Association of frailty with mortality in older inpatients with Covid-19: a cohort study

The association of inflammatory markers with frailty and in-hospital mortality in older COVID-19 patients

INTRODUCTION

During the COVID19 pandemic, older patients hospitalized for COVID-19 exhibited an increased mortality risk compared to younger patients. While ageing is associated with compromised immune responses and frailty, their contributions and interplay remain understudied. This study investigated the association between inflammatory markers and mortality and potential modification by frailty among older patients hospitalized for COVID-19.

METHODS

Data were from three multicenter Dutch cohorts (COVID-OLD, CliniCo, Covid-Predict). Patients were 70 years or older, hospitalized for COVID-19and categorized into three frailty groups: fit (Clinical frailty score (CFS) 1-3), pre-frail (CFS 4-5), and frail (CFS 6-9). Immunological markers (lymphocyte count, neutrophil count, C-reactive protein, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and systemic inflammation index (SII)) were measured at baseline. Associations with in hospital mortality were examined using logistic regression.

RESULTS

A total of 1697 patients were included from COVID-OLD, 656 from Covid-Predict, and 574 from CliniCo. The median age was 79, 77, and 78 years for each cohort. Hospital mortality rates were 33 %, 27 % and 39 % in the three cohorts, respectively. A lower CRP was associated with a higher frailty score in all three cohorts (all p < 0.01). Lymphocyte count, neutrophil count, NLR, PLR, or SII, were similar across frailty groups. Higher CRP levels were associated with increased in-hospital mortality risk across all frailty groups, across all cohorts (OR (95 % CI), 2.88 (2.20-3.78), 3.15 (1.95-5.16), and 3.28 (1.87-5.92)), and frailty did not modify the association between inflammatory markers and in-hospital mortality (all p-interaction>0.05).

CONCLUSION

While frailty is a significant factor in determining overall outcomes in older patients, our study suggests that the elevated risk of mortality in older patients with frailty compared to fit patients is likely not explained by difference in inflammatory responses.

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.

Functional Dependence Prior to ICU Admission is Associated with Worse Clinical and Functional Outcomes in Individuals with COVID-19: A Prospective Observational Study

Objectives: To determine whether low functional capacity (FC) prior to intensive care unit (ICU) admission due to coronavirus disease 2019 (COVID-19) might be associated with worse clinical outcomes. To monitor FC until discharge from the ICU. To identify associations between physical outcomes and decreased FC at discharge from the ICU. Design: Prospective observational study conducted from March to August 2021. Setting: ICU for adult patients with COVID-19. Participants: Adults (≥18 years) with COVID-19. Interventions: Not applicable. Main outcome measures: Clinical and demographic data were obtained from medical records. At ICU admission, evaluation was made of FC using the Barthel index (BI), and of the level of mobility using the ICU mobility scale. At ICU discharge, FC and mobility level were reassessed, and muscle strength was measured using the Medical Research Council (MRC) scale and the handgrip test. Results: The study was performed with 108 individuals. At the initial assessment, 73.1% of the patients were functionally independent. Length of hospital stay (odds ratio [OR]  =  1.05; 95%confidence interval [CI]  =  1.00-1.10) and death (OR  =  5.27; 95%CI  =  1.37-20.28) were related to functional status prior to ICU admission. Between ICU admission and discharge, the BI evaluation indicated a functional decline of 22.5 points. Low mobility level (P  =  .003) and low muscle strength assessed by the MRC scale (P < .001), measured at ICU discharge, were associated with a greater decrease of FC during the ICU stay. Conclusions: Patients with COVID-19 who were functionally dependent prior to ICU admission presented worse clinical outcomes, with low functional status being associated with longer hospitalization and higher mortality. However, irrespective of the initial functionality status, the surviving individuals suffered from functional decline at ICU discharge. Greater functional decline during the ICU stay was associated with lower muscle strength and lower mobility level at ICU discharge.

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.

Application of Mixture and Non-mixture Cure Models in Survival Analysis of Patients With COVID-19

Background Due to the emergence of new COVID-19 mutations and an increase in re-infection rates, it has become an important priority for the medical community to identify the factors affecting the short- and long-term survival of patients. This study aimed to determine the risk factors of short- and long-term survival in patients with COVID-19 based on mixture and non-mixture cure models. Methodology In this study, the data of 880 patients with COVID-19 confirmed with polymerase chain reaction in Fereydunshahr city (Isfahan, Iran) from February 20, 2020, to December 21, 2021, were gathered, and the vital status of these patients was followed for at least one year. Due to the high rate of censoring, mixture and non-mixture cure models were applied to estimate the survival. Akaike information criterion values were used to evaluate the fit of the models. Results In this study, the mean age of the patients was 48.9 ± 21.23 years, and the estimated survival rates on the first day, the fourth day, the first week, the first month, and at one year were 0.997, 0.982, 0.973, 0.936, and 0.928, respectively. Among the parametric models, the log-logistic mixed cure model with the logit link, which showed the lowest Akaike information criterion value, demonstrated the best fit. The variables of age and prescribed medication type were significant predictors of long-term survival, while occupation was influential in the short-term survival of patients. Conclusions According to the results of this study, it can be concluded that elderly patients should observe health protocols more strictly and consider receiving booster vaccine doses. The log-logistic cure model with a logit link can be used for survival analysis in COVID-19 patients, a fraction of whom have long-term survival.

Effects of SARS-CoV-2 infection on health and functional capacity in institutionalized older adults

OBJECTIVE

To assess the effect of SARS-CoV-2 infection on the health conditions and functional capacity of older adults living in long-term care units in Maceió City - Alagoas State.

METHODS

A prospective cohort was conducted with institutionalized older adults of both sexes. Older adults were assessed for clinical conditions (diagnosis of chronic diseases and biochemical tests), functional capacity, and nutritional status. All assessments were repeated on two occasions, maintaining a 6-month interval between them.

RESULTS

The sample was composed of 289 older adults. Of the total, 98 (33.9%) were positive for COVID-19 and eight died (2.8%). Men were more likely to have COVID-19 (OR = 3.50; p < 0.01). It was observed that the disease contributed to increasing the frequency of dependent older adults after six months (OR = 1.38; p-interaction < 0.01). It was also observed that after six months of positive diagnosis for COVID-19, there was greater weight loss (p < 0.01), reduced BMI (p < 0.01), increased mean SBP (p = 0.04), and DBP (p = 0.03).

CONCLUSION

Effects of COVID-19 in institutionalized older adults go beyond acute complications and compromise blood pressure control, functional capacity, and favor weight loss.

Patients with low ALT levels are at increased risk for severe COVID-19

Introduction

Frailty is a known risk factor for many diseases, including COVID-19. However, many frail patients are undiagnosed as the diagnosis can be cumbersome. Alanine transaminase (ALT) is found not only in the liver but also in the muscle tissue, and multiple studies show that frail sarcopenic patients have lower ALT. Frail patients are at increased risk for severe COVID-19. We evaluated the association between pre-infection low ALT and the risk for severe COVID-19.

Methods

We collected data regarding all subjects tested for SARS-CoV-2 between 1 March 2020 and 31 December 2021 from a national state-mandatory HMO in Israel, serving more than 1.3 million patients. Clinical and laboratory data were collected, including ALT from the year prior to infection. Severe COVID-19 was defined either as death, ICU admission, or ≥10 hospitalization days. Patients with low ALT (ALT ≤ 10 IU/l) were compared with patients with normal ALT (11-40 IU/l). Patients younger than 18 years with a diagnosis of liver disease and with ALT > 40 IU/l were excluded.

Results

During the study period, 58,961 patients tested positive for SARS-CoV-2. The patients in the low ALT group were younger (40.53 vs. 42.73, p < 0.001), less likely to be males (12.3 vs. 38.7%, p < 0.001), and had lower BMI (25.97 vs. 27.15, p < 0.001). The patients in the low ALT group had higher mortality (2.36 vs. 0.57%, p < 0.001), more ICU hospitalizations (0.49 vs. 0.41%, p = 0.47), and more prolonged hospitalizations [2.63% (95% CI 2-3.2%) vs. 0.98% (95% CI 0.86-1.1%) p < 0.001]. In multivariate logistic regression analyses, low ALT was associated with an increased risk of severe COVID-19, with increased mortality (OR 1.88, 95% CI 1.37-2.56) and prolonged hospitalization (OR 1.78, 95% CI 1.33-2.35).

Conclusion

Low ALT level prior to infection is a significant risk factor for morbidity and mortality from COVID-19 infection. Further studies are warranted to address treatment options for this population.

Clinical features and outcomes of hospitalised patients with COVID-19 and Parkinsonian disorders: A multicentre UK-based study

BACKGROUND

Parkinson's disease has been identified as a risk factor for severe Coronavirus disease 2019 (COVID-19) outcomes. However, whether the significant high risk of death from COVID-19 in people with Parkinson's disease is specific to the disease itself or driven by other concomitant and known risk factors such as comorbidities, age, and frailty remains unclear.

OBJECTIVE

To investigate clinical profiles and outcomes of people with Parkinson's disease and atypical parkinsonian syndromes who tested positive for COVID-19 in the hospital setting in a multicentre UK-based study.

METHODS

A retrospective cohort study of Parkinson's disease patients with a positive SARS-CoV-2 test admitted to hospital between February 2020 and July 2021. An online survey was used to collect data from clinical care records, recording patient, Parkinson's disease and COVID-19 characteristics. Associations with time-to-mortality and severe outcomes were analysed using either the Cox proportional hazards model or logistic regression models, as appropriate.

RESULTS

Data from 552 admissions were collected: 365 (66%) male; median (inter-quartile range) age 80 (74-85) years. The 34-day all-cause mortality rate was 38.4%; male sex, increased age and frailty, Parkinson's dementia syndrome, requirement for respiratory support and no vaccination were associated with increased mortality risk. Community-acquired COVID-19 and co-morbid chronic neurological disorder were associated with increased odds of requiring respiratory support. Hospital-acquired COVID-19 and delirium were associated with requiring an increase in care level post-discharge.

CONCLUSIONS

This first, multicentre, UK-based study on people with Parkinson's disease or atypical parkinsonian syndromes, hospitalised with COVID-19, adds and expands previous findings on clinical profiles and outcomes in this population.

Development and validation of an electronic database-based frailty index to predict mortality and hospitalization in a population-based study of adults with SARS-CoV-2

Background

Electronic health databases are used to identify people at risk of poor outcomes. Using electronic regional health databases (e-RHD), we aimed to develop and validate a frailty index (FI), compare it with a clinically based FI, and assess its association with health outcomes in community-dwellers with SARS-CoV-2.

Methods

Data retrieved from the Lombardy e-RHD were used to develop a 40-item FI (e-RHD-FI) in adults (i.e., aged ≥18 years) with a positive nasopharyngeal swab polymerase chain reaction test for SARS-CoV-2 by May 20, 2021. The considered deficits referred to the health status before SARS-CoV-2. The e-RHD-FI was validated against a clinically based FI (c-FI) obtained from a cohort of people hospitalized with COVID-19 and in-hospital mortality was evaluated. e-RHD-FI performance was evaluated to predict 30-day mortality, hospitalization, and 60-day COVID-19 WHO clinical progression scale, in Regional Health System beneficiaries with SARS-CoV-2.

Results

We calculated the e-RHD-FI in 689,197 adults (51.9% females, median age 52 years). On the clinical cohort, e-RHD-FI correlated with c-FI and was significantly associated with in-hospital mortality. In a multivariable Cox model, adjusted for confounders, each 0.1-point increment of e-RHD-FI was associated with increased 30-day mortality (Hazard Ratio, HR 1.45, 99% Confidence Intervals, CI: 1.42-1.47), 30-day hospitalization (HR per 0.1-point increment = 1.47, 99%CI: 1.46-1.49), and WHO clinical progression scale (Odds Ratio = 1.84 of deteriorating by one category, 99%CI 1.80-1.87).

Conclusion

The e-RHD-FI can predict 30-day mortality, 30-day hospitalization, and WHO clinical progression scale in a large population of community-dwellers with SARS-CoV-2 test positivity. Our findings support the need to assess frailty with e-RHD.

Collective and Individual Assessment of the Risk of Death from COVID-19 for the Elderly, 2020-2022

Introduction

Coronavirus disease 2019 (COVID-19) has had profound disruptions worldwide. For a population or individual, it is critical to assess the risk of death for making preventative decisions.

Methods

In this study, clinical data from approximately 100 million cases were statistically analyzed. A software and an online assessment tool were developed in Python to evaluate the risk of mortality.

Results

Our analysis revealed that 76.51% of COVID-19-related fatalities occurred among individuals aged over 65 years, with frailty-associated deaths accounting for more than 80% of these cases. Furthermore, over 80% of the reported deaths involved unvaccinated individuals. A notable overlap was observed between aging and frailty-associated deaths, both of which were connected to underlying health conditions. For those with at least two comorbidities, the proportion of frailty and the proportion of COVID-19-related death were both close to 75 percent. Subsequently, we established a formula to calculate the number of deaths, which was validated using data from twenty countries and regions. Using this formula, we developed and verified an intelligent software designed to predict the death risk for a given population. To facilitate rapid risk screening on an individual level, we also introduced a six-question online assessment tool.

Conclusions

This study examined the impact of underlying diseases, frailty, age, and vaccination history on COVID-19-related mortality, resulting in a sophisticated software and a user-friendly online scale to assess mortality risk. These tools offer valuable assistance in informed decision-making.

Mortality Risks after Two Years in Frail and Pre-Frail Older Adults Admitted to Hospital

BACKGROUND

Frailty is characterized by a progressive decline in the physiological functions of multiple body systems that lead to a more vulnerable condition, which is prone to the development of various adverse events, such as falls, hospitalization, and mortality. This study aims to determine whether frailty increases mortality compared to pre-frailty and to identify variables associated with a higher risk of mortality.

MATERIALS

Two cohorts, frail and pre-frail subjects, are evaluated according to the Fried phenotype. A complete examination of frailty, cognitive status, comorbidities and pharmacology was carried out at hospital admission and was extracted through electronic health record (EHR). Mortality was evaluated from the EHR.

METHODS

Kaplan-Meier estimates of survival probability functions were calculated at two years censoring time for frail and pre-frail cohorts. The log-rank test assessed significant differences between survival probability functions. Significant variables for frailty (p < 0-05) were extracted by independent sample t-test. Further selection was based on variable significance found in multivariate logistic regression discrimination between frail and pre-frail subjects. Cox regression over univariate t-test-selected variables was calculated to identify variables associated with higher proportional hazard risks (HR) at two years.

RESULTS

Frailty is associated with greater mortality at two years censoring time than pre-frailty (log-rank test, p < 0.0001). Variables with significant (p < 0.05) association with mortality identified in both cohorts (HR 95% (CI in the frail cohort) are male sex (0.44 (0.29-0.66)), age (1.05 (1.01-1.09)), weight (0.98 (0.96-1.00)), and use of proton-pump inhibitors (PPIs) (0.60 (0.41-0.87)). Specific high-risk factors in the frail cohort are readmission at 30 days (0.50 (0.33-0.74)), SPPB sit and stand (0.62 (0.45-0.85)), heart failure (0.67 (0.46-0.98)), use of antiplatelets (1.80 (1.19-2.71)), and quetiapine (0.31 (0.12-0.81)). Specific high-risk factors in the pre-frail cohort are Barthel's score (120 (7.7-1700)), Pfeiffer test (8.4; (2.3-31)), Mini Nutritional Assessment (MNA) (1200 (18-88,000)), constipation (0.025 (0.0027-0.24)), falls (18,000 (150-2,200,000)), deep venous thrombosis (8400 (19-3,700,000)), cerebrovascular disease (0.01 (0.00064-0.16)), diabetes (360 (3.4-39,000)), thyroid disease (0.00099 (0.000012-0.085)), and the use of PPIs (0.062 (0.0072-0.54)), Zolpidem (0.000014 (0.0000000021-0.092)), antidiabetics (0.00015 (0.00000042-0.051)), diuretics (0.0003 (0.000004-0.022)), and opiates (0.000069 (0.00000035-0.013)).

CONCLUSIONS

Frailty is associated with higher mortality at two years than pre-frailty. Frailty is recognized as a systemic syndrome with many links to older-age comorbidities, which are also found in our study. Polypharmacy is strongly associated with frailty, and several commonly prescribed drugs are strongly associated with increased mortality. It must be considered that frail patients need coordinated attention where the diverse specialist taking care of them jointly examines the interactions between the diversity of treatments prescribed.

Relationship between Muscle Mass, Bone Density and Vascular Calcifications in Elderly People with SARS-CoV-2 Pneumonia

BACKGROUND

Little is known about the changes in organs and tissues that may make elder patients more vulnerable to acute stressors such as SARS-CoV-2 infection.

METHODS

In 80 consecutive elderly patients with SARS-CoV-2 infection, we evaluated the association between the descending thoracic aorta calcium score, L1 bone density and T12 skeletal muscle density measured on the same scan by high-resolution computed tomography.

RESULTS

At median regression, the ln-transformed DTA calcium score was inversely associated with L1 bone density (-0.02, 95%CI -0.04 to -0.01 ln-Agatston units for an increase of 1 HU) and with T12 muscle density (-0.03, -0.06 to -0.001 ln-Agatston units for an increase of 1 HU). At penalized logistic regression, an increase of 1 ln-Agatston unit of DTA calcium score was associated with an OR of death of 1.480 (1.022 to 2.145), one of 1 HU of bone density with an OR of 0.981 (0.966 to 0.996) and one of 1 HU of muscle density with an OR of 0.973 (0.948 to 0.999). These relationships disappeared after correction for age and age was the stronger predictor of body composition and death.

CONCLUSIONS

Age has a big effect on the relationship between vascular calcifications, L1 bone density and T12 muscle density and on their relationship with the odds of dying.

Impact of frailty on the performance of the National Early Warning Score 2 to predict poor outcome in patients hospitalised due to COVID-19

BACKGROUND

The National Early Warning Score 2 (NEWS2) is a scoring tool predictive of poor outcome in hospitalised patients. Older patients with COVID-19 have increased risk of poor outcome, but it is not known if frailty may impact the predictive performance of NEWS2. We aimed to investigate the impact of frailty on the performance of NEWS2 to predict in-hospital mortality in patients hospitalised due to COVID-19.

METHODS

We included all patients admitted to a non-university Norwegian hospital due to COVID-19 from 9 March 2020 until 31 December 2021. NEWS2 was scored based on the first vital signs recorded upon hospital admission. Frailty was defined as a Clinical Frailty Scale score ≥ 4. The performance of a NEWS2 score ≥ 5 to predict in-hospital mortality was assessed with sensitivity, specificity and area under the receiver operating characteristic curve (AUROC) according to frailty status.

RESULTS

Out of 412 patients, 70 were aged ≥ 65 years and with frailty. They presented less frequently with respiratory symptoms, and more often with acute functional decline or new-onset confusion. In-hospital mortality was 6% in patients without frailty, and 26% in patients with frailty. NEWS2 predicted in-hospital mortality with a sensitivity of 86%, 95% confidence interval (CI) 64%-97% and AUROC 0.73, 95% CI 0.65-0.81 in patients without frailty. In older patients with frailty, sensitivity was 61%, 95% CI 36%-83% and AUROC 0.61, 95% CI 0.48-0.75.

CONCLUSION

A single NEWS2 score at hospital admission performed poorly to predict in-hospital mortality in patients with frailty and COVID-19 and should be used with caution in this patient group. Graphical abstract summing up study design, results and conclusion.

Prevalence of physical frailty, including risk factors, up to 1 year after hospitalisation for COVID-19 in the UK: a multicentre, longitudinal cohort study

Background

The scale of COVID-19 and its well documented long-term sequelae support a need to understand long-term outcomes including frailty.

Methods

This prospective cohort study recruited adults who had survived hospitalisation with clinically diagnosed COVID-19 across 35 sites in the UK (PHOSP-COVID). The burden of frailty was objectively measured using Fried's Frailty Phenotype (FFP). The primary outcome was the prevalence of each FFP group-robust (no FFP criteria), pre-frail (one or two FFP criteria) and frail (three or more FFP criteria)-at 5 months and 1 year after discharge from hospital. For inclusion in the primary analysis, participants required complete outcome data for three of the five FFP criteria. Longitudinal changes across frailty domains are reported at 5 months and 1 year post-hospitalisation, along with risk factors for frailty status. Patient-perceived recovery and health-related quality of life (HRQoL) were retrospectively rated for pre-COVID-19 and prospectively rated at the 5 month and 1 year visits. This study is registered with ISRCTN, number ISRCTN10980107.

Findings

Between March 5, 2020, and March 31, 2021, 2419 participants were enrolled with FFP data. Mean age was 57.9 (SD 12.6) years, 933 (38.6%) were female, and 429 (17.7%) had received invasive mechanical ventilation. 1785 had measures at both timepoints, of which 240 (13.4%), 1138 (63.8%) and 407 (22.8%) were frail, pre-frail and robust, respectively, at 5 months compared with 123 (6.9%), 1046 (58.6%) and 616 (34.5%) at 1 year. Factors associated with pre-frailty or frailty were invasive mechanical ventilation, older age, female sex, and greater social deprivation. Frail participants had a larger reduction in HRQoL compared with before their COVID-19 illness and were less likely to describe themselves as recovered.

Interpretation

Physical frailty and pre-frailty are common following hospitalisation with COVID-19. Improvement in frailty was seen between 5 and 12 months although two-thirds of the population remained pre-frail or frail. This suggests comprehensive assessment and interventions targeting pre-frailty and frailty beyond the initial illness are required.

Funding

UK Research and Innovation and National Institute for Health Research.

Multimodal single-cell analyses of peripheral blood mononuclear cells of COVID-19 patients in Japan

SARS-CoV-2 continues to spread worldwide. Patients with COVID-19 show distinct clinical symptoms. Although many studies have reported various causes for the diversity of symptoms, the underlying mechanisms are not fully understood. Peripheral blood mononuclear cells from COVID-19 patients were collected longitudinally, and single-cell transcriptome and T cell receptor repertoire analysis was performed. Comparison of molecular features and patients' clinical information revealed that the proportions of cells present, and gene expression profiles differed significantly between mild and severe cases; although even among severe cases, substantial differences were observed among the patients. In one severely-infected elderly patient, an effective antibody response seemed to have failed, which may have caused prolonged viral clearance. Naïve T cell depletion, low T cell receptor repertoire diversity, and aberrant hyperactivation of most immune cell subsets were observed during the acute phase in this patient. Through this study, we provided a better understanding of the diversity of immune landscapes and responses. The information obtained from this study can help medical professionals develop personalized optimal clinical treatment strategies for COVID-19.

COVID-19 mRNA Vaccine Effectiveness against Elderly Frail People

The frail, elderly population is often characterized by poor immunogenicity post COVID-19 mRNA vaccination. "Inflame-ageing" and "immune-senescence" are pathogenetic mechanisms that might explain this phenomenon. Complex interplay with cytokines and microbiota is also implicated in this inflammatory cascade. The abovementioned population, although very important from immunologic perspective, has barely been included in the mRNA vaccination clinical trials.

Risk of Covid-19 Severe Outcomes and Mortality in Migrants and Ethnic Minorities Compared to the General Population in the European WHO Region: a Systematic Review

The Covid-19 pandemic has had a major impact on migrants and ethnic minorities (MEMs). Socio-economic factors and legal, administrative and language barriers are among the reasons for this increased susceptibility. The aim of the study is to investigate the impact of Covid-19 on MEMs compared to the general population in terms of serious outcomes. We conducted a systematic review collecting studies on the impact of Covid-19 on MEMs compared to the general population in the WHO European Region regarding hospitalisation, intensive care unit (ICU) admission and mortality, published between 01/01/2020 and 19/03/2021. Nine researchers were involved in selection, study quality assessment and data extraction. Of the 82 studies included, 15 of the 16 regarding hospitalisation for Covid-19 reported an increased risk for MEMs compared to the white and/or native population and 22 out of the 28 studies focusing on the ICU admission rates found an increased risk for MEMs. Among the 65 studies on mortality, 43 report a higher risk for MEMs. An increased risk of adverse outcomes was reported for MEMs. Social determinants of health are among the main factors involved in the genesis of health inequalities: a disadvantaged socio-economic status, a framework of structural racism and asymmetric access to healthcare are linked to increased susceptibility to the consequences of Covid-19. These findings underline the need for policymakers to consider the socio-economic barriers when designing prevention plans.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12134-023-01007-x.

Clinical Features of Hypoxemia Due to Infection Under Home-Based Medication During the COVID-19 Pandemic Period

BACKGROUND

Despite the growing demand for home-based medication during the COVID-19 pandemic period, there remains scarce evidence of hypoxemic infection in home-care settings. In this study, we investigated the clinical features of hypoxemic respiratory failure due to infection during the period under home-based medication (defined as 'home-care-acquired infection').

METHODS

This retrospective observational study enrolled patients with home-care-acquired infection, other than COVID-19, in two home-care clinics in Sapporo, Japan, between April 2020 and May 2021 (the early phase of the COVID-19 pandemic). The participants were divided into two groups according to whether they required additional home oxygen therapy, and were compared to assess the predictors of hypoxemic respiratory failure. Furthermore, the clinical features were compared with those in patients aged >60 years with COVID-19 who were admitted to Toyama University Hospital during the same period.

RESULTS

A total of 107 patients with home-care-acquired infections were included in the study (median age, 82 years). Twenty-two patients required home oxygen therapy, and 85 did not. Thirty-day mortality rates were 32% and 8%. Among the patients in the hypoxemia group, none had desired a care-setting transition, following the advanced care planning. Multivariable logistic regression analysis showed that initial antibiotic treatment failure and malignant disease were independently associated with hypoxemic respiratory failure (odds ratio, 7.28 and 7.10; p=0.023 and p<0.005, respectively). In comparison with hypoxemia in the COVID-19 cohort, the lower incidence of febrile co-habitants and earlier onset of hypoxemia were significant in those due to home-care-acquired infection.

CONCLUSION

This study demonstrated that hypoxemia due to home-care-acquired infection was characterized by distinct features, possibly different from those due to COVID-19 in the early pandemic period.

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.

Impact of frailty on clinical outcomes in patients with and without COVID-19 pneumonitis admitted to intensive care units in Australia and New Zealand: a retrospective registry data analysis

BACKGROUND

It is unclear if the impact of frailty on mortality differs between patients with viral pneumonitis due to COVID-19 or other causes. We aimed to determine if a difference exists between patients with and without COVID-19 pneumonitis.

METHODS

This multicentre, retrospective, cohort study using the Australian and New Zealand Intensive Care Society Adult Patient Database included patients aged ≥ 16 years admitted to 153 ICUs between 01/012020 and 12/31/2021 with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome, and Clinical Frailty Scale (CFS). The primary outcome was hospital mortality.

RESULTS

A total of 4620 patients were studied, and 3077 (66.6%) had COVID-19. The patients with COVID-19 were younger (median [IQR] 57.0 [44.7-68.3] vs. 66.1 [52.0-76.2]; p < 0.001) and less frail (median [IQR] CFS 3 [2-4] vs. 4 [3-5]; p < 0.001) than non-COVID-19 patients. The overall hospital mortality was similar between the patients with and without COVID-19 (14.7% vs. 14.9%; p = 0.82). Frailty alone as a predictor of mortality showed only moderate discrimination in differentiating survivors from those who died but was similar between patients with and without COVID-19 (AUROC 0.68 vs. 0.66; p = 0.42). Increasing frailty scores were associated with hospital mortality, after adjusting for Australian and New Zealand Risk of Death score and sex. However, the effect of frailty was similar in patients with and without COVID-19 (OR = 1.29; 95% CI: 1.19-1.41 vs. OR = 1.24; 95% CI: 1.11-1.37).

CONCLUSION

The presence of frailty was an independent risk factor for mortality. However, the impact of frailty on outcomes was similar in COVID-19 patients compared to other causes of viral pneumonitis.

Impact of nutrition and physical activity on outcomes of hospital-acquired pneumonia

Frailty is an important risk factor for adverse health-related outcomes. It is classified into several phenotypes according to nutritional state and physical activity. In this context, we investigated whether frailty phenotypes were related to clinical outcome of hospital-acquired pneumonia (HAP). During the study period, a total of 526 patients were screened for HAP and 480 of whom were analyzed. The patients were divided into four groups according to physical inactivity and malnutrition: nutritional frailty (Geriatric Nutritional Risk Index [GNRI] < 82 and Clinical Frailty Scale [CFS] ≥ 4), malnutrition (GNRI < 82 and CFS < 4), physical frailty (GNRI ≥ 82 and CFS ≥ 4), and normal (GNRI ≥ 82 and CFS < 4). Among the phenotypes, physical frailty without malnutrition was the most common (39.4%), followed by nutritional frailty (30.2%), normal (20.6%), and malnutrition (9.8%). There was a significant difference in hospital survival and home discharge among the four phenotypes (p = 0.009), and the nutritional frailty group had the poorest in-hospital survival and home discharge (64.8% and 34.6%, respectively). In conclusion, there were differences in clinical outcomes according to the four phenotypes of HAP. Assessment of frailty phenotypes during hospitalization may improve outcomes through adequate nutrition and rehabilitation treatment of patients with HAP.

Risk factors for hospitalization and death due to COVID-19 among frail community-dwelling elderly people: a retrospective cohort study

BACKGROUND

Advanced age, multiple chronic diseases and frailty have been correlated with worse prognosis among coronavirus disease 2019 (COVID-19) inpatients.

OBJECTIVE

To investigate potential risk factors for hospitalization and death due to COVID-19 among frail community-dwelling elderly people.

DESIGN AND SETTING

Retrospective cohort study of patients followed up at a geriatric outpatient clinic in Belo Horizonte, Minas Gerais, Brazil.

METHODS

The associations of demographic characteristics (age and sex) and clinical characteristics (frailty, multimorbidity, number of medications with long-term use, obesity, smoking, diabetes mellitus, pulmonary diseases, cardiovascular diseases, cerebrovascular disease, and chronic kidney disease) with the risk of hospitalization and death due to COVID-19 were explored using a multivariable logistic regression model.

RESULTS

5,295 patients (mean age 78.6 ± 9.4 years; 72.6% females) were included. After adjustments, the number of medications with long-term use was found to increase the odds of hospitalization due to COVID-19 (odds ratio, OR: 1.13; 95% confidence interval, CI: 1.06-1.22). Frailty, multimorbidity and diabetes mellitus also increased the odds of hospitalization (OR: 1.06, 95% CI: 1.02-1.09; OR: 1.17, 95% CI: 1.09-1.26; and OR: 2.27, 95% CI: 1.45-3.54, respectively) and the odds of death due to COVID-19 (OR: 1.07, 95% CI: 1.00-1.14; OR: 1.16, 95% CI: 1.03-1.32; and OR: 2.69, 95% CI: 1.79-6.14, respectively).

CONCLUSIONS

Multimorbidity, frailty and diabetes mellitus increased the odds of hospitalization and death due to COVID-19 and the number of medications with long-term use increased the odds of hospitalization due to COVID-19 among frail community-dwelling elderly people.

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.

Survival Evaluation of Hospitalized COVID-19 Patients with Cox Frailty Approach

INTRODUCTION

The survival cox analysis is becoming more popular in time-to-event data analysis. When there are unobserved /unmeasured individual factors, then the results of this model may not be dependable. Hence, this study aimed to determine the factors associated with Covid-19 patients' survival time with considering frailty factor.

METHODS

This study was conducted at 1 of the hospitals in Iran, so that hospitalized patients with COVID-19 were included. Epidemiological, clinical, laboratory, and outcome data on admission were extracted from electronic medical records. Gamma-frailty Cox model was used to identify the effects of the risk factors.

RESULTS

A total of 360 patients with COVID-19 enrolled in the study. The median age was 74 years (IQR 61 - 83), 903 (57·7%) were men, and 661 (42·3%) were women; the mortality rate was 17%. The Cox frailty model showed that there is at least a latent factor in the model (P = 0.005). Age and platelet count were negatively associated with the length of stay, while red blood cell count was positively associated with the length of stay of patients.

CONCLUSION

The Cox frailty model indicates that in addition to age, the frailty factor is a useful predictor of survival in Covid-19 patients.

The devastating trio of sarcopenia, frailty, and COVID-19 - A systematic review and meta-analysis

Background & aims

Sarcopenia, frailty, and COVID-19 appear to be intertwined. Preventive and intervention measures are required to break this link and mitigate the consequences of rising morbidity and mortality among older adults. This study aimed to identify and synthesize important factors related to the interaction of the devastating trio and their impact on the health and mortality of older adults.

Methods

Data were gathered via searches of PubMed, Cochrane Library, Google Scholar, and Elsevier Mendeley Website. Study selection and data extraction were conducted by the two authors independently. The primary outcome was mortality, secondary outcomes included hospitalization and risk of development of severe disease among older Covid-19 patients. The study results are presented as adjusted odds and hazard ratios with 95% CI.

Results

A total of 1725 studies were identified through our electronic databases searches. After screening and assessing for eligibility, 39 studies were included in this review, a total of 51,796 patients were included in the systematic review. Our results indicated that frail patients recorded a higher mean age compared to non-frail patients (p < 0.00001), and COVID-19 frail patients had significantly increased mortality rate compared to non-frail patients, the log adjusted OR was 2.10 (1.63, 2.71); I² = 78%; p < 0.00001.

Conclusion

Age and frailty are important risk factors for mortality among older adults COVID-19 patients. COVID-19 patients with sarcopenia had a higher risk of developing severe conditions, including hospitalization and ICU admission. Findings that support the use of frailty and sarcopenia indicators to help in the decision-making process for medical care in older adults COVID-19 patients.

Understanding the COVID-19 Pandemic in Nursing Homes (Aragón, Spain): Sociodemographic and Clinical Factors Associated With Hospitalization and Mortality

Old people residing in nursing homes have been a vulnerable group to the coronavirus disease 2019 (COVID-19) pandemic, with high rates of infection and death. Our objective was to describe the profile of institutionalized patients with a confirmed COVID-19 infection and the socioeconomic and morbidity factors associated with hospitalization and death. We conducted a retrospective cohort study including data from subjects aged 65 years or older residing in a nursing home with a confirmed COVID-19 infection from March 2020 to March 2021 (4,632 individuals) in Aragón (Spain). We analyzed their sociodemographic and clinical profiles and factors related to hospitalization and mortality at 7, 30, and 90 days of COVID-19 diagnosis using logistic regression analyses. We found that the risk of hospitalization and mortality varied according to sociodemographic and morbidity profile. There were inequalities in hospitalization by socioeconomic status and gender. Patients with low contributory pensions and women had a lower risk of hospitalization. Diabetes mellitus, heart failure, and chronic kidney disease were associated with a higher risk of hospitalization. On the contrary, people with dementia showed the highest risk of mortality with no hospitalization. Patient-specific factors must be considered to develop equitable and effective measures in nursing homes to be prepared for future health threats.

Choices and Outcomes of the Oldest Old Admitted During the First Wave of COVID-19 in New York City

Objectives: Morbidity and mortality are higher in older adults with COVID-19, but their decisions about aggressive care, severity of disease, and outcomes during the first surge in New York City are not well characterized. We sought to determine if the oldest patients chose intubation and comfort care at different rates compared to younger geriatric patients. We also studied outcomes among patients admitted with severe disease and those who chose aggressive versus comfort care. Methods: This retrospective analysis used electronic health record data from patients 65 years and older at two medical centers in New York City admitted between 3/5/2020 and 5/15/2020. The primary outcome was comfort care orders, and secondary outcomes included death, palliative care consultation, goals of care discussion, code status, and ventilator weaning. Results: Of the 854 patients, 214 were in the oldest old (OO, age > = 85) group, 269 middle old (MO, age 75-84), and 371 young old (YO, age 65-74). Among those with serious disease, the OO were more likely to choose comfort care (45% vs. 21% MO and 6.8% YO), less likely to be intubated (17% vs. 37% MO and 44% YO), more likely to have a palliative care consult, more likely to be DNR/DNI on admission (60% vs. 17% MO and 9.3%% YO), and more likely to die during admission (65% vs. 42% MO and 21% YO) (all p-values < 0.001). Of all 216 intubated patients, 78% of the OO died, versus 66% of the MO and 36% of the YO (p = <0.001). Conclusions: Adults 85 and above admitted with COVID-19 were more likely to forego intubation and die with comfort-based care. Irrespective of intubation choice, patients 85 and older had a markedly poorer prognosis than other cohorts over 65.

Functional decline, long term symptoms and course of frailty at 3-months follow-up in COVID-19 older survivors, a prospective observational cohort study

BACKGROUND

Aging is one of the most important prognostic factors increasing the risk of clinical severity and mortality of COVID-19 infection. However, among patients over 75 years, little is known about post-acute functional decline.

OBJECTIVE

The aim of this study was to identify factors associated with functional decline 3 months after COVID-19 onset, to identify long term COVID-19 symptoms and transitions between frailty statesafter COVID-19 onset in older hospitalized patients.

METHODS

This prospective observational study included COVID-19 patients consecutively hospitalized from March to December 2020 in Acute Geriatric Ward in Nantes University Hospital. Functional decline, frailty status and long term symptoms were assessed at 3 month follow up. Functional status was assessed using the Activities of Daily Living simplified scale (ADL). Frailty status was evaluated using Clinical Frailty Scale (CFS). We performed multivariable analyses to identify factors associated with functional decline.

RESULTS

Among the 318 patients hospitalized for COVID-19 infection, 198 were alive 3 months after discharge. At 3 months, functional decline occurred in 69 (36%) patients. In multivariable analysis, a significant association was found between functional decline and stroke (OR = 4,57, p = 0,003), history of depressive disorder (OR = 3,05, p = 0,016), complications (OR = 2,24, p = 0,039), length of stay (OR = 1,05, p = 0,025) and age (OR = 1,08, p = 0,028). At 3 months, 75 patients described long-term symptoms (49.0%). Of those with frailty (CFS scores ≥5) at 3-months follow-up, 30% were not frail at baseline. Increasing frailty defined by a worse CFS state between baseline and 3 months occurred in 41 patients (26.8%).

CONCLUSIONS

This study provides evidence that both the severity of the COVID-19 infection and preexisting medical conditions correlates with a functional decline at distance of the infection. This encourages practitioners to establish discharge personalized care plan based on a multidimensional geriatric assessment and in parallel on clinical severity evaluation.

Oxidative stress and endogenous DNA damage in blood mononuclear cells may predict anti-SARS-CoV-2 antibody titers after vaccination in older adults

Immune senescence in the elderly has been associated with chronic oxidative stress and DNA damage accumulation. Herein we tested the hypothesis that increased endogenous DNA damage and oxidative stress in peripheral blood mononuclear cells of older adults associate with diminished humoral immune response to SARS-CoV-2 vaccination. Increased oxidative stress and DNA double-strand breaks (DSBs) were detected in 9 non-immunocompromised individuals aged 80-96 years compared to 11 adults aged 27-44 years, before, as well as on days 1 and 14 after the first dose, and on day 14 after the second dose of the BNT162B2-mRNA vaccine (all p < 0.05). SARS-CoV-2 vaccination induced a resolvable increase in oxidative stress and DNA damage, but individual DSB-repair efficiency was unaffected by vaccination irrespective of age, confirming vaccination safety. Individual titers of anti-Spike-Receptor Binding Domain (S-RBD)-IgG antibodies, and the neutralizing capacity of circulating anti-SARS-CoV-2 antibodies, measured on day 14 after the second dose in all participants, correlated inversely with the corresponding pre-vaccination endogenous oxidative stress and DSB levels (all p < 0.05). In particular, a strong inverse correlation of individual pre-vaccination DSB levels with both the respective anti-S-RBD-IgG antibodies titers (r = -0.867) and neutralizing capacity of circulating anti-SARS-CoV-2 antibodies (r = -0.983) among the 9 older adults was evident. These findings suggest that humoral responses to SARS-CoV-2 vaccination may be weaker when immune cells are under oxidative and/or genomic stress. Whether such measurements may serve as biomarkers of vaccine efficacy in older adults warrants further studies.

One-Year Report of COVID-19 Impact on Geriatric Patients: a Bio-Psycho-Social Approach

Background

Since December of 2019, coronavirus 19 (COVID-19) has spread rapidly around the world. Our understanding of the infection has grown over the past year, and its impact on older adults is particularly significant. Apart from the direct impacts of COVID-19 infections, it has also led to lockdowns which, in turn, result in isolation and loneliness.

Method

We conducted a literature review of publicly available articles of the COVID-19 pandemic impact on the geriatric population between December 2019 and April 2021, a total of 748 articles.

Results

The review will be presented with the Bio-Psycho-Social model, covering how the biological, psychological, and sociological aspects of health are intertwined and impact older adults. Early studies have also highlighted the prevalence of post-COVID infection symptoms that typically fall under geriatric medicine care. We highlight the bidirectional impact of isolation and COVID-19 infections on geriatric health, as well as discuss pertinent topics such as vaccine efficacy, long-term sequelae of COVID-19 infections, and ageism.

Conclusion

This review seeks to present a one-year report of what is known about COVID-19 and geriatric medicine, as well as provide guidance to practitioners who care for older adults based on the most up-to-date literature.

Caring for older adults during the COVID-19 pandemic

BACKGROUND

Elderly patients represent a high-risk group with increased risk of death from COVID-19. Despite the number of published studies, several unmet needs in care for older adults exist.

OBJECTIVES

To discuss unmet needs of COVID-19 in this special population.

SOURCES

A literature review for studies on COVID-19 in elderly patients published between December 2019 and November 2021 was performed. Clinical questions were formulated to guide the literature search. The search was conducted in the MEDLINE database, combining specific search terms. Two reviewers independently conducted the search and selected the studies according to the prespecified clinical questions.

CONTENT

Elderly patients with COVID-19 have peculiar characteristics. They may have atypical clinical presentation, with no fever and with delirium or neurological manifestations as the most common signs, with potential delayed diagnosis and increased risk of death. The reported fatality rates among elderly patients with COVID-19 are extremely high. Several factors, including comorbidities, atypical presentation, and exclusion from intensive care unit care, contribute to this excess of mortality. Age alone is frequently used as a key factor to exclude the elderly from intensive care, but there is evidence that frailty rather than age better predicts the risk of poor outcome in this category. Durability of vaccine efficacy in the elderly remains debated, and the need for a third booster dose is becoming increasingly evident. Finally, efforts to care for elderly patients who have survived after acute COVID-19 should be implemented, considering the high rates of long COVID sequelae and the risk of longitudinal functional and cognitive decline.

IMPLICATIONS

We highlight peculiar aspects of COVID-19 in elderly patients and factors contributing to high risk of poor outcome in this category. We also illuminated gaps in current evidence, suggesting future research directions and underlining the need for further studies on the optimal management of elderly patients with COVID-19.

Heterogeneity and Risk of Bias in Studies Examining Risk Factors for Severe Illness and Death in COVID-19: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis synthesized the evidence on the impacts of demographics and comorbidities on the clinical outcomes of COVID-19, as well as the sources of the heterogeneity and publication bias of the relevant studies. Two authors independently searched the literature from PubMed, Embase, Cochrane library, and CINAHL on 18 May 2021; removed duplicates; screened the titles, abstracts, and full texts by using criteria; and extracted data from the eligible articles. The variations among the studies were examined by using Cochrane, Q.; I2, and meta-regression. Out of 11,975 articles that were obtained from the databases and screened, 559 studies were abstracted, and then, where appropriate, were analyzed by meta-analysis (n = 542). COVID-19-related severe illness, admission to the ICU, and death were significantly correlated with comorbidities, male sex, and an age older than 60 or 65 years, although high heterogeneity was present in the pooled estimates. The study design, the study country, the sample size, and the year of publication contributed to this. There was publication bias among the studies that compared the odds of COVID-19-related deaths, severe illness, and admission to the ICU on the basis of the comorbidity status. While an older age and chronic diseases were shown to increase the risk of developing severe illness, admission to the ICU, and death among the COVID-19 patients in our analysis, a marked heterogeneity was present when linking the specific risks with the outcomes.

Impacto de la fragilidad en la enfermedad por COVID-19 en una cohorte de gente mayor de la ciudad de Barcelona

Objetivo

Describir la incidencia y mortalidad de COVID-19, durante la primera ola, en la población de personas mayores de Barcelona, según sus niveles previos de fragilidad.

Diseño

Estudio de cohortes retrospectivo.

Emplazamiento y participantes

Población de 65 o más años asignada a los centros de Atención Primaria de Barcelona del Institut Català de la Salut, seguidos entre marzo y junio de 2020.

Mediciones principales

Fragilidad calculada al inicio a partir de la historia clínica informatizada. Resultados durante el seguimiento: diagnóstico de COVID-19, posible o confirmado con PCR y mortalidad por todas las causas.

Resultados

Se analizaron 251788 mayores de 64 años. Un 61,3% tenían algún nivel de fragilidad, 27,8% moderada o grave. La incidencia de COVID-19 fue de 3,13 casos por 100 habitantes (N = 7883) y la mortalidad por COVID-19 fue del 21,5% (N =1 691). Tanto la incidencia como la mortalidad por COVID-19 fueron superiores a mayor edad, en hombres, a mayor privación y a mayor nivel de fragilidad. Los individuos con fragilidad leve, moderada y grave tuvieron un hazard ratio ajustado de enfermedad por COVID-19 de 1,47, 2,08 y 3,50 respectivamente. Entre los sujetos con COVID-19, aquéllos con fragilidad leve, moderada y grave tuvieron un hazard ratio ajustado de mortalidad por COVID-19 de 1,44, 1,69 y 2,47 respectivamente.

Conclusiones

Consideramos necesario el abordaje de la fragilidad también en situación de pandemia, dado que es una condición tratable y a su vez factor de riesgo de COVID-19 más grave, donde el papel de la Atención Primaria es primordial, por su accesibilidad y longitudinalidad.

Acceptance, efficacy, and safety of COVID-19 vaccination in older patients with cancer

Purpose

The COVID-19 vaccination campaign began in December 2020, in France, and primarily targeted the oldest people. Our study aimed to determine the level of acceptance of vaccination in a population of older patients with cancer.

Methods

From January 2021, we offered vaccination with the BNT162b2 COVID-19 vaccine to all patients 70 years and older referred to our geriatric oncology center in Marseille University Hospital (AP-HM) for geriatric assessment before initiation of an oncological treatment. Objectives were to evaluate acceptance rate of COVID-19 vaccination and to assess vaccine safety, reactogenicity, and efficacy two months after the first dose.

Results

Between January 18, 2021 and May 7, 2021, 150 older patients with cancer were offered vaccination after a geriatric assessment. The majority were men (61.3%), with a mean age of 81 years. The two most frequent primary tumors were digestive (29.4%) and thoracic (18%). The vaccine acceptance rate was 82.6% and the complete vaccination rate (2 doses) reached 75.3%. Among the vaccinated patients, 15.9% reported mild side effects after the first dose and 23.4% after the second dose, mostly arm pain and fatigue. COVID-19 cases were observed in 5.1% of vaccinated patients compared with 16.7% in unvaccinated patients. Of the 22 vaccinated patients who agreed to have their serum tested, 15 had antibodies against the spike protein at day 21 after the first dose.

Conclusion

Our study showed a high acceptance rate of COVID-19 vaccination, with good tolerance in this frail population. These results highlight the benefits of organizing vaccination campaigns at the very beginning of oncological management in older patients.

Clinical trial registration: This study was registered May 23, 2019 in ClinicalTrials.gov (NCT03960593).

Nutritional and Functional Impact of Acute SARS-CoV-2 Infection in Hospitalized Patients

Aim: To assess the prevalence of malnutrition, frailty, and sarcopenia and the relationships between them in patients hospitalized for COVID-19. Methods: This was a cross-sectional study of the prevalence, determinants, and associations between malnutrition (GLIM 2019 criteria), sarcopenia (SARC-F scale, dynamometry, and calf circumference), and frailty (FRAIL scale) upon discharge following hospitalization for COVID 19. Results: A total of 101 patients (67.3% men, mean age 66.3 years) were recruited. Malnutrition was diagnosed in 49.5%, sarcopenia in 32.7%, and frailty in 28.7% of patients. Of the patients with malnutrition, 48% were also sarcopenic, and 42% were frail. There was a significant association between malnutrition and the severity of pneumonia according to the CURB-65 scale (odds ratio [OR] 2.61, p = 0.036), between sarcopenia and a Barthel score lower than 60 points (OR 29.52, p < 0.001), and between frailty and both a Barthel score lower than 60 points (OR 32.27, p < 0.001) and a length of hospital stay of over 30 days (OR 9.11, p = 0.008). Conclusions: Malnutrition, sarcopenia, and frailty are prevalent and interrelated entities in patients hospitalized for acute SARS CoV-2 infection, especially in patients with greater baseline functional impairment prior to admission and a higher infection severity.

Frailty assessment for COVID-19 follow-up: a prospective cohort study

BACKGROUND

The Clinical Frailty Scale (CFS) is increasingly used for clinical decision making in acute care but little is known about frailty after COVID-19.

OBJECTIVES

To investigate frailty and the CFS for post-COVID-19 follow-up.

METHODS

This prospective multicentre cohort study included COVID-19 survivors aged ≥50 years presenting for a follow-up visit ≥3 months after the acute illness. Nine centres retrospectively collected pre-COVID-19 CFS and prospectively CFS at follow-up. Three centres completed the Frailty Index (FI), the short physical performance battery (SPPB), 30 s sit-to-stand test and handgrip strength measurements. Mixed effect logistic regression models accounting for repeated measurements and potential confounders were used to investigate factors associated with post-COVID-19 CFS. Criterion and construct validity were determined by correlating the CFS to other concurrently assessed frailty measurements and measures of respiratory impairment, respectively.

RESULTS

Of the 288 participants 65% were men, mean (SD) age was 65.1 (9) years. Median (IQR) CFS at follow-up was 3 (2-3), 21% were vulnerable or frail (CFS ≥4). The CFS was responsive to change, correlated with the FI (r=0.69, p<0.001), the SPPB score (r=-0.48, p<0.001) (criterion validity) and with the St George's Respiratory Questionnaire score (r=0.59, p<0.001), forced vital capacity %-predicted (r=-0.25, p<0.001), 6 min walk distance (r=-0.39, p<0.001) and modified Medical Research Council (mMRC) (r=0.59, p<0.001). Dyspnoea was significantly associated with a higher odds for vulnerability/frailty (per one mMRC adjusted OR 2.01 (95% CI 1.13 to 3.58), p=0.02).

CONCLUSIONS

The CFS significantly increases with COVID-19, and dyspnoea is an important risk factor for post-COVID-19 frailty and should be addressed thoroughly.

Clinical frailty scale as a predictor of disease severity in patients hospitalised with COVID-19 - an observational cohort study

BACKGROUND

The coronavirus disease 2019 pandemic makes proper resource allocation and prioritisation important. Frailty increases the risk of adverse outcomes and can be quantified using the Clinical frailty scale. The aim of this study was to determine the role of the Clinical frailty scale, in patients ≥65 years of age with coronavirus disease 2019, as a risk factor either for critical coronavirus disease 2019 measured as intensive care unit admission or death or as a risk factor for death.

METHODS

This was a retrospective observational study on patients ≥65 years hospitalised with coronavirus disease 2019 verified by polymerase chain reaction between 5 March 5 and 5 July 2020. The association between Clinical frailty scale and the composite primary outcome intensive care unit admission or death within 30 days post hospitalisation and the secondary outcome death within 30 days post hospitalisation was analysed using multivariable logistic regression models adjusting for gender, age, body mass index, hypertension, and diabetes. Clinical frailty scale was used as a categorical variable (fit score 1-4, frail score 5-6, and severely frail score 7-9).

RESULTS

In total, 169 patients were included (47.3% women, mean age 79.2 ± 7.8 years). In the fully adjusted model, adjusted odds ratio for intensive care unit admission or death was 1.84 (95%-confidence interval 0.67-5.03, p = .234) for frail and 6.08 (1.70-21.81, p = .006) for severely frail compared to fit patients. For death, adjusted odds ratio was 2.81 (0.89-8.88, p = .079) for frail and 9.82 (2.53-38.10, p = .001) for severely frail compared to fit patients.

CONCLUSIONS

A high Clinical frailty scale score was an independent risk factor for the composite outcome intensive care unit admission or death and for the secondary outcome death.

Health Impact On The Elderly Survivors Of Covid-19: Six Months Follow Up

Purpose

To analyse factors associated with mortality at 6 months in survivors older than 70 years after hospital admission for SARS-CoV-2.

Methods

Descriptive observational study with follow-up at 6 months. All patients over 70 years of age, discharged from the Hospital Central de la Cruz Roja, after hospitalization for COVID-19 consecutively during the months March to May 2020 were included. The outcome at 6 months (mortality, readmissions) were collected.

Results

A total of 165 patients were included. Mean age 88.5 ± 6.73, women 69.1%. High comorbidity 33.9%. Mean previous Barthel Index was 65.39 ± 33.64 and at discharge 58.12 ± 34.04.

24.2% had severe polypharmacy and 47.9% severe frailty.

Six months after hospital discharge, 13% died and 23.8% required at least one readmission. More than half of the sample had some of the following sequelae: dyspnea 20%(33), functional impairment 41.7%(69), cognitive impairment 31.3%(52) or depressive symptoms 42.4%(70).

Functional impairment at discharge was associated with an increased risk of mortality (OR 5.33; 95% CI 1.11–25.73).

Conclusions

The functional status was a factor associated with risk of mortality at 6 months.

Frailty in Elderly Patients with Covid-19: A Narrative Review

Introduction

The SARS CoV-2 pandemic still generates a very high number of affected patients and a significant mortality rate. It is essential to establish objective criteria to stratify COVID-19 death risk. Frailty has been identified as a potential determinant of increased vulnerability in older adults affected by COVID-19, because it may suggest alterations of physical performance and functional autonomy.

Methods

We have conducted a narrative review of the literature on the evidences regarding COVID-19 and the frailty condition. Thirteen observational studies were included.

Conclusion

Data emerging from the studies indicate that older COVID-19 patients with a frailty condition have an increased risk of mortality compared with non-frail patients, and this association is independent of other clinical and demographic factors. A frailty evaluation is required to help clinicians to better stratify the overall risk of death for older patients with COVID-19.

Clinical Frailty Scale (CFS) indicated frailty is associated with increased in-hospital and 30-day mortality in COVID-19 patients: a systematic review and meta-analysis

BACKGROUND

The concept of frailty provides an age-independent, easy-to-use tool for risk stratification. We aimed to summarize the evidence on the efficacy of frailty tools in risk assessment in COVID-19 patients.

METHODS

The protocol was registered (CRD42021241544). Studies reporting on frailty in COVID-19 patients were eligible. The main outcomes were mortality, length of hospital stay (LOH) and intensive care unit (ICU) admission in frail and non-frail COVID-19 patients. Frailty was also compared in survivors and non-survivors. Five databases were searched up to 24th September 2021. The QUIPS tool was used for the risk of bias assessment. Odds ratios (OR) and weighted mean differences (WMD) were calculated with 95% confidence intervals (CI) using a random effect model. Heterogeneity was assessed using the I² and χ² tests.

RESULTS

From 3640 records identified, 54 were included in the qualitative and 42 in the quantitative synthesis. Clinical Frailty Scale (CFS) was used in 46 studies, the Hospital Frailty Risk Score (HFRS) by 4, the Multidimensional Prognostic Index (MPI) by 3 and three studies used other scores. We found that patients with frailty (CFS 4-9 or HFRS ≥ 5) have a higher risk of mortality (CFS: OR: 3.12; CI 2.56-3.81; HFRS OR: 1.98; CI 1.89-2.07). Patients with frailty (CFS 4-9) were less likely to be admitted to ICU (OR 0.28, CI 0.12-0.64). Quantitative synthesis for LOH was not feasible. Most studies carried a high risk of bias.

CONCLUSIONS

As determined by CFS, frailty is strongly associated with mortality; hence, frailty-based patient management should be included in international COVID-19 treatment guidelines. Future studies investigating the role of frailty assessment on deciding ICU admission are strongly warranted.

Humoral and Cellular Responses to COVID-19 Vaccination Indicate the Need for Post-Vaccination Testing in Frail Population

Despite the high efficacy of the BNT162b2 vaccine in the general population, data on its immunogenicity among frail elderly individuals are limited. Recently, levels of anti-SARS-CoV-2 spike IgG antibodies and serum neutralization titers were confirmed as good immune markers of protection against the virus, with evidence showing a reverse correlation between these two parameters and susceptibility to infection. Here we analyzed sera from 138 nursing home residents (median age of 88.9 years) and 312 nursing home staff (median age of 50.7 years) to determine the humoral response to two doses of the BNT162b2 vaccine, and found markedly decreased serum anti-spike antibody levels and neutralization titers in the nursing home resident (NHR) group, with over 11% non-responders compared to only 1.3% among the controls. Moreover, three months post-vaccination, a significant decrease in antibody titers was observed in COVID-19-naive nursing home residents. Subsequent flow cytometry and interferon gamma secretion analyses indicated that antibody non-responders among NHRs also failed to mount cellular responses. The presented data emphasize that additional measures are needed in the population of frail elderly individuals. Given the high proportion of non-responders among NHRs, continued monitoring should be considered in this group.

Predictive value of frailty in the mortality of hospitalized patients with COVID-19: a systematic review and meta-analysis

Background

The present study aimed to analyze the impact of frailty on mortality risk among hospitalized patients with coronavirus disease 2019 (COVID-19).

Methods

Literature searches were conducted using the MEDLINE, Embase, and Cochrane databases for articles reporting the association between frailty and mortality in hospitalized patients with COVID-19. The quality of the included studies was assessed using the Newcastle-Ottawa scale (NOS). A random-effects meta-analysis was performed to calculate the pooled effects.

Results

A total of 21 studies with 26,652 hospitalized patients were included. Sixteen studies used the Clinical Frailty Score (CFS), and five used other frailty assessment tools. The pooled estimates of frailty in hospitalized patients with COVID-19 were 51.4% [95% confidence interval (CI): 39.9–62.9%]. In the CFS group, frail patients experienced a higher rate of short-term mortality than non-frail patients [odds ratio (OR) =3.0; 95% CI: 2.3–3.9; I²=72.7%; P<0.001]. In the other tools group, frail patients had a significantly increased short-term mortality risk compared with non-frail patients (OR =2.4; 95% CI: 1.4–4.1; P=0.001). Overall, a higher short-term mortality risk was observed for frail patients than non-frail patients (OR =2.8; 95% CI: 2.3–3.5; P<0.001). In older adults, frail patients had a higher rate of short-term mortality than non-frail patients (OR =2.3; 95% CI: 1.8–2.9; P<0.001).

Conclusions

Compared to non-frail hospitalized patients with COVID-19, frail patients suffered a higher risk of all-cause mortality, and this result was also found in the older adult group.

Frailty and mortality associations in patients with COVID ‐19: A Systematic Review and Meta‐analysis

Background

Observational data during the pandemic have demonstrated mixed associations between frailty and mortality.

Aim

To examine associations between frailty and short‐term mortality in patients hospitalised with coronavirus disease 2019 (COVID‐19).

Methods

In this systematic review and meta‐analysis, we searched PubMed, Embase and the COVID‐19 living systematic review from 1 December 2019 to 15 July 2021. Studies reporting mortality and frailty scores in hospitalised patients with COVID‐19 (age ≥18 years) were included. Data on patient demographics, short‐term mortality (in hospital or within 30 days), intensive care unit (ICU) admission and need for invasive mechanical ventilation (IMV) were extracted. The quality of studies was assessed using the Newcastle−Ottawa Scale.

Results

Twenty‐five studies reporting 34 628 patients were included. Overall, 26.2% (n = 9061) died. Patients who died were older (76.7 ± 9.6 vs 69.2 ± 13.4), more likely male (risk ratio (RR) = 1.08; 95% confidence interval (CI): 1.06–1.11) and had more comorbidities. Fifty‐eight percent of patients were frail. Adjusting for age, there was no difference in short‐term mortality between frail and non‐frail patients (RR = 1.04; 95% CI: 0.84–1.28). The non‐frail patients were commonly admitted to ICU (27.2% (4256/15639) vs 29.1% (3567/12274); P = 0.011) and had a higher mortality risk (RR = 1.63; 95% CI: 1.30–2.03) than frail patients. Among patients receiving IMV, there was no difference in mortality between frail and non‐frail (RR = 1.62; 95% CI 0.93–2.77).

Conclusion

This systematic review did not demonstrate an independent association between frailty status and short‐term mortality in patients with COVID‐19. Patients with frailty were less commonly admitted to ICU and non‐frail patients were more likely to receive IMV and had higher mortality risk. This finding may be related to allocation decisions for patients with frailty amidst the pandemic.

Characteristics and Outcomes of Patients With Frailty Admitted to ICU With Coronavirus Disease 2019: An Individual Patient Data Meta-Analysis

Supplemental Digital Content is available in the text.

Frailty is often used in clinical decision-making for patients with coronavirus disease 2019, yet studies have found a variable influence of frailty on outcomes in those admitted to the ICU. In this individual patient data meta-analysis, we evaluated the characteristics and outcomes across the range of frailty in patients admitted to ICU with coronavirus disease 2019.

Association between vaccination and preventive routines on COVID-19-related mortality in nursing home facilities: a population-based systematic retrospective chart review

Background:

Older and frail individuals are at high risk of dying from COVID-19, and residents in nursing homes (NHs) are overrepresented in death rates. We explored four different periods during the COVID-19 pandemic to analyze the effects of improved preventive routines and vaccinations, respectively, on mortality in NHs.

Methods:

We undertook a population-based systematic retrospective chart review comprising 136 NH facilities in southeast Sweden. All residents, among these facilities, who died within 30 days after a laboratory-verified COVID-19 diagnosis during four separate 92-day periods representing early pandemic (second quarter 2020), middle of the pandemic (fourth quarter 2020), early post-vaccination phase (first quarter 2021), and the following post-vaccination phase (second quarter 2021). Mortality together with electronic chart data on demographic variables, comorbidity, frailty, and cause of death was collected.

Results:

The number of deaths during the four periods was 104, 120, 34 and 4, respectively, with a significant reduction in the two post-vaccination periods (P < 0.001). COVID-19 was assessed as the dominant cause of death in 20 (19%), 19 (16%), 4 (12%) and 1 (3%) residents in each period (P < 0.01). The respective median age in the four studied periods varied between 87and 89 years, and three or more diagnoses besides COVID-19 were present in 70–90% of the respective periods’ study population. Considerable or severe frailty was found in all residents.

Conclusions:

Vaccination against COVID-19 seems associated with a reduced number of deaths in NHs. We could not demonstrate an effect on mortality merely from the protective routines that were undertaken.

Functional dependency and COVID-19 in elderly patients with mild to moderate disease. Experience of tertiary geriatric hospital

Clinical course of COVID-19 may be associated with functional dependency of geriatric patients. Data from the records of patients admitted to the COVID-19 Geriatric Unit were gathered during three months, including background, clinical aspects, time to resolution of infection and functional status. Functionally dependent patients had higher rates of diabetes (p = 0.03) and stroke (p = 0.004), as well as longer time to resolution of infection (p < 0.001), but less respiratory COVID-19 symptoms (p = 0.007), compared to independent patients. Time to resolution of infection was longer in women (p = 0.01) and positively associated with WBC level (p < 0.01) and age (p < 0.001). An adjusted analysis which controlled these variables confirmed the significant effect of functional status on the time to resolution of infection (p = 0.015). Functionally dependent geriatric patients with mild to moderate infection had less respiratory COVID-19 symptoms but showed longer time to resolution of infection compared to independent. Assessment of functional status in the elderly population may contribute to decision making for care of geriatric inpatients with COVID-19.

Can vaccination roll-out be more equitable if population risk is taken into account?

Background

COVID-19 vaccination in many countries, including England, has been prioritised primarily by age. However, people of the same age can have very different health statuses. Frailty is a commonly used metric of health and has been found to be more strongly associated with mortality than age among COVID-19 inpatients.

Methods

We compared the number of first vaccine doses administered across the 135 NHS Clinical Commissioning Groups (CCGs) of England to both the over 50 population and the estimated frail population in each area. Area-based frailty estimates were generated using the English Longitudinal Survey of Ageing (ELSA), a national survey of older people. We also compared the number of doses to the number of people with other risk factors associated with COVID-19: atrial fibrillation, chronic kidney disease, diabetes, learning disabilities, obesity and smoking status.

Results

We estimate that after 79 days of the vaccine program, across all Clinical Commissioning Group areas, the number of people who received a first vaccine per frail person ranged from 4.4 (95% CI 4.0-4.8) and 20.1 (95% CI 18.3-21.9). The prevalences of other risk factors were also poorly associated with the prevalence of vaccination across England.

Conclusions

Vaccination with age-based priority created area-based inequities in the number of doses administered relative to the number of people who are frail or have other risk factors associated with COVID-19. As frailty has previously been found to be more strongly associated with mortality than age for COVID-19 inpatients, an age-based priority system may increase the risk of mortality in some areas during the vaccine roll-out period. Authorities planning COVID-19 vaccination programmes should consider the disadvantages of an age-based priority system.

Characteristics, hospital referrals and 60-day mortality of older patients living in nursing homes with COVID-19 assessed by a liaison geriatric team during the first wave: a research article

BACKGROUND

The infection by SARS-CoV-2 (COVID-19) has been especially serious in older patients. The aim of this study is to describe baseline and clinical characteristics, hospital referrals, 60-day mortality, factors associated with hospital referrals and mortality in older patients living in nursing homes (NH) with suspected COVID-19.

METHODS

A retrospective observational study was performed during March and April 2020 of institutionalized patients assessed by a liaison geriatric hospital-based team. Were collected all older patients living in 31 nursing homes of a public hospital catchment area assessed by a liaison geriatric team due to the suspicion of COVID-19 during the first wave, when the hospital system was collapsed. Sociodemographic variables, comprehensive geriatric assessment, clinical characteristics, treatment received including care setting, and 60-days mortality were recorded from electronic medical records. A logistic regression analysis was performed to analyze the factors associated with mortality.

RESULTS

419 patients were included in the study (median age 89 years old, 71.6 % women, 63.7 % with moderate-severe dependence, and 43.8 % with advanced dementia). 31.1 % were referred to the emergency department in the first assessment, with a higher rate of hospital referral in those with better functional and mental status. COVID-19 atypical symptoms like functional decline, delirium, or eating disorders were frequent. 36.9% had died in the 60 days following the first call. According to multivariate logistic regression age (p 0.010), Barthel index <60 (p 0.002), presence of tachypnea (p 0.021), fever (p 0.006) and the use of ceftriaxone (p 0.004) were associated with mortality. No mortality differences were found between those referred to the hospital or cared at the nursing home.

CONCLUSIONS AND IMPLICATIONS

31% of the nursing home patients assessed by a liaison geriatric hospital-based team for COVID-19 were referred to the hospital, being more frequently referred those with a better functional and cognitive situation. The 60-days mortality rate due to COVID-19 was 36.8% and was associated with older age, functional dependence, the presence of tachypnea and fever, and the use of ceftriaxone. Geriatric comprehensive assessment and coordination between NH and the hospital geriatric department teams were crucial.

Association of Frailty With the Risk of Mortality and Resource Utilization in Elderly Patients in Intensive Care Units: A Meta-Analysis

Background: The associations of frailty with the risk of mortality and resource utilization in the elderly patients admitted to intensive care unit (ICU) remain unclear. To address these issues, we performed a meta-analysis to determine whether frailty is associated with adverse outcomes and increased resource utilization in elderly patients admitted to the ICU.

Methods: We searched PubMed, EMBASE, ScienceDirect, and Cochrane Central Register of Controlled Trials through August 2021 to identify the relevant studies that investigated frailty in elderly (≥ 65 years old) patients admitted to an ICU and compared outcomes and resource utilization between frail and non-frail patients. The primary outcome was mortality. We also investigated the prevalence of frailty and the impact of frailty on the health resource utilization, such as hospital length of stay (LOS) and resource utilization of ICU.

Results: A total of 13 observational studies enrolling 64,279 participants (28,951 frail and 35,328 non-frail) were finally included. Frailty was associated with an increased risk of short-term mortality (10 studies, relative risk [RR]: 1.70; 95% CI: 1.45–1.98), in-hospital mortality (five studies, RR: 1.73; 95% CI: 1.55–1.93), and long-term mortality (six studies, RR: 1.86; 95% CI: 1.44–2.42). Subgroup analysis showed that retrospective studies identified a stronger correlation between frailty and hospital LOS (three studies, MD 1.14 d; 95% CI: 0.92–1.36).

Conclusions: Frailty is common in the elderly patients admitted to ICU, and is associated with increased mortality and prolonged hospital LOS.

Trial registration: This study was registered in the PROSPERO database (CRD42020207242).