Frailty predicts poor outcomes and mortality in COVID-19

Decades of frailty research consistently demonstrate an increase in poor outcomes from all stressors – disease, trauma, and acute illness – as frailty increases. COVID-19, our most recent acute and severe illness, presents another opportunity to study the effect of frailty on outcomes of interest. The research adds much-needed knowledge to our understanding of COVID-19 and supports the value of routinely identifying frailty, using it to assess risk and as an aid to clinical decision-making.

The study cited here presents the findings of a recent multicenter, European study, using the Clinical Frailty Scale to determine the degree of frailty in hospitalized COVID-19 patients and its association with in-hospital mortality and length of stay.

Conclusions:

  1. “Frailty was associated with both mortality and time to discharge after adjustment for age, sex, smoking status, and other comorbidities, exhibiting worsening clinical outcomes with increasing frailty.”
  2. The Clinical Frailty Scale, combined with clinical judgment, is a good decision aid for shared decision making in people with COVID-19.

Patient Pattern’s Perspective:

Identifying the frailest patients remains beneficial in planning care to prevent as much decline, disability, and death as possible. Frailty will always merit our attention because it will always impact outcomes. This is especially true while COVID-19 is stalking our most vulnerable. Identifying those who are frail, using frailty assessment tools, is better than relying on age or physical appearance to determine who is at risk and who needs our attention.

Reference: Hewitt J, Carter B, Vilches-Moraga A, Quinn TJ, et al. The effect of frailty on survival in patients with COVID-19 (COPE): a multicenter, European, observational cohort study. Read the Study here.

 

Stories from the Field: Patsy & Rosy

Patsy and Rosie, 82 years old, resided in the same nursing home unit and both had moderate dementia, diabetes, and congestive heart failure. They loved to wear colorful clothes and fun jewelry and every day sat at the nurses’ station talking with visitors and staff alike.

They appeared to be doing well until an outbreak of Influenza A hit their nursing unit and both became sick. Patsy spent several days in bed, tolerated the antiviral medication, and was able to drink enough liquids to avoid dehydration. While her blood sugars were impacted by the infection and she was clearly more fatigued, she managed to return to her favorite spot at the nurse’s station and ask for chocolates and cookies by the end of the second week.

Rosie did not do so well with the infection. She ran a higher temperature, became delirious from the antiviral medication and the fever, and was not able to maintain adequate oral hydration. She received the medical management indicated in her Advance Care Directive, including intravenous hydration, antibiotics for accompanying pneumonia, and aggressive nursing care to avoid skin breakdown.

Even though Rosie appeared to be doing as well as her friend Patsy prior to the flu outbreak, and despite the high level of quality care she received, Rosie did not recover.  During week three of her illness, she died in the facility.  The staff and her family were saddened but not surprised.  They knew Rosie was frail and what the likely outcome would be if she became ill.  Her family was by her side.

The difference in their pattern of illness and outcomes was to a large extent associated with their different degrees of frailty. Their Frailty Risk Score, automatically calculated from MDS data, indicated that Patsy, Mildly Frail, would likely recover from a new illness, fall, or hospitalization.  Rosie, Moderately Frail, would likely become sicker and less able to recover completely or return to baseline. Their degree of risk was not obvious from looking at the ladies but could be calculated from routine data.

Patsy and Rosie were alike in several ways but physiologically unique because of their different degrees of risk associated with frailty. Even though both had the same infection and received the same level of clinical and nursing care, their outcomes were impacted by frailty. Knowing their degree of frailty, and that of every resident on the unit, informs the professionals on where to focus their attention first. This is of particular significance and value when an entire unit is exposed to a virulent infection.

Communicating the degree of frailty with the families allowed them to be prepared for the risk associated with an acute illness and provided a framework for decision-making and completion of Advance Care documents. When families are prepared for what might be around the corner, they are not surprised and looking for someone to blame.

APPLYING A FRAILTY METRIC TO THE CARE OF THOSE WITH CHRONIC ILLNESSES BENEFITS THE PATIENTS, FAMILIES, AND THE FACILITY.