-day and 6-month mortality using Cox regression, and the length of stay using linear regression. Predictive accuracy of the logistic regression and Cox models was evaluated by area under the receiver operating characteristic curve (AUC) and Harrell's C-statistic, respectively.

RESULTS

Across the study period, the in-hospital mortality rate decreased from 13.9% in the first wave to 3.6% in the latest (Omicron) wave. Controlling for age and sex, a 10% increment in the eFI was significantly associated with higher risks of in-hospital mortality (odds ratio = 2.95; 95% confidence interval = 2.42-3.62), 30-day mortality (hazard ratio [HR] = 2.39; 2.08-2.74), 6-month mortality (HR = 2.29; 2.04-2.56), and a longer length of stay (β-coefficient = 2.00; 1.65-2.34) but not with 30-day readmission. The association between the eFI and in-hospital mortality remained robust across the waves, even after the vaccination rollout. Among all measures, the eFI had the best discrimination for in-hospital (AUC = 0.780), 30-day (Harrell's C = 0.733), and 6-month mortality (Harrell's C = 0.719).

CONCLUSION

An eFI based on routinely collected EHRs can be applied in identifying high-risk older COVID-19 patients during the continuing pandemic.

Aetiological and prognostic roles of frailty, multimorbidity and socioeconomic characteristics in the development of SARS-CoV-2 health outcomes: protocol for systematic reviews of population-based studies

INTRODUCTION

There is growing evidence that the impact of COVID-19 crisis may be stronger for individuals with multimorbidity, frailty and lower socioeconomic status. Existing reviews focus on few, mainly short-term effects of COVID-19 illness and patients with single chronic disease. Information is also largely missing for population representative samples.Applying population-based approach, the systematic reviews will have two objectives: (1) to evaluate the aetiological roles of frailty, multimorbidity and socioeconomic status on SARS-CoV-2 infection probability, hospitalisation, intensive care unit (ICU) admission, mechanical ventilation and COVID-19 related mortality among general population and (2) to investigate the prognostic roles of frailty, multimorbidity and socioeconomic characteristics on the risk of hospitalisation, ICU admission, mechanical ventilation, COVID-19 mortality, functioning, quality of life, disability, mental health and work absence.

METHODS AND ANALYSIS

For this ongoing work, four databases were searched: PubMed, Embase, WHO COVID-19 Global literature on coronavirus disease and PsycINFO, for the period between January 2020 and April 7 2021. Peer-reviewed published literature in English and all types of population-based studies will be considered. Studies using standard tools to assess multimorbidity such as disease count, comorbidity indices or disease combinations will be retained, as well as studies with standard scales and scores for frailty or measurement of a socioeconomic gradient. Initial search included 10 139 articles, 411 for full-text reading. Results will be summarised by risk factor, objective and outcome. The feasibility of meta-analysis will be determined by the findings and will aim to better understand uncertainties of the results. Quality of studies will be assessed using standardised scales.

ETHICS AND DISSEMINATION

The study will be based on published evidence, and it is exempt from the ethical approval. This work is part of the Population Health Information Research Infrastructure (PHIRI) project. Dissemination of the results will imply conference presentation, submission for scientific publication and PHIRI project report.

PROSPERO REGISTRATION NUMBER

CRD42021249444.

Zulfiqar Frailty Scale (ZFS): Concordance Study with the Clinical Frailty Scale (CFS)

Introduction: We designed a new scale for the rapid detection of frailty for use in primary care, referred to as the Zulfiqar Frailty Scale (ZFS). Objective: To evaluate the performance of the “ZFS” tool to screen for frailty as defined in the Clinical Frailty Scale (CFS) criteria in an ambulatory population of patients at least 75 years old. Method: A prospective study conducted in Alsace, France, for a duration of 6 months that included patients aged 75 and over was judged to be autonomous with an ADL (Activity of Daily Living) > 4/6. Results: In this ambulatory population of 124 patients with an average age of 79 years, the completion time for our scale was less than two minutes, and the staff required no training beforehand. Sensibility was 67%, while specificity was 87%. The positive predictive value was 80%, and the negative predictive value was 77%. The Youden index was 59.8%. In our study, we have a moderate correlation between CFS and ZFS (r = 0.674 with 95%CI = [0.565; 0.760]; p-value < 2.2 × 10−16 < 0.05). The Pearson correlations between these two geriatric scores were all strong and roughly equivalent to each other. The kappa of Cohen (k) = 0.46 (Unweighted), moderate concordance between the ZFS and CFS scales according to Fleiss classification. Conclusion: The “ZFS” tool makes it possible to screen for frailty with a high level of specificity and positive/negative predictive value.

Frailty and Survival After In-Hospital Cardiopulmonary Resuscitation

BACKGROUND

Older adults face high mortality following resuscitation efforts for in-hospital cardiac arrest. Less is known about the role of frailty in survival to discharge after in-hospital cardiopulmonary resuscitation.

OBJECTIVE

To investigate whether frailty, measured by the Clinical Frailty Scale, is associated with mortality after cardiopulmonary resuscitation following in-hospital cardiac arrest in older adults in the USA.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients ≥ 65 years who had undergone cardiopulmonary resuscitation during an inpatient admission at two urban academic hospitals and three suburban community hospitals within a Boston area healthcare system from January 2018-January 2020. Patients with Clinical Frailty Scale scores 1-3 were considered not frail, 4-6 were considered very mildly, mildly, and moderately frail, respectively, and 7-9 were considered severely frail.

MAIN MEASURES

In-hospital mortality after cardiopulmonary resuscitation.

KEY RESULTS

Among 324 patients who underwent cardiopulmonary resuscitation following in-hospital cardiac arrest, 73.1% experienced in-hospital mortality. Patients with a Clinical Frailty Scale score of 1-3 had 54% in-hospital mortality, which increased to 66%, 78%, 84%, and 84% for those with a Clinical Frailty Scale score of 4, 5, 6, and 7-9, respectively (p = 0.001). After adjusting for age, sex, race, and Charlson Comorbidity Index, higher frailty scores were significantly associated with higher odds of in-hospital mortality. Compared to those with a Clinical Frailty Scale score of 1-3, odds ratios (95% CI) for in-hospital mortality for patients with a Clinical Frailty Scale score of 4, 5, 6, and 7-9 were 1.6 (0.8-3.3), 3.0 (1.3-7.1), 4.4 (1.9-9.9), and 4.6 (1.8-11.8), respectively (p = 0.001).

CONCLUSIONS

Higher levels of frailty are associated with increased mortality after in-hospital cardiopulmonary resuscitation in older adults. Clinicians may consider using the Clinical Frailty Scale to help guide goals of care conversations, including discussion of code status, in this patient population.

Delirium in older COVID-19 patients: Evaluating risk factors and outcomes

OBJECTIVES

A high incidence of delirium has been reported in older patients with Coronavirus disease 2019 (COVID-19). We aimed to identify determinants of delirium, including the Clinical Frailty Scale, in hospitalized older patients with COVID-19. Furthermore, we aimed to study the association of delirium independent of frailty with in-hospital outcomes in older COVID-19 patients.

METHODS

This study was performed within the framework of the multi-center COVID-OLD cohort study and included patients aged ≥60 years who were admitted to the general ward because of COVID-19 in the Netherlands between February and May 2020. Data were collected on demographics, co-morbidity, disease severity, and geriatric parameters. Prevalence of delirium during hospital admission was recorded based on delirium screening using the Delirium Observation Screening Scale (DOSS) which was scored three times daily. A DOSS score ≥3 was followed by a delirium assessment by the ward physician In-hospital outcomes included length of stay, discharge destination, and mortality.

RESULTS

A total of 412 patients were included (median age 76, 58% male). Delirium was present in 82 patients. In multivariable analysis, previous episode of delirium (Odds ratio [OR] 8.9 [95% CI 2.3-33.6] p = 0.001), and pre-existent memory problems (OR 7.6 [95% CI 3.1-22.5] p < 0.001) were associated with increased delirium risk. Clinical Frailty Scale was associated with increased delirium risk (OR 1.63 [95%CI 1.40-1.90] p < 0.001) in univariable analysis, but not in multivariable analysis. Patients who developed delirium had a shorter symptom duration and lower levels of C-reactive protein upon presentation, whereas vital parameters did not differ. Patients who developed a delirium had a longer hospital stay and were more often discharged to a nursing home. Delirium was associated with mortality (OR 2.84 [95% CI1.71-4.72] p < 0.001), but not in multivariable analyses.

CONCLUSIONS

A previous delirium and pre-existent memory problems were associated with delirium risk in COVID-19. Delirium was not an independent predictor of mortality after adjustment for frailty.

Geriatric Health Care During the COVID-19 Pandemic: Managing the Health Crisis

COVID-19 pandemic significantly threatens the health and well-being of older adults. Aging-related changes, including multimorbidity, weakened immunity and frailty, may make older people more susceptible to severe infection and place them at higher risk of morbidity and mortality from COVID-19. Various quarantine measures have been implemented to control the spread of COVID-19. Nevertheless, such social distancing has disrupted routine health care practices, such as accessibility of medical services and long-term continuous care services. The medical management of older adults with multimorbidity is significantly afflicted by COVID-19. Older persons with frailty or multiple chronic disease may poorly adapt to the altered health care system, having detrimental consequences on their physical and mental health. COVID-19 pandemic has posed great challenges to the health of older adults. We highlighted the difficulties and obstacles of older adults during this unprecedented time. Also, we provided potential strategies and recommendations for actions to mitigate the COVID-19 pandemic threats. Certain strategies like community primary health care, medication delivery and home care support are adopted by many health facilities and caregivers, whereas other services such as internet hospital and virtual medical care are promoted to be accessible in many regions. However, guidelines and policies based on high-quality data are still needed for better health promotion of older groups with increasing resilience during the COVID-19 pandemic.

Development and validation of an early warning model for hospitalized COVID-19 patients: a multi-center retrospective cohort study

Background

Timely identification of deteriorating COVID-19 patients is needed to guide changes in clinical management and admission to intensive care units (ICUs). There is significant concern that widely used Early warning scores (EWSs) underestimate illness severity in COVID-19 patients and therefore, we developed an early warning model specifically for COVID-19 patients.

Methods

We retrospectively collected electronic medical record data to extract predictors and used these to fit a random forest model. To simulate the situation in which the model would have been developed after the first and implemented during the second COVID-19 ‘wave’ in the Netherlands, we performed a temporal validation by splitting all included patients into groups admitted before and after August 1, 2020. Furthermore, we propose a method for dynamic model updating to retain model performance over time. We evaluated model discrimination and calibration, performed a decision curve analysis, and quantified the importance of predictors using SHapley Additive exPlanations values.

Results

We included 3514 COVID-19 patient admissions from six Dutch hospitals between February 2020 and May 2021, and included a total of 18 predictors for model fitting. The model showed a higher discriminative performance in terms of partial area under the receiver operating characteristic curve (0.82 [0.80–0.84]) compared to the National early warning score (0.72 [0.69–0.74]) and the Modified early warning score (0.67 [0.65–0.69]), a greater net benefit over a range of clinically relevant model thresholds, and relatively good calibration (intercept = 0.03 [− 0.09 to 0.14], slope = 0.79 [0.73–0.86]).

Conclusions

This study shows the potential benefit of moving from early warning models for the general inpatient population to models for specific patient groups. Further (independent) validation of the model is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40635-022-00465-4.

[Coronavirus disease 2019 and frailty]

Der Verlauf der Coronavirus disease 2019 (COVID-19) ist individuell sehr unterschiedlich. Menschen höheren Lebensalters mit Komorbiditäten sind gefährdeter, schwer zu erkranken oder zu versterben. Gebrechlichkeit (Frailty) ist ein wesentlicher Risikofaktor. Ein Fünftel der Bevölkerung in Mitteleuropa ist älter als 65 Jahre, 10–15 % davon sind als „frail“ anzusehen. Die Pandemie bringt die Gesundheitssysteme vieler Länder an deren Grenzen. Die Entscheidung, welche Patienten noch intensivmedizinisch behandelt werden, führt zu ethischen Diskussionen. Die Clinical Frailty Scale von Rockwood (CFS; CMAJ 173:489–495, 2005) wird in manchen Ländern eingesetzt, diese Entscheidungen zu unterstützen.

Von COVID-19 betroffene 80-jährige Patienten haben ein fast 3,6faches Sterblichkeitsrisiko, verglichen mit der Altersgruppe von 18 bis 49 Jahren. Das Risiko gebrechlicher Patienten (CFS-Scores 6–9) ist mehr als 3fach höher als von robusten (CFS-Scores 1–3). Ein CFS-Cut-off-Wert ≥ 6 korreliert mit der Mortalität von COVID-19-Patienten über 65 Jahre. Das mittel- und längerfristige Überleben ist auch mit dem Ausmaß von „Frailty“ vor der Erkrankung und weniger mit dem Schweregrad der COVID-19 assoziiert.

Besonders Patienten über 60 Jahre sind gefährdet, bei moderaten und schweren COVID-19-Verläufen rasch Muskelmasse zu verlieren. Patienten auf Intensive Care Units (ICU) verlieren innerhalb von 10 Tagen 20–30 % der Oberschenkelstreckmuskulaturmasse. Das Ausmaß der COVID-19-assoziierten Sarkopenie bestimmt wesentlich den Verlauf der Erkrankung und macht individuelle Rehabilitationsprogrammen erforderlich. Bis zu 50 % der hospitalisierten Patienten benötigen weitere Rehabilitation nach der Entlassung. Aerobes Training mit niedriger Intensität, kombiniert mit Krafttraining, sowie die Sicherstellung einer ausreichenden Energie- und Eiweißzufuhr sind unerlässlich.

Frailty and risks of all-cause and cause-specific death in community-dwelling adults: a systematic review and meta-analysis

BACKGROUND

The associations of frailty with all-cause and cause-specific mortality remain unclear. Therefore, we performed this meta-analysis to fill this gap.

METHODS

We searched the PubMed and Embase databases through June 2022. Prospective cohort studies or clinical trials examining frailty were evaluated, and the multiple adjusted risk estimates of all-cause and cause-specific mortality, such as death from cardiovascular disease (CVD), cancer, respiratory illness, dementia, infection, and coronavirus disease 2019 (COVID-19), were included. A random effects model was used to calculate the summary hazard ratio (HR).

RESULTS

Fifty-eight studies were included for the qualitative systematic review, of which fifty-six studies were eligible for the quantitative meta-analysis, and the studies included a total of 1,852,951 individuals and more than 145,276 deaths. Compared with healthy adults, frail adults had a significantly higher risk of mortality from all causes (HR 2.40; 95% CI 2.17-2.65), CVD (HR 2.64; 95% CI 2.20-3.17), respiratory illness (HR 4.91; 95% CI 2.97-8.12), and cancer (HR 1.97; 95% CI 1.50-2.57). Similar results were found for the association between prefrail adults and mortality risk. In addition, based on the studies that have reported the HRs of the mortality risk per 0.1 and per 0.01 increase in the frailty index, we obtained consistent results.

CONCLUSIONS

The present study demonstrated that frailty was not only significantly related to an increased risk of all-cause mortality but was also a strong predictor of cause-specific mortality from CVD, cancer, and respiratory illness in community-dwelling adults. More studies are warranted to clarify the relationship between frailty and cause-specific mortality from dementia, infection, and COVID-19.

TRIAL REGISTRATION

PROSPERO (CRD42021276021).

In-hospital mortality prediction using frailty scale and severity score in elderly patients with severe COVID-19

Background

Elderly patients with coronavirus disease 2019 (COVID-19) have a high disease severity and mortality. However, the use of the frailty scale and severity score to predict in-hospital mortality in the elderly is not well established. Therefore, in this study, we investigated the use of these scores in COVID-19 cases in the elderly.

Methods

This multicenter retrospective study included severe COVID-19 patients admitted to seven hospitals in Korea from February 2020 to February 2021. We evaluated patients’ Acute Physiology and Chronic Health Evaluation (APACHE) II score; confusion, urea nitrogen, respiratory rate, blood pressure, 65 years of age and older (CURB-65) score; modified early warning score (MEWS); Sequential Organ Failure Assessment (SOFA) score; clinical frailty scale (CFS) score; and Charlson comorbidity index (CCI). We evaluated the predictive value using receiver operating characteristic (ROC) curve analysis.

Results

The study included 318 elderly patients with severe COVID-19 of whom 237 (74.5%) were survivors and 81 (25.5%) were non-survivors. The non-survivor group was older and had more comorbidities than the survivor group. The CFS, CCI, APACHE II, SOFA, CURB-65, and MEWS scores were higher in the non-survivor group than in the survivor group. When analyzed using the ROC curve, SOFA score showed the best performance in predicting the prognosis of elderly patients (area under the curve=0.766, P<0.001). CFS and SOFA scores were associated with in-hospital mortality in the multivariate analysis.

Conclusions

The SOFA score is an efficient tool for assessing in-hospital mortality in elderly patients with severe COVID-19.