Beyond Chronological Age: Frailty and Multimorbidity Predict In-Hospital Mortality in Patients With Coronavirus Disease 2019

Progression of frailty and cardiovascular outcomes among Medicare beneficiaries

BACKGROUND

Frailty is associated with adverse cardiovascular outcomes independent of age and comorbidities, yet the independent influence of frailty progression on cardiovascular outcomes remains uncertain.

METHODS

To determine whether frailty progression is associated with adverse cardiovascular outcomes, independent of baseline frailty and age, we evaluated all Medicare Fee-for-Service beneficiaries ≥65 years at cohort inception with continuous enrollment from 2003 to 2015. Linear mixed effects models, adjusted for baseline frailty and age, were used to estimate change in a validated claims-based frailty index (CFI) over a 5-year period. Survival analysis was used to examine frailty progression and risk of adverse health outcomes.

RESULTS

There were 8.9 million unique patients identified, mean age 77.3 ± 7.2 years, 58.7% female, 10.9% non-White race. In total, 60% had frailty progression and 40% frailty regression over median follow-up of 2.4 years. Compared to those with frailty regression, when adjusting for age and baseline CFI, those with frailty progression had a significantly greater risk of incident major adverse cardiovascular and cerebrovascular events (MACCE) (hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.31-1.31), all-cause mortality (HR 1.34, 95% CI 1.34-1.34), acute myocardial infarction (HR 1.08, 95% CI 1.07-1.09), heart failure exacerbation (HR 1.30, 95% CI 1.29-1.30), ischemic stroke (HR 1.14, 95% CI 1.14-1.15). There was also a graded increase in risk of each outcome with more rapid progression, as well as significantly fewer days alive at home (DAH) with more rapid progression compared to the slowest progression group (270.4 ± 112.3 vs. 308.6 ± 93.0 days, rate ratio 0.88, 95% CI 0.87-0.88, p < 0.001).

CONCLUSIONS

In this large, nationwide sample of older Medicare beneficiaries, frailty progression, independent of age and baseline frailty, was associated with fewer DAH and a graded risk of MACCE, all-cause mortality, myocardial infarction, heart failure, and ischemic stroke compared to those with frailty regression.

Deaths related to post-COVID in Italy: a national study based on death certificates

Introduction

SARS-CoV-2 infection has been associated with the onset or persistence of symptoms in the long-term after the acute infection is resolved. This condition known as Post-COVID, might be particularly severe and potentially life-threatening. However, little is known on the impact of post-COVID condition on mortality. Aim of the present study is to assess and quantify Post-COVID deaths in Italy in years 2020 and 2021, based on an analysis of death certificates.

Methods

Data from the Italian National Cause of Death Register were analyzed. ICD-10 code U09.9, released by the World Health Organization in September 2020, was used to identify the 'Post-COVID' condition. Numbers of post-COVID deaths from October 2020 to December 2021 were analyzed. Rates of post-COVID deaths were calculated for the year 2021.

Results

Between October 2020 and December 2021, 4,752 death certificates reporting post-COVID condition were identified. Of these, 14.9% (n = 706) occurred between October and December 2020 and 85.1% (n = 4,046) in 2021. In 46.0% of post-COVID-related deaths, the underlying cause of death was COVID-19. Other frequent underlying causes were heart disease (14.3% of cases), neoplasms (9.2%), cerebrovascular diseases (6.3%) and Alzheimer's disease and other dementias (5.5%). The mortality rate related to post-COVID conditions in year 2021 was 5.1 deaths per 100 thousand inhabitants and it increased with increasing age. Men showed a higher mortality rate than women (4.3 deaths per 100 thousand in women and 6.0 deaths per 100 thousand in men).

Discussion

Post-COVID conditions contributed to a substantial number of deaths in Italy. Strategies to identify the population at risk of severe long-term consequences of SARS-CoV-2 infection and interventions aimed at reducing this risk must be developed.

The relationship between comprehensive geriatric assessment on the pneumonia prognosis of older adults: a cross-sectional study

BACKGROUND

The mortality of pneumonia in older adults surpasses that of other populations, especially with the prevalence of coronavirus disease 2019 (COVID-19). Under the influence of multiple factors, a series of geriatric syndromes brought on by age is one of the main reasons for the poor prognosis of pneumonia. This study attempts to analyze the impact of geriatric syndrome on the prognosis of pneumonia.

METHODS

This is a prospective cross-sectional study. Patients over 65 years old with COVID-19 and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-negative community-acquired pneumonia (SN-CAP) were included in the research. General characteristics, laboratory tests, length of stay (LOS), and comprehensive geriatric assessment (CGA) were collected. Multivariate regression analysis to determine the independent predictors of the severity, mortality, and LOS of COVID-19. At the same time, the enrolled subjects were divided into three categories by clustering analysis of 10 CGA indicators, and their clinical characteristics and prognoses were analyzed.

RESULTS

A total of 792 subjects were included in the study, including 204 subjects of SN-CAP (25.8%) and 588 subjects (74.2%) of COVID-19. There was no significant difference between non-severe COVID-19 and SN-CAP regarding mortality, LOS, and CGA (P > 0.05), while severe COVID-19 is significantly higher than both (P < 0.05). The Barthel Index used to assess the activities of daily living was an independent risk factor for the severity and mortality of COVID-19 and linearly correlated with the LOS (P < 0.05). The cluster analysis based on the CGA indicators divided the geriatric pneumonia patients into three groups: Cluster 1 (n = 276), named low ability group, with the worst CGA, laboratory tests, severity, mortality, and LOS; Cluster 3 (n = 228), called high ability group with the best above indicators; Cluster 2 (n = 288), named medium ability group, falls between the two.

CONCLUSION

The Barthel Index indicates that decreased activities of daily living are an independent risk factor for the severity, mortality, and LOS of geriatric COVID-19. Geriatric syndrome can help judge the prognosis of pneumonia in older adults.

Trajectories of chronic multimorbidity patterns in older patients: MTOP study

BACKGROUND

Multimorbidity is associated with negative results and poses difficulties in clinical management. New methodological approaches are emerging based on the hypothesis that chronic conditions are non-randomly associated forming multimorbidity patterns. However, there are few longitudinal studies of these patterns, which could allow for better preventive strategies and healthcare planning. The objective of the MTOP (Multimorbidity Trajectories in Older Patients) study is to identify patterns of chronic multimorbidity in a cohort of older patients and their progression and trajectories in the previous 10 years.

METHODS

A retrospective, observational study with a cohort of 3988 patients aged > 65 was conducted, including suspected and confirmed COVID-19 patients in the reference area of Parc Taulí University Hospital. Real-world data on socio-demographic and diagnostic variables were retrieved. Multimorbidity patterns of chronic conditions were identified with fuzzy c-means cluster analysis. Trajectories of each patient were established along three time points (baseline, 5 years before, 10 years before). Descriptive statistics were performed together with a stratification by sex and age group.

RESULTS

3988 patients aged over 65 were included (58.9% females). Patients with ≥ 2 chronic conditions changed from 73.6 to 98.3% in the 10-year range of the study. Six clusters of chronic multimorbidity were identified 10 years before baseline, whereas five clusters were identified at both 5 years before and at baseline. Three clusters were consistently identified in all time points (Metabolic and vascular disease, Musculoskeletal and chronic pain syndrome, Unspecific); three clusters were only present at the earliest time point (Male-predominant diseases, Minor conditions and sensory impairment, Lipid metabolism disorders) and two clusters emerged 5 years before baseline and remained (Heart diseases and Neurocognitive). Sex and age stratification showed different distribution in cluster prevalence and trajectories.

CONCLUSIONS

In a cohort of older patients, we were able to identify multimorbidity patterns of chronic conditions and describe their individual trajectories in the previous 10 years. Our results suggest that taking these trajectories into consideration might improve decisions in clinical management and healthcare planning.

TRIAL REGISTRATION NUMBER

NCT05717309.

Geroscience and pathology: a new frontier in understanding age-related diseases

Geroscience, a burgeoning discipline at the intersection of aging and disease, aims to unravel the intricate relationship between the aging process and pathogenesis of age-related diseases. This paper explores the pivotal role played by geroscience in reshaping our understanding of pathology, with a particular focus on age-related diseases. These diseases, spanning cardiovascular and cerebrovascular disorders, malignancies, and neurodegenerative conditions, significantly contribute to the morbidity and mortality of older individuals. We delve into the fundamental cellular and molecular mechanisms underpinning aging, including mitochondrial dysfunction and cellular senescence, and elucidate their profound implications for the pathogenesis of various age-related diseases. Emphasis is placed on the importance of assessing key biomarkers of aging and biological age within the realm of pathology. We also scrutinize the interplay between cellular senescence and cancer biology as a central area of focus, underscoring its paramount significance in contemporary pathological research. Moreover, we shed light on the integration of anti-aging interventions that target fundamental aging processes, such as senolytics, mitochondria-targeted treatments, and interventions that influence epigenetic regulation within the domain of pathology research. In conclusion, the integration of geroscience concepts into pathological research heralds a transformative paradigm shift in our understanding of disease pathogenesis and promises breakthroughs in disease prevention and treatment.

Progression of Frailty and Cardiovascular Outcomes Among Medicare Beneficiaries

Background

Frailty is associated with adverse cardiovascular outcomes independent of age and comorbidities, yet the independent influence of frailty progression remains uncertain.

Methods

Medicare Fee-for-service beneficiaries ≥ 65 years at cohort inception with continuous enrollment from 2003-2015 were included. Frailty trajectory was measured by annualized change in a validated claims-based frailty index (CFI) over a 5-year period. Linear mixed effects models, adjusting for baseline frailty, were used to estimate CFI change over a 5-year period. Survival analysis was used to evaluate associations of frailty progression and future health outcomes (major adverse cardiovascular and cerebrovascular events [MACCE], all-cause death, heart failure, myocardial infarction, ischemic stroke, and days alive at home [DAH] within the following calendar year).

Results

26.4 million unique beneficiaries were included (mean age 75.4 ± 7.0 years, 57% female, 13% non-White). In total, 20% had frailty progression, 66% had no change in frailty, and 14% frailty regression over median follow-up of 2.4 years. Compared to those without a change in CFI, when adjusting for baseline frailty, those with frailty progression had significantly greater risk of incident MACCE (hazard ratio [HR] 2.30, 95% confidence interval [CI] 2.30-2.31), all-cause mortality (HR 1.59, 95% CI 1.58-1.59), acute myocardial infarction (HR 1.78, 95% CI 1.77-1.79), heart failure (HR 2.78, 95% CI 2.77-2.79), and stroke (HR 1.78, 95% CI 1.77-1.79). There was also a graded increase in risk of each outcome with more rapid progression and significantly fewer DAH with the most rapid vs. the slowest progression group (270.4 ± 112.3 vs. 308.6 ± 93.0 days, rate ratio 0.88, 95% CI 0.87-0.88, p < 0.001).

Conclusions

In this large, nationwide sample of Medicare beneficiaries, frailty progression, independent of baseline frailty, was associated with fewer DAH and a graded risk of MACCE, all-cause mortality, myocardial infarction, heart failure, and stroke compared to those without progression.

Frailty and sarcopenia: A bibliometric analysis of their association and potential targets for intervention

Frailty and sarcopenia are age-related diseases, and exhibit a concomitant relationship, as they share many common clinical features and etiological factors. Transitions within frailty status would be influenced by the presence of sarcopenia. Investigating their association to devise efficacious intervention and management strategies for geriatric patients is imperative, given their potentially unfavorable outcomes. In this study, the literature on sarcopenia and frailty was screened in the Web of Science core collection database over the past 30 years to ascertain the link between them through bibliometric analysis and the exploration of disease-related molecular pathways within the GeneCards and OMIM databases was conducted. Per inclusion and exclusion criteria, 3889 literature sources were selected for subsequent analysis. Keywords, including "cirrhosis" and "postoperative complications," represent the current and potential future research trends and focal points in this field. Moreover, 63 common potential targets between the two diseases were identified. Their pathogenesis involved cellular aging and endocrine metabolism regulation pathways, including AMPK, cell senescence, and the endocrine resistance pathway. This study identified an intimate correlation between frailty and sarcopenia in pathogenesis, prevention, and treatment measures, establishing a foundation for exploring shared prevention and treatment strategies for these two disorders.

Inclusion of functional measures and frailty in the development and evaluation of medicines for older adults

The International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) E7, the guidance for the conduct of clinical trials in people older than age 65 years, dates from 1994. Since then, the inclusion of older people in clinical trials has hardly improved, particularly for the oldest old age group (individuals older than age 75 years), which is the fastest growing demographic bracket in the EU. Even though most medications are taken by this group, relevant endpoints and safety outcomes for this cohort are rarely included and reported, both in clinical trials and regulatory approval documents. To improve the critical appraisal and the regulatory review of medicines taken by frail older adults, eight recommendations are presented and discussed in this Health Policy. These recommendations are brought together from different perspectives and experience of the treatment of older patients. On one side, the perspective of medical practitioners from various clinical disciplines, with their direct experience of clinical decision making; on the other, the perspective of regulators assessing the data submitted in medicine registration dossiers, their relevance to the risk-benefit balance for older patients, and the communication of the findings in the product information. Efforts to improve the participation of older people in clinical trials have been in place for more than a decade, with little success. The recommendations presented here are relevant for stakeholders, authorities, pharmaceutical companies, and researchers alike, as the implementation of these measures is not under the capacity of a single entity. Improving the inclusion of frail older adults requires awareness, focus, and action on the part of those who can effect a much needed change.

Impact of sarcopenia on outcomes in surgical patients: a systematic review and meta-analysis

BACKGROUND

Surgeons have historically used age as a preoperative predictor of postoperative outcomes. Sarcopenia, the loss of skeletal muscle mass due to disease or biological age, has been proposed as a more accurate risk predictor. The prognostic value of sarcopenia assessment in surgical patients remains poorly understood. Therefore, the authors aimed to synthesize the available literature and investigate the impact of sarcopenia on perioperative and postoperative outcomes across all surgical specialties.

METHODS

The authors systematically assessed the prognostic value of sarcopenia on postoperative outcomes by conducting a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching the PubMed/MEDLINE and EMBASE databases from inception to 1st October 2022. Their primary outcomes were complication occurrence, mortality, length of operation and hospital stay, discharge to home, and postdischarge survival rate at 1, 3, and 5 years. Subgroup analysis was performed by stratifying complications according to the Clavien-Dindo classification system. Sensitivity analysis was performed by focusing on studies with an oncological, cardiovascular, emergency, or transplant surgery population and on those of higher quality or prospective study design.

RESULTS

A total of 294 studies comprising 97 643 patients, of which 33 070 had sarcopenia, were included in our analysis. Sarcopenia was associated with significantly poorer postoperative outcomes, including greater mortality, complication occurrence, length of hospital stay, and lower rates of discharge to home (all P <0.00001). A significantly lower survival rate in patients with sarcopenia was noted at 1, 3, and 5 years (all P <0.00001) after surgery. Subgroup analysis confirmed higher rates of complications and mortality in oncological (both P <0.00001), cardiovascular (both P <0.00001), and emergency ( P =0.03 and P =0.04, respectively) patients with sarcopenia. In the transplant surgery cohort, mortality was significantly higher in patients with sarcopenia ( P <0.00001). Among all patients undergoing surgery for inflammatory bowel disease, the frequency of complications was significantly increased among sarcopenic patients ( P =0.007). Sensitivity analysis based on higher quality studies and prospective studies showed that sarcopenia remained a significant predictor of mortality and complication occurrence (all P <0.00001).

CONCLUSION

Sarcopenia is a significant predictor of poorer outcomes in surgical patients. Preoperative assessment of sarcopenia can help surgeons identify patients at risk, critically balance eligibility, and refine perioperative management. Large-scale studies are required to further validate the importance of sarcopenia as a prognostic indicator of perioperative risk, especially in surgical subspecialties.

Knowledge domain and emerging trends in multimorbidity and frailty research from 2003 to 2023: a scientometric study using citespace and VOSviewer

BACKGROUND

Multimorbidity and frailty represent emerging global health burdens that have garnered increased attention from researchers over the past two decades. We conducted a scientometric analysis of the scientific literature on the coexistence of multimorbidity and frailty to assess major research domains, trends, and inform future lines of research.

METHODS

We systematically retrieved scientific publications on multimorbidity and frailty from the Web of Science Core Collection, spanning from 2003 to 2023. Scientometric analysis was performed using CiteSpace and VOSviewer, enabling the visualization and evaluation of networks comprising co-citation references, co-occurring keywords, countries, institutions, authors, and journals.

RESULTS

A total of 584 eligible publications were included in the analysis. An exponential rise in research interest in multimorbidity and frailty was observed, with an average annual growth rate of 47.92% in publications between 2003 and 2022. Three major research trends were identified: standardized definition and measurement of multimorbidity and frailty, comprehensive geriatric assessment utilizing multimorbidity and frailty instruments for older adults, and the multifaceted associations between these two conditions. The United States of America, Johns Hopkins University, Fried LP, and the Journal of the American Geriatrics Society were identified as the most influential entities within this field, representing the leading country, institution, author, and journal, respectively.

CONCLUSIONS

Scientometric analysis provides invaluable insights to clinicians and researchers involved in multimorbidity and frailty research by identifying intellectual bases and research trends. While the instruments and assessments of multimorbidity and frailty with scientific validity and reliability are of undeniable importance, further investigations are also warranted to unravel the underlying biological mechanisms of interactions between multimorbidity and frailty, explore the mental health aspects among older individuals with multimorbidity and frailty, and refine strategies to reduce prescriptions in this specific population.

Role of Cardio-Renal Dysfunction, Inflammation Markers, and Frailty on In-Hospital Mortality in Older COVID-19 Patients: A Cluster Analysis

Our study aimed to identify clusters of hospitalized older COVID-19 patients according to their main comorbidities and routine laboratory parameters to evaluate their association with in-hospital mortality. We performed an observational study on 485 hospitalized older COVID-19 adults (aged 80+ years). Patients were aggregated in clusters by a K-medians cluster analysis. The primary outcome was in-hospital mortality. Medical history and laboratory parameters were collected on admission. Frailty, defined by the Clinical Frailty Scale (CFS), referred to the two weeks before hospitalization and was used as a covariate. The median age was 87 (83-91) years, with a female prevalence (59.2%). Three different clusters were identified: cluster 1 (337), cluster 2 (118), and cluster 3 (30). In-hospital mortality was 28.5%, increasing from cluster 1 to cluster 3: cluster 1 = 21.1%, cluster 2 = 40.7%, and cluster 3 = 63.3% (p < 0.001). The risk for in-hospital mortality was higher in clusters 2 [HR 1.96 (95% CI: 1.28-3.01)] and 3 [HR 2.87 (95% CI: 1.62-5.07)] compared to cluster 1, even after adjusting for age, sex, and frailty. Patients in cluster 3 were older and had a higher prevalence of atrial fibrillation, higher admission NT-proBNP and C-reactive protein levels, higher prevalence of concurrent bacterial infections, and lower estimated glomerular filtration rates. The addition of CFS significantly improved the predictive ability of the clusters for in-hospital mortality. Our cluster analysis on older COVID-19 patients provides a characterization of those subjects at higher risk for in-hospital mortality, highlighting the role played by cardio-renal impairment, higher inflammation markers, and frailty, often simultaneously present in the same patient.

[Role of statins in clinical evolution of octogenarian patients admitted due to COVID-19]

INTRODUCTION AND OBJECTIVES

coronavirus disease 2019 (COVID-19) causes high mortality in elderly patients. Some studies have shown a benefit of statin treatment in the evolution of this disease. Since there are no similar publications in this population group, the aim of this study is to analyze in-hospital mortality in relation to preadmission treatment with statins in an exclusively elderly population of octogenarian patients.

MATERIALS AND METHODS

A single-center retrospective cohort study was performed including a total of 258 patients ≥80 years with hospital admission for confirmed COVID-19 between March 1 and May 31, 2020. They were divided into two groups: taking statins prior to admission (n=129) or not (n=129).

RESULTS

In-hospital mortality due to COVID-19 in patients ≥80 years (86.13±4.40) during the first wave was 35.7% (95% CI: 30.1-41.7%). Mortality in patients previously taking statins was 25.6% while in those not taking statins was 45.7%. Female sex (RR 0.62 [0.44-0.89]; p=0.008), diabetes (RR 0.61 [0.41-0.92]; p=0.017) and pre-admission treatment with statins (RR 0.58 95% CI [0.41-0.83]; p=0.003) were associated with lower in-hospital mortality. Severe lung involvement was associated with increased in-hospital mortality (RR 1.45 95% CI [1.04-2.03]; p=0.028). Hypertension, obesity, age, cardiovascular disease and a higher Charlson index did not, however, show influence on in-hospital mortality.

CONCLUSIONS

In octogenarian patients treated with statins prior to admission for COVID-19 in the first wave, lower in-hospital mortality was observed.

The interRAI COVID-19 vulnerability screener: Results of a health surveillance initiative for vulnerable adults in the community during the COVID-19 pandemic

During the pandemic, the interRAI COVID-19 Vulnerability Screener (CVS) was used to identify community-dwelling older adults or adults with disabilities at risk of negative outcomes and facilitate triage for follow-up with health/social services. The interRAI CVS, a standardized self-report instrument administered virtually by a lay-person, includes COVID-19-related items and psychosocial and physical vulnerability. Our objective was to describe those assessed and identify sub-groups at highest risk of adverse outcomes. Seven community-based organizations in Ontario, Canada, implemented the interRAI CVS. We used descriptive statistics to report results and created a priority indicator for monitoring and/or intervention based on possible COVID-19 symptoms and psychosocial/physical vulnerabilities. We used logistic regression to examine the association between priority level and risk of poor outcomes using fair/poor self-rated health as a proxy measure. The sample included 942 adults assessed (April-November 2020; mean age=79). About 10% of individuals reported potential COVID-19 symptoms and <1% had a positive COVID-19 test/diagnosis. Of those with psychosocial/physical vulnerabilities (73.1%), most common were depressed mood (20.9%), loneliness (21.6%), and limited access to food/medications (7.5%). Overall, 45.7% had a recent doctor or nurse practitioner visit. Odds of fair/poor self-reported health were highest among those who reported both possible symptoms of COVID-19 and psychosocial/physical vulnerabilities (OR 10.9, 95% CI 5.96-20.12) compared to those with neither symptoms nor psychosocial/physical vulnerabilities. The sample represents a population largely unaffected by COVID-19 itself but with identified vulnerabilities. The interRAI CVS allows community providers to stay connected and obtain a better understanding of vulnerable individuals' needs during the pandemic.

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.

Insights from comparison of the clinical presentation and outcomes of patients hospitalized with COVID-19 in an Italian internal medicine ward during first and third wave

Background

The reasons of variability of clinical presentation of coronavirus disease-19 (COVID-19) across different pandemic waves are not fully understood, and may include individual risk profile, SARS-CoV-2 lineage and seasonal variations of viral spread. The objective of this retrospective study was to compare the characteristics and outcomes of patients admitted with confirmed coronavirus disease-19 (COVID-19) in the same season during the first (March 2020) and the third pandemic wave (March 2021, dominance of SARS-CoV-2 B.1.1.7 lineage) in an internal medicine ward of a large teaching hospital in Italy.

Materials and methods

Data of 769 unvaccinated patients (399 from the first and 370 from the third wave) were collected from clinical records, including symptom type and duration, extension of lung abnormalities on chest computed tomography (CT) and PaO₂/FiO₂ ratio on admission arterial blood gas analysis.

Results

Third wave patients were in average younger (median 65, interquartile range [IQR] 55-75, vs. 72, IQR 61-81 years old, p < 0.001), with less comorbidities and better pulmonary (CT visual score median 25, IQR 15-40, vs. 30, IQR 15-50, age- and sex-adjusted p = 0.017) and respiratory involvement (PaO₂/FiO₂ median 288, IQR 237-338, vs. 233, IQR 121-326 mmHg, age- and sex-adjusted p < 0.001) than first wave patients. Hospital mortality was lower (19% vs. 36%, p < 0.001), but not for subjects over 75 years old (46 vs. 49%). Age, number of chronic illnesses, PCT levels, CT visual score [Odds Ratio (OR) 1.022, 95% confidence interval (CI) 1.009-1.036, p < 0.001] and PaO₂/FiO₂ (OR 0.991, 95% CI 0.988-0.994, p < 0.001), but not the pandemic wave, were associated with mortality on stepwise multivariate logistic regression analysis.

Conclusion

Despite the higher virulence of B.1.1.7 lineage, we detected milder clinical presentation and improved mortality in patients hospitalized during the third COVID-19 wave, with involvement of younger subjects. The reasons of this discrepancy are unclear, but could involve the population effect of vaccination campaigns, that were being conducted primarily in older frail subjects during the third wave.

Frailty as a predictor of adverse outcomes in head and neck reconstruction: A systematic review

BACKGROUND

Frailty has been shown to adversely impact outcomes in a number of surgical disciplines. In head and neck reconstructive surgery, frailty may represent a significant risk factor in predicting post-operative outcomes due to the common characteristics of the patient population undergoing these procedures.

OBJECTIVES

To summarize the available evidence about frailty as a predictor of post-operative complications, length of hospital stay and quality of life in patients undergoing head and neck reconstructive surgery.

STUDY DESIGN

Systematic Review.

METHODS

The study protocol was registered with PROSPERO, registration CRD42022302899. Methodology was in keeping with the PRISMA Guidelines for Systematic Reviews. MEDLINE, SCOPUS, EMBASE, Web of Science and CENTRAL were the databases searched. Qualitative synthesis of the included studies was carried out, and quality assessment was performed.

RESULTS

Nine studies that reported data on 10,457 patients undergoing reconstruction of the head and neck were included in the review. A number of different tools were used to assess frailty, with the modified frailty index being the most frequently used. In total, 8 studies reported increased rates of complications in patients with increased levels of frailty, irrespective of the frailty tool used, with varied levels of statistical significance across the studies.

CONCLUSION

An association is observed between increased rates of perioperative complications and increased levels of frailty in patients undergoing head and neck reconstruction. Frailty tools may represent a useful method to risk stratify patients undergoing reconstructive head and neck surgery.

Risk factors associated with bacteremia with drug-resistant organisms: Review of blood culture results in emergency department of a regional hospital

Background:

Early antibiotic administration in sepsis improves patient survival. Treatment with antibiotics should cover potential pathogens and should avoid overusing broad-spectrum antibiotics. We have to identify patients who have high risks of infection with drug-resistant organisms.

Objectives:

A retrospective cohort study was conducted to identify potential risk factors associated with bloodstream infections with drug-resistant organisms to help the choice of empirical antibiotics in the emergency department.

Methods:

Adult patients with bloodstream infection diagnosed by blood culture in the emergency department in the period of 1 January 2020 to 31 December 2020 were included. Clinical features including chronic medical illnesses, clinical presentation and severity, and patients’ outcomes were identified in the electronic medical records. Bloodstream infection with drug-resistant organisms is defined as positive blood culture with bacteria resistant to either (1) amoxicillin/ clavulanic acid AND ceftriaxone or (2) amoxicillin/ clavulanic acid or ceftriaxone PLUS amikacin or levofloxacin. Univariate and multivariate analyses were conducted to identify risk factors associated with the study outcome.

Results:

Among 105 patients with bloodstream infection, 17% were caused by drug-resistant organisms. Multivariate analysis showed that age is a risk factor associated with bloodstream infection with drug-resistant organisms (odds ratio: 1.04, 95% confidence interval: 1.0–1.08, p = 0.03).

Conclusion:

In conclusion, age is a significant risk factor for drug-resistant bloodstream infection in emergency department patients. Further research may be needed to find out the relationship between frailty and infection with drug-resistant organisms.

Health trajectories in older patients hospitalized for COVID-19: Results from the GeroCovid multicenter study

BACKGROUND

COVID-19 has disproportionately affected older adults. Yet, healthcare trajectories experienced by older persons hospitalized for COVID-19 have not been investigated. This study aimed at estimating the probabilities of transitions between severity states in older adults admitted in COVID-19 acute wards and at identifying the factors associated with such dynamics.

METHODS

COVID-19 patients aged ≥60 years hospitalized between March and December 2020 were involved in the multicentre GeroCovid project-acute wards substudy. Sociodemographic and health data were obtained from medical records. Clinical states during hospitalization were categorized on a seven-category scale, ranging from hospital discharge to death. Based on the transitions between these states, first, we defined patients' clinical course as positive (only improvements), negative (only worsening), or fluctuating (both improvements and worsening). Second, we focused on the single transitions between clinical states and estimated their probability (through multistage Markov modeling) and associated factors (with proportional intensity models).

RESULTS

Of the 1024 included patients (mean age 78.1 years, 51.1% women), 637 (62.2%) had a positive, 66 (6.4%) had a fluctuating, and 321 (31.3%) had a negative clinical course. Patients with a fluctuating clinical course were younger, had better mobility and cognitive levels, fewer diseases, but a higher prevalence of cardiovascular disease and obesity. Considering the single transitions, the probability that older COVID-19 patients experienced clinical changes was higher within a 10-day timeframe, especially for milder clinical states. Older age, male sex, lower mobility level, multimorbidity, and hospitalization during the COVID-19 first wave (compared with the second one) were associated with an increased probability of progressing towards worse clinical states or with a lower recovery.

CONCLUSION

COVID-19 in older inpatients has a complex and dynamic clinical course. Identifying individuals more likely to experience a fluctuating clinical course and sudden worsening may help organize healthcare resources and clinical management across settings at different care intensity levels.

Factors associated with mortality in hospitalised, non-severe, older COVID-19 patients - the role of sarcopenia and frailty assessment

BACKGROUND

COVID-19 has affected older persons the most. The propensity to have severe COVID-19 or die of the infection was especially prevalent among older subjects with multimorbidity, frailty and sarcopenia. The aim of our study was to check which of the simple clinical biomarkers, including the assessment of muscle and frailty, would associate with the survival and the length of hospital stay in older patients with COVID-19. An additional aim was to report the influence of chronic diseases, chronic medication use, and COVID-19 signs and symptoms on the aforementioned outcome measures.

METHODS

The CRACoV study was a prospective single-center (University Hospital in Krakow, Krakow, Poland) observational study of clinical outcomes in symptomatic COVID-19 patients that required hospital treatment. We analysed data of persons aged ≥ 65 years. We assessed muscular parameters in accordance with EWGSOP2, frailty with the Rockwood Clinical Frailty Scale. We used the data of the initial and 3-month assessment. Demographic characteristics, past medical history, and baseline laboratory values were gathered as a part of routine care. We calculated sex and age, and additionally number-of-diseases adjusted odds ratios of mortality associated with studied factors and betas of the relation with these factors and the length of hospital stay.

RESULTS

The mean (standard deviation, SD) age of 163 participants (44.8% women, 14.8% died) was 71.8 (5.6) years, age range 65-89 years. One score greater SARC-F was associated with 34% (p = 0.003) greater risk of death, and 16.8 h longer hospital stay (p = 0.01). One score greater Rockwood was associated with 86% (p = 0.002) greater risk of death, but was unrelated to the length of hospital stay. Hand grip strength and dynapenia were unrelated to mortality, but dynapenia was related to longer hospital stay. Probable sarcopenia was associated with 441% (p = 0.01) greater risk of death.

CONCLUSIONS

In conclusion, the patient assessment with SARC-F and the Rockwood Clinical Frailty Scale may significantly improve the prediction of outcomes in older patients with COVID-19 and by extension might be of use in other acute severe infections. This, however, requires further research to confirm.

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.

Frailty trajectories in community-dwelling older adults during COVID-19 pandemic: The PRESTIGE study

BACKGROUND

Frailty has been recognized as potential surrogate of biological age and relevant risk factor for COVID-19 severity. Thus, it is important to explore the frailty trajectories during COVID-19 pandemic and understand how COVID-19 directly and indirectly impacts on frailty condition.

METHODS

We enrolled 217 community-dwelling older adults with available information on frailty condition as assessed by multidimensional frailty model both at baseline and at one-year follow-up using Multidimensional Prognostic Index (MPI) tools. Pre-frail/frail subjects were identified at baseline as those with MPI score >0.33 (MPI grades 2-3). Frailty worsening was defined by MPI difference between 12 months follow-up and baseline ≥0.1. Multivariable logistic regression was modelled to identify predictors of worsening of frailty condition.

RESULTS

Frailer subjects at baseline (MPI grades 2-3 = 48.4%) were older, more frequently female and had higher rates of hospitalization and Sars-CoV-2 infection compared to robust ones (MPI grade 1). Having MPI grades 2-3 at baseline was associated with higher risk of further worsening of frailty condition (adjusted odd ratio (aOR): 13.60, 95% confidence interval (CI): 4.01-46.09), independently by age, gender and Sars-CoV-2 infection. Specifically, frail subjects without COVID-19 (aOR: 14.84, 95% CI: 4.26-51.74) as well as those with COVID-19 (aOR: 12.77, 95% CI: 2.66-61.40, p = 0.001) had significantly higher risk of worsening of frailty condition.

CONCLUSIONS

Effects of COVID-19 pandemic among community-dwelling frailer individuals are far beyond the mere infection and disease, determining a significant deterioration of frailty status both in infected and non-infected subjects.

Multimorbidity and Frailty Are the Key Characteristics of Patients Hospitalized with COVID-19 Breakthrough Infection during Delta Variant Predominance in Italy: A Retrospective Study

The aims of this study were to describe the characteristics of patients hospitalized with delta SARS-CoV-2 breakthrough infection, and to identify factors associated with pneumonia on chest Computed Tomography (CT) and mortality. The clinical records of 229 patients (105 F), with a median age of 81 (interquartile range, IQR, 73−88) years old, hospitalized between June and December 2021 after completion of the primary vaccination cycle, were retrospectively analyzed, retrieving data on comorbidities, Clinical Frailty Scale (CFS), clinical presentation and outcomes. Multimorbidity (91.7% with ≥2 chronic illnesses) and frailty (61.6% with CFS ≥ 5) were highly prevalent. CFS (OR 0.678, 95% CI 0.573−0.803, p < 0.001) and hypertension were independently associated with interstitial pneumonia. Mortality was 25.1% and unrelated with age. PaO2/FiO2 on blood gas analysis performed upon admission (OR 0.986, 95% CI 0.977−0.996, p = 0.005), and CFS (OR 1.723, 95% CI 1.152−2.576, p = 0.008) were independently associated with mortality only in subjects < 85 years old. Conversely, serum PCT levels were associated with mortality in subjects ≥ 85 years old (OR 3.088, 95% CI 1.389−6.8628, p = 0.006). In conclusion, hospitalization for COVID-19 breakthrough infection mainly involved geriatric patients, with those aged ≥ 85 more characterized by decompensation of baseline comorbidities rather than typical COVID-19 respiratory symptoms.

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.

Efficacy of power training to improve physical function in individuals diagnosed with frailty and chronic disease: A meta-analysis

Muscle power training with emphasis on high-velocity of concentric movement improves physical functionality in healthy older adults, and, maybe superior to traditional exercise programs. Power training may also be advantageous for patients with acute and chronic illnesses, as well as frail individuals. To determine the efficacy of power training compared with traditional resistance training on physical function outcomes in individuals diagnosed with frailty, acute illness or chronic disease. PubMed (MEDLINE), CINAHL, PEDro, Web of Science, and Google Scholar. (1) at least one study group receives muscle power training of randomized controlled trial (RCT) (2) study participants diagnosed as prefrail, frail or have an ongoing acute or chronic disease, condition or illness; (3) study participants over the age of 18; (4) publication in English language; (5) included physical function as the primary or secondary outcome measures. Two independent reviewers assessed articles for inclusion and graded the methodological quality using Cochrane Risk-of-Bias tool for RCTs. Fourteen RCTs met the inclusion criteria. In seven studies, muscle power training was more effective at improving physical function compared to control activities with a mean fixed effect size (ES) of 0.41 (p = 0.006; 95% CI 0.12 to 0.71). Power training and conventional resistance training had similar effectiveness in eight studies with a mean fixed ES of 0.10 (p = 0.061; 95% CI -0.01 to 0.40). Muscle power training is just as efficacious for improving physical function in individuals diagnosed with frailty and chronic disease when compared to traditional resistance training. The advantages of power training with reduced work per session may support power training as a preferential exercise modality for clinical populations. The findings should be interpreted with caution since generalizability is questioned due to the heterogeneity of patient populations enrolled and participants were relatively mobile at baseline.

Routine laboratory parameters, including complete blood count, predict COVID-19 in-hospital mortality in geriatric patients

To reduce the mortality of COVID-19 older patients, clear criteria to predict in-hospital mortality are urgently needed. Here, we aimed to evaluate the performance of selected routine laboratory biomarkers in improving the prediction of in-hospital mortality in 641 consecutive COVID-19 geriatric patients (mean age 86.6 ± 6.8) who were hospitalized at the INRCA hospital (Ancona, Italy). Thirty-four percent of the enrolled patients were deceased during the in-hospital stay. The percentage of severely frail patients, assessed with the Clinical Frailty Scale, was significantly increased in deceased patients compared to the survived ones. The age-adjusted Charlson comorbidity index (CCI) score was not significantly associated with an increased risk of death. Among the routine parameters, neutrophilia, eosinopenia, lymphopenia, neutrophil-to-lymphocyte ratio (NLR), C-reactive protein, procalcitonin, IL-6, and NT-proBNP showed the highest predictive values. The fully adjusted Cox regressions models confirmed that high neutrophil %, NLR, derived NLR (dNLR), platelet-to-lymphocyte ratio (PLR), and low lymphocyte count, eosinophil %, and lymphocyte-to-monocyte ratio (LMR) were the best predictors of in-hospital mortality, independently from age, gender, and other potential confounders. Overall, our results strongly support the use of routine parameters, including complete blood count, in geriatric patients to predict COVID-19 in-hospital mortality, independent from baseline comorbidities and frailty.

COVID-19 as an effect modifier of the relationship between age and in-hospital survival in older patients admitted to an Italian Emergency Department

BACKGROUND

The SARS-CoV-2 pandemic modified how persons got into contact with emergency services, particularly during the first wave.

AIM

The aim is to describe the characteristics of older persons with and without COVID-19 visiting the Emergency Department of a tertiary hospital and to investigate the impact of age on in-hospital survival in the two groups.

METHODS

Patients older than 70 years were followed-up till discharge or in-hospital death. Cox regression models stratified by COVID-19 diagnosis were used to investigate survival.

RESULTS

Out of 896 patients, 36.7% had COVID-19. Those without COVID-19 were older and affected by a higher number of chronic conditions but exhibited lower mortality (10.5 vs 48.1%). After the adjustment, age was associated with mortality only among those with COVID-19.

DISCUSSION

COVID-19 modified the relationship between older age and in-hospital survival: whether this finding is explained by other biological vulnerabilities or by a selection of treatments based on age should be further investigated.

30-day Mortality Following COVID-19 and Influenza Hospitalization Among US Veterans Aged 65 and Older

Background

COVID‐19 and influenza are important sources of morbidity and mortality among older adults. Understanding how outcomes differ for older adults hospitalized with either infection is important for improving care. We compared outcomes from infection with COVID‐19 and influenza among hospitalized older adults.

Methods

We conducted a retrospective study of 30‐day mortality among veterans aged 65+ hospitalized with COVID‐19 from March 1, 2020–December 31, 2020 or with influenza A/B from September 1, 2017 to August 31, 2019 in Veterans Affairs Health Care System (VAHCS). COVID‐19 infection was determined by a positive PCR test and influenza by tests used in the VA system. Frailty was defined by the claims‐based Veterans Affairs Frailty Index (VA‐FI). Logistic regressions of mortality on frailty, age, and infection were adjusted for multiple confounders.

Results

A total of 15,474 veterans were admitted with COVID‐19 and 7867 with influenza. Mean (SD) ages were 76.1 (7.8) and 75.8 (8.3) years, 97.7% and 97.4% were male, and 66.9% and 76.4% were white in the COVID‐19 and influenza cohorts respectively. Crude 30‐day mortality (95% CI) was 18.9% (18.3%–19.5%) for COVID‐19 and 4.3% (3.8%–4.7%) for influenza.

Combining cohorts, the odds ratio for 30‐day mortality from COVID‐19 (versus influenza) was 6.61 (5.74–7.65). There was a statistically significant interaction between infection with COVID‐19 and frailty, but there was no significant interaction between COVID‐19 and age.

Separating cohorts, greater 30‐day mortality was significantly associated with older age (p: COVID‐19: <0.001, Influenza: <0.001) and for frail compared with robust individuals (p for trend: COVID‐19: <0.001, Influenza: <0.001).

Conclusion

Mortality from COVID‐19 exceeded that from influenza among hospitalized older adults. However, odds of mortality were higher at every level of frailty among those admitted with influenza compared to COVID‐19. Prevention will remain key to reducing mortality from viral illnesses among older adults.

Before the COVID-Vaccine-Vulnerable Elderly in Homecare

BACKGROUND

At the beginning of 2020, the COVID-19 virus was spreading all over the world. Frail elderly were at risk for illness and death. Isolation seemed to be the best solution. The aim of this paper was to describe how the lockdown affected elderly homecare patients.

METHODS

We used an international self-reported screening instrument built on well-documented risk factors adapted to COVID-19. We considered ethical, legal, and practical concerns. The research included telephone interviews with 30 homecare patients.

RESULTS

Seventy percent lived alone. Seventy-three percent of the sample suffered from major comorbidity. Cardiovascular disorder was the most frequent diagnosis. Nineteen (63.3%) needed help for personal care. Several of the participants were lonely and depressed. The homecare teams struggled to give proper care. The health authorities encouraged the population to reduce their outside physical activities to a minimum. The restrictions due to COVID-19 affected daily life and several respondents expressed uncertainties about the future.

CONCLUSIONS

It is important to describe the patients' experiences in a homecare setting at the initiation of lockdowns due to COVID-19. The isolation protected them from the virus, but they struggled with loneliness and the lack of physical contact with their loved ones. In the future, we need to understand and address the unmet needs of elderly homecare patients in lockdown.

A rapid and feasible tool for clinical decision making in community-dwelling patients with COVID-19 and those admitted to emergency departments: the Braden-LDH-HorowITZ Assessment-BLITZ

There is no univocal standardized strategy to predict outcomes and stratify risk of SARS-CoV-2 infected patients, notably in emergency departments. Our aim is to develop an accurate indicator of adverse outcomes based on a retrospective analysis of a COVID-19 database established at the Emergency Department (ED) of a North-Italian hospital during the first wave of SARS-CoV-2 infection. Laboratory, clinical, psychosocial and functional characteristics including those obtained from the Braden Scale-a standardized scale to quantify the risk of pressure sores which takes into account aspects of sensory perception, activity, mobility and nutrition-from the records of 117 consecutive patients with swab-positive COVID-19 disease admitted to the Emergency Medicine ward between March 1, 2020 and April 15, 2020 were included in the analysis. Adverse outcomes included admission to the Intensive Care Unit (ICU) and in-hospital death. Among the parameters collected, the highest cutoff sensitivity and specificity scores to best predict adverse outcomes were displayed by lactate dehydrogenase (LDH) blood value at admission > 439 U/L, Horowitz Index (P/F Ratio) < 257 and Braden score < 18. The estimation power reached 93.6%. We named the assessment BLITZ (Braden-LDH-HorowITZ). Despite the retrospective and preliminary nature of the data, a multidimensional tool to assess overall functions, not chronological age, produced the highest prediction power for poor outcomes in relation to SARS-CoV-2 infection. Further analyses are now needed to establish meaningful correlations between ventilation therapies and multidimensional frailty as assessed by ad-hoc validated and standardized tools.

Multimorbidity Patterns and 5-Year Mortality in Institutionalized Older Adults

OBJECTIVES

The aim was to characterize multimorbidity patterns in a large sample of older individuals living in nursing homes (NHs) and to investigate their association with mortality, also considering the effect of functional status.

DESIGN

Observational and retrospective study.

SETTING AND PARTICIPANTS

We analyzed data on 4131 NH residents in Italy, aged 60 years and older, assessed through the interRAI long-term care facility instrument. Entry date was between 2014 and 2018, and participants were followed until 2019.

METHODS

Multimorbidity patterns were identified through principal component analysis; for the identified components, subjects were stratified in quintiles (Q) with respect to their loading values, with the higher quantiles indicating greater expression of the component's pattern. Their association [hazard ratio (HR) and 95% CI] with mortality was tested in Cox regression models. Analyses were stratified by disability status.

RESULTS

Four patterns of multimorbidity were identified: (1) heart diseases; (2) dementia and sensory impairments; (3) heart, respiratory, and psychiatric diseases; and (4) diabetes, musculoskeletal, and vascular diseases. For the heart diseases pattern [HR Q5 vs Q1 = 1.83 (1.53-2.20)] and the dementia and sensory impairments pattern [HR Q5 vs Q1 = 1.23 (1.06-1.42)], as the specific multimorbidity expression increases, the risk of mortality increases. On stratifying by disability status, the association between the multimorbidity patterns and mortality was not always present.

CONCLUSIONS AND IMPLICATIONS

Different multimorbidity patterns are differentially associated with mortality in older residents of NHs, confirming that multimorbidity's prognosis is strictly dependent on the underlying disease combinations. This knowledge may be useful to implement personalized preventive and therapeutic care pathways for institutionalized older adults, which respond to individuals' health needs.

Dementia Clinical Care in Relation to COVID-19

PURPOSE OF REVIEW

This review discusses the complex relationship between COVID-19 and dementia and how the pandemic has affected the management of patients with dementia. This population resulted particularly susceptible to SARS-CoV-2 infection and its effects and also to the negative effects of the measures taken worldwide to control the spread of the virus.

RECENT FINDINGS

Patients with dementia were at increased risk for COVID-19 compared to patients without dementia, and diagnosis of dementia represents an independent risk factor for hospitalization in COVID-19 patients. Mortality due to SARS-CoV2 infection in subjects with dementia is 2-5 times higher than in the general population. Cognitive impairment and delirium have been described in COVID-19 survivors. SARS-COV2 pandemic exacerbates the vulnerability of dementia patients and their caregivers, due to the morbidity and mortality from COVID-19, the indirect effects of the pandemic on the social supports, and the effects on healthcare system on which they depend.

SUMMARY

The COVID-19 pandemic requires people with dementia to move from traditional models of health care to innovative models for home care, to support caregivers' burden, and to improve long term care.

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.

COVID-19 collateral damage-psychological burden and behavioural changes among older adults during the first outbreak in Stockholm, Sweden: a cross-sectional study

OBJECTIVES

To explore the indirect negative effects of COVID-19 restrictions (collateral damage) on the lives and health of older adults living in central Stockholm, and to characterise the sociodemographic profile of those with the highest susceptibility to this damage.

DESIGN

Cross-sectional study.

SETTING

District of Kungsholmen in Stockholm, Sweden.

PARTICIPANTS

Older adults aged 68 years and above (n=1231) who participated in the ad hoc COVID-19-related phone questionnaire administered by trained staff between May and June 2020 and who had previously attended the regular follow-up assessment of the Swedish National study on Aging and Care in Kungsholmen (SNAC-K) during 2016-2019.

PRIMARY AND SECONDARY OUTCOME MEASURES

Three dimensions of collateral damage: psychological burden (feelings of worry, stress and loneliness), reductions in social and physical activities, and reductions in medical and social care use since the beginning of the pandemic. Logistic regression models were used to test the association between age, sex, education and living arrangement, and the risk of collateral damage.

RESULTS

Vast majority of participants adhered to the national public health recommendations, with over three-quarters practising self-isolation (n=928). Half of the sample reported psychological burden, 55.3% reported reductions in social or physical activity, and 11.3% reported decreased medical or social care use. Over three quarters of participants (77.8%) were affected by at least one of the three collateral damage dimensions. Female sex was the strongest sociodemographic predictor of both individual and co-occurring dimensions of collateral damage.

CONCLUSIONS

COVID-19 and its restrictions during the first half of 2020 had a negative effect on the health and lives of a majority of the elderly living in central Stockholm. Women were at a higher risk of these negative consequences. We emphasise the need for predefined, evidence-based interventions to support those who are most susceptible to these consequences, both during the pandemic and once the outbreak is overcome.

Integrating Multimorbidity into a Whole-Body Understanding of Disease Using Spatial Genomics

Multimorbidity is characterized by multidimensional complexity emerging from interactions between multiple diseases across levels of biological (including genetic) and environmental determinants and the complex array of interactions between and within cells, tissues and organ systems. Advances in spatial genomic research have led to an unprecedented expansion in our ability to link alterations in genome folding with changes that are associated with human disease. Studying disease-associated genetic variants in the context of the spatial genome has enabled the discovery of transcriptional regulatory programmes that potentially link dysregulated genes to disease development. However, the approaches that have been used have typically been applied to uncover pathological molecular mechanisms occurring in a specific disease-relevant tissue. These forms of reductionist, targeted investigations are not appropriate for the molecular dissection of multimorbidity that typically involves contributions from multiple tissues. In this perspective, we emphasize the importance of a whole-body understanding of multimorbidity and discuss how spatial genomics, when integrated with additional omic datasets, could provide novel insights into the molecular underpinnings of multimorbidity.

Associations of pre-pandemic levels of physical function and physical activity with COVID-19-like symptoms during the outbreak

Background

One’s physical function and physical activity levels can predispose or protect from the development of respiratory infections. We aimed to explore the associations between pre-pandemic levels of physical function and physical activity and the development of COVID-19-like symptoms in Swedish older adults.

Methods

We analyzed data from 904 individuals aged ≥ 68 years from the population-based Swedish National study on Aging and Care in Kungsholmen. COVID-19-like symptoms were assessed by phone interview (March–June 2020) and included fever, cough, sore throat and/or a cold, headache, pain in muscles, legs and joints, loss of taste and/or odor, breathing difficulties, chest pain, gastrointestinal symptoms, and eye inflammation. Muscle strength, mobility, and physical activity were examined in 2016–2018 by objective testing. Data were analyzed using logistic regression models in the total sample and stratifying by age.

Results

During the first outbreak of the pandemic, 325 (36%) individuals from our sample developed COVID-19-like symptoms. Those with slower performance in the chair stand test had an odds ratio (OR) of 1.5 (95% confidence interval [CI] 1.1–2.1) for presenting with COVID-19-like symptoms compared to better performers, after adjusting for potential confounders. The association was even higher among people aged ≥ 80 years (OR 2.6; 95% CI 1.5–4.7). No significant associations were found between walking speed or engagement in moderate-to-vigorous physical activity and the likelihood to develop COVID-19-like symptoms.

Conclusion

Poor muscle strength, a possible indicator of frailty, may predispose older adults to higher odds of developing COVID-19-like symptoms, especially among the oldest-old.

Lessons Learned From the COVID-19 Pandemic as Experienced by Older Adults Treated for COVID-19

Background

In order to provide the best care, the perspective of older COVID-19 patients must be involved in the development of treatment protocols. This study describes the experiences of older adults affected by COVID-19 who recovered in the hospital or at home.

Methods

Qualitative semi-structured interviews were conducted with 23 older adults affected by COVID-19. A content-based thematic analysis was conducted.

Results

Nine categories were identified as recurring topics, which were grouped into three major themes. The first theme describes experiences in the first phase of the disease when older adults fell ill. The second theme includes experiences during the illness, ranging from illness severity to participation in decision-making, communication barriers and isolation effects. The final theme covers the recovery course, residual symptoms and social aspects.

Conclusion

Older adults treated for COVID-19 experienced a feeling of being in a fast-paced whirlwind and lost total control over the situation. Extra attention should be paid to shared decision making, coordinated information provision and the instalment of a primary contract to the patient. The uncertainty of their situation, isolation measures and fears could result in psychological consequences and hinder rehabilitation in older adults.

The association of anticoagulation before admission and survival of patients with COVID-19

Background

Severe coronavirus disease 2019 (COVID-19) is associated with systematic coagulopathy which might result in fatality. We aimed to investigate whether systematic anticoagulation before admission with COVID infection was associated with patients’ survival.

Methods

We reviewed medical records of 6,095 hospitalized patients with laboratory confirmed COVID-19 from the Mount Sinai Health System. Patients were stratified into two groups: patients with therapeutic anticoagulation before admission (7.9%, N=480), or those without (92.1%, N=5,615). Propensity score matched analysis was conducted to assess the association of anticoagulation before admission and in-hospital mortality (N=296 in each group). Multiple imputation for missing data was conducted.

Results

A total of 480 patients (7.9%) received anticoagulation before admission. Patients with anticoagulation before admission were older (72.1±14.7 years vs. 63.1±17.2 years), and had more comorbidities including chronic pulmonary obstructive disease, hypertension, diabetes, chronic kidney disease, atrial fibrillation, and heart failure (all p< 0.05). Notably, patients with anticoagulation before admission had lower D-dimer [1.48 (IQR 0.75, 2.79) μg/mL vs 1.66 (0.89, 3.52) μg/mL, p=0.002]. In a propensity score matched analysis (N=296 in each group), in-hospital mortality was not significantly different in patients with anticoagulation before admission compared to those without (28.4% vs 31.1%, p=0.53). In addition, inverse probability weighted analysis and multiple imputation for missing data did not change the result. Furthermore, these differences were not significant after excluding endotracheal intubation from both groups.

Conclusion

Anticoagulation before admission was not associated with lower risk of in-hospital mortality of COVID-19 patients. Further investigation is needed to confirm these findings.

COVID-19, Vulnerability, and Long-Term Mortality in Hospitalized and Nonhospitalized Older Persons

Objective

Studies suggesting that vulnerability increased short-term mortality in older patients with COVID-19 enrolled hospitalized patients and lacked COVID-negative comparators. Aim of this study was to examine the relationship between frailty and 1-year mortality in older patients with and without COVID-19, hospitalized and nonhospitalized.

Design

Cohort study.

Setting and Participants

Patients over 75 years old accessing the emergency departments (ED) were identified from the ED archives in Florence, Italy.

Methods

Vulnerability status was estimated with the Dynamic Silver Code (DSC). COVID-19 hospital discharges (HC+) were compared with non-COVID-19 discharges (HC-). Linkage with a national COVID-19 registry identified nonhospitalized ED visitors with (NHC+) or without COVID-19 (NHC-).

Results

In 1 year, 48.4% and 33.9% of 1745 HC+ and 15,846 HC- participants died (P < .001). Mortality increased from 27.5% to 64.0% in HC+ and from 19.9% to 51.1% in HC- across DSC classes I to IV, with HC+ vs HC- hazard ratios between 1.6 and 2.2. Out of 1039 NHC+ and 18,722 NHC- participants, 18% and 8.7% died (P < .001). Mortality increased from 14.2% to 46.7% in NHC+ and from 2.9% to 26% in NHC- across DSC; NHC+ vs NHC- hazard ratios decreased from 5.3 in class I to 2.0 in class IV.

Conclusions and Implications

In hospitalized older patients, mortality increases with vulnerability similarly in the presence and in the absence of COVID-19. In nonhospitalized patients, vulnerability-associated excess mortality is milder in individuals with than in those without COVID-19. The disease reduces survival even when background risk is low. Thus, apparently uncomplicated patients deserve closer clinical monitoring than commonly applied.

Early prediction of in-hospital death of COVID-19 patients: a machine-learning model based on age, blood analyses, and chest x-ray score

An early-warning model to predict in-hospital mortality on admission of COVID-19 patients at an emergency department (ED) was developed and validated using a machine-learning model. In total, 2782 patients were enrolled between March 2020 and December 2020, including 2106 patients (first wave) and 676 patients (second wave) in the COVID-19 outbreak in Italy. The first-wave patients were divided into two groups with 1474 patients used to train the model, and 632 to validate it. The 676 patients in the second wave were used to test the model. Age, 17 blood analytes, and Brescia chest X-ray score were the variables processed using a random forests classification algorithm to build and validate the model. Receiver operating characteristic (ROC) analysis was used to assess the model performances. A web-based death-risk calculator was implemented and integrated within the Laboratory Information System of the hospital. The final score was constructed by age (the most powerful predictor), blood analytes (the strongest predictors were lactate dehydrogenase, D-dimer, neutrophil/lymphocyte ratio, C-reactive protein, lymphocyte %, ferritin std, and monocyte %), and Brescia chest X-ray score (https://bdbiomed.shinyapps.io/covid19score/). The areas under the ROC curve obtained for the three groups (training, validating, and testing) were 0.98, 0.83, and 0.78, respectively. The model predicts in-hospital mortality on the basis of data that can be obtained in a short time, directly at the ED on admission. It functions as a web-based calculator, providing a risk score which is easy to interpret. It can be used in the triage process to support the decision on patient allocation.

Factors Associated With Severe COVID-19 Infection Among Persons of Different Ages Living in a Defined Midwestern US Population

OBJECTIVE

To identify risk factors associated with severe COVID-19 infection in a defined Midwestern US population overall and within different age groups.

PATIENTS AND METHODS

We used the Rochester Epidemiology Project research infrastructure to identify persons residing in a defined 27-county Midwestern region who had positive results on polymerase chain reaction tests for COVID-19 between March 1, 2020, and September 30, 2020 (N=9928). Age, sex, race, ethnicity, body mass index, smoking status, and 44 chronic disease categories were considered as possible risk factors for severe infection. Severe infection was defined as hospitalization or death caused by COVID-19. Associations between risk factors and severe infection were estimated using Cox proportional hazard models overall and within 3 age groups (0 to 44, 45 to 64, and 65+ years).

RESULTS

Overall, 474 (4.8%) persons developed severe COVID-19 infection. Older age, male sex, non-White race, Hispanic ethnicity, obesity, and a higher number of chronic conditions were associated with increased risk of severe infection. After adjustment, 36 chronic disease categories were significantly associated with severe infection. The risk of severe infection varied significantly across age groups. In particular, persons 0 to 44 years of age with cancer, chronic neurologic disorders, hematologic disorders, ischemic heart disease, and other endocrine disorders had a greater than 3-fold increased risk of severe infection compared with persons of the same age without those conditions. Associations were attenuated in older age groups.

CONCLUSION

Older persons are more likely to experience severe infections; however, severe cases occur in younger persons as well. Our data provide insight regarding younger persons at especially high risk of severe COVID-19 infection.

Prevalence, incidence and mortality of delirium in patients with COVID-19: a systematic review and meta-analysis

Background: Attention should be paid to delirium in COVID-19 patients, especially older people, since advanced age poses increased risk of both delirium and COVID-19-related death.

Objective: This study aims to summarize the evidence on prevalence, incidence and mortality of delirium in COVID-19 patients.

Methods: We conducted a comprehensive literature search on Pubmed and Embase from inception to December 1, 2020. Three independent reviewers evaluated study eligibility and data extraction, and assessed study quality. Outcomes were analyzed as proportions with 95% confidence interval (CI). We also compared mortality differences in COVID-19 patients using odds ratio.

Results: In total, we identified 48 studies with 11,553 COVID-19 patients from 13 countries. Pooled prevalence, incidence and mortality rates for delirium in COVID-19 patients were 24.3% (95% CI: 19.4–29.6%), 32.4% (95% CI: 20.8–45.2%) and 44.5% (95% CI: 36.1–53.0%), respectively. For patients aged over 65 yrs, prevalence, incidence and mortality rates for delirium in COVID-19 patients were 28.2% (95% CI: 23.5–33.1%), 25.2% (95% CI: 16.0–35.6%) and 48.4% (95% CI: 40.6–56.1%), respectively. For patients under 65 yrs, prevalence, incidence and mortality rates for delirium in COVID-19 patients were 15.7% (95% CI: 9.2–23.6%), 71.4% (95% CI: 58.5–82.7%) and 21.2% (95% CI: 15.4–27.6%), respectively. Overall, COVID-19 patients with delirium suffered higher risk of mortality, compared to those without delirium (OR: 3.2, 95% CI: 2.1–4.8).

Conclusion: Delirium developed in almost 1 out of 3 COVID-19 patients, and was associated with 3-fold overall mortality. Our findings suggest that first-line healthcare providers should systematically assess delirium and monitor related symptoms among COVID-19 patients.

Frailty as a mortality predictor in older adults with COVID-19: A systematic review and meta-analysis of cohort studies

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has caused the coronavirus diseases 2019 (COVID-19) pandemic, continues to spread rapidly worldwide and is associated with high rates of mortality among older adults, those with comorbidities, and those in poor physiological states. This paper aimed to systematically identify the impact of frailty on overall mortality among older adults with COVID-19. We conducted a systematic review of the literature indexed in 4 databases. A random-effects model with inverse variance-weighted meta-analysis using the odds ratio was used to study the association of frailty levels with clinical outcomes among older adults with COVID-19. Heterogeneity was measured using the I2 statistic and Egger's test. We identified 22 studies that met our inclusion criteria, including 924,520 total patients. Overall, frailty among older adults was associated with high rates of COVID-19-related mortality compared with non-frail older adults (OR [odds ratio]:5.76; 95% confidence interval [95% CI]: 3.85-8.61, I2: 40.5%). Our results show that physical limitations, such as those associated with frailty among older adults, are associated with higher rates of COVID-19-related mortality.

Characteristics of the ideal hospitalist inpatient care program: perceptions of Canadian health system leaders

Background

Despite the growing prevalence of hospitalist programs in Canada, it is not clear what program features are deemed desirable by administrative and medical leaders who oversee them. We aimed to understand perceptions of a wide range of healthcare administrators and frontline providers about the implementation and necessary characteristics of a hospitalist service.

Methods

We conducted semi-structured interviews with a range of administrators, medical leaders and frontline providers across three hospital sites operated by an integrated health system in British Columbia, Canada.

Results

Most interviewees identified the hospitalist model as the ideal inpatient care service line, but identified a number of challenges. Interviewees identified the necessary features of an ideal hospitalist service to include considerations for program design, care and non-clinical processes, and alignment between workload and physician staffing. They also identified continuity of care as an important challenge, and underlined the importance of communication as an important enabler of implementation of a new hospitalist service.

Conclusions

Most hospital administrators and frontline providers in our study believed the hospitalist model resulted in improvements in clinical processes and work environment.

The Clinical Significance of Procalcitonin Elevation in Patients over 75 Years Old Admitted for COVID-19 Pneumonia

Aim

To investigate the clinical significance of procalcitonin (PCT) elevation on hospital admission for coronavirus disease-19 (COVID-19) and its association with mortality in oldest old patients (age > 75 years).

Methods

The clinical records of 1074 patients with chest high-resolution computed-tomography (HRCT) positive for interstitial pneumonia and symptoms compatible for COVID-19, hospitalized in medical wards during the first pandemic wave in a single academic center in Northern Italy, were retrospectively analyzed. All patients had serum PCT testing performed within six hours from admission. Information on COVID-19-related symptoms, comorbidities, drugs, autonomy in daily activities, respiratory exchanges, other routine lab tests, and outcomes were collected. Clinical characteristics were compared across different admission PCT levels and ages. The association of admission PCT with mortality was tested separately in participants aged > 75 and ≤75 years old by stepwise multivariate Cox regression model with forward selection.

Results

With increasing classes of PCT levels (<0.05, 0.05-0.49, 0.5-1.99, and ≥2 ng/ml), there was a significant trend (P < 0.0001) towards older age, male gender, wider extension of lung involvement on HRCT, worse respiratory exchanges, and several other laboratory abnormalities. Each incremental PCT class was associated with increased risk of hospital death at multivariate models in subjects older than 75 (hazard ratio for PCT ≥ 2 vs. <0.05 ng/ml: 30.629, 95% confidence interval 4.176-224.645, P = 0.001), but not in subjects aged 75 or younger.

Conclusions

In patients admitted for COVID-19, PCT elevation was associated with several clinical, radiological, and laboratory characteristics of disease severity. However, PCT elevation was strongly associated with hospital mortality only in oldest old subjects (age > 75).

Clinical frailty scale as a point of care prognostic indicator of mortality in COVID-19: a systematic review and meta-analysis

BACKGROUND

COVID-19 has resulted in the largest pandemic experienced since 1918, accounting for over 2 million deaths globally. Frail and older people are at the highest risk of mortality. The main objective of the present research was to quantify the impact of clinical frailty scale (CFS) by increasing severity of frailty and to identify other personal prognostic factors associated with increased mortality from COVID-19.

METHODS

This study offers a contemporary systematic review and meta-analysis to analyse the stratified mortality risk by increasing CFS sub-categories (1-3, 4-5 and 6-9). Databases searched included EMBASE, MEDLINE, CAB Abstracts, PsychInfo, and Web of Science with end-search restriction the 18th December 2020. Publications identified via MedRevix were followed up on the 23rd March 2021 in peer-reviewed database search, and citations were updated as published. Prospective and retrospective cohort studies which reported the association between CFS and COVID-19 mortality were included. Thirty-four studies were eligible for systematic review and seventeen for meta-analysis, with 81-87% (I2) heterogeneity.

FINDINGS

All studies [N: 34] included patients from a hospital setting, comprising a total of 18,042 patients with mean age 72.8 (Min: 56; Max: 86). The CFS 4-5 patient group had significantly increased mortality when compared to patients with CFS 1-3 [(RE) OR 1.95 (1.32 (95% CI), 2.87 (95% CI)); I2 81%; p = 0.0008]. Furthermore, CFS 6-9 patient group displayed an even more noticeable mortality increase when compared to patients with CFS 1-3 [(RE) OR 3.09 (2.03, 4.71); I2 87%; p<0.0001]. Generic inverse variance analysis of adjusted hazard ratio among included studies highlighted that CFS (p = 0.0001), male gender (p = 0.0009), National Early Warning Score (p = 0.0001), Ischaemic Heart Disease (IHD) (p = 0.07), Hypertension (HT) (p<0.0001), and Chronic Kidney Disease (CKD) (p = 0.0009) were associated with increased COVID-19 mortality.

INTERPRETATION

Our findings suggest a differential stratification of CFS scores in the context of COVID-19 infection, in which CFS 1-3 patients may be considered at lower risk, CFS 4-5 at moderate risk, and CFS 6-9 at high risk of mortality regardless of age. Overall, our study not only aims to alert clinicians of the value of CFS scores, but also highlight the multiple dimensions to consider such as age, gender and co-morbidities, even among moderately frail patients in relation to COVID-19 mortality.

FUNDING

None.