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

Association between physical activity and frailty transitions in middle-aged and older adults: a nationwide longitudinal study

BACKGROUND

Frailty has become an important health problem in the middle-aged and older people population. Physical activity (PA) is a key intervention for frailty prevention and management. However, studies of the association between COVID-19 pre-pandemic PA and the worsening or improvement of frailty during the pandemic remain unclear.

METHODS

This longitudinal cohort study used data from the English Longitudinal Study of Ageing (ELSA), including participants aged 50 and over. Three intensities of PA (vigorous, moderate, and mild) were categorized as less than once per week and at least once per week, respectively, based on participant self-report. The frailty index (FI) assessed the frailty status, defining frailty as FI ≥ 25. Logistic regression was applied to examine the association between PA and frailty, estimating odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

Of the 4379 non-frail participants at baseline (median age 67, 54.9% female), 8.1% developed frailty during a mean follow-up of 3.5 years. Among 564 frail participants at baseline (median age 71, 66.5% female), 17.9% regained health. Compared to those engaging in PA less than once per week, participants who engaged in vigorous (OR: 0.47 [95% CI: 0.35-0.62]), moderate (OR: 0.37 [95% CI: 0.29-0.48]), or mild (OR: 0.38 [95% CI: 0.26-0.56]) PA at least once a week had a lower risk of frailty worsening. Additionally, participants who engaged in moderate (OR: 2.04 [95% CI: 1.29-3.21]) or mild (OR: 2.93 [95% CI: 1.54-5.58]) PA at least once a week had a higher likelihood of frailty improvement. Sensitivity analyses based on comprehensive PA levels confirmed these findings. Participants who maintained at least one PA per week had lower frailty worsening (Vigorous, OR: 0.20 [95%CI: 0.12-0.33]; Moderate, OR: 0.13 [95%CI: 0.09-0.19]; Mild, OR: 0.20 [95%CI: 0.11-0.38]) and higher frailty improvement rates (Moderate, OR: 3.43 [95%CI: 1.93-6.11]; Mild, OR: 4.65 [95%CI: 1.90-11.42]). In addition, individuals (Vigorous, OR: 0.35 [95%CI: 0.20-0.60]; Moderate, OR: 0.36 [95%CI: 0.22-0.56]) who transitioned from inactive to active also exhibited a lower risk of frailty.

CONCLUSIONS

This study emphasized the critical role of PA in preventing and improving frailty in middle-aged and older people, especially during the COVID-19 pandemic. Our study also highlighted the importance of maintaining PA habits to reduce frailty risk and promote its improvement. Also, the study indicated that individuals who transitioned from inactive to active had a lower risk of frailty. These findings enriched the understanding of the association between PA and frailty and provided valuable insights for addressing the health impact of future pandemics on middle-aged and older people.

Polypharmacy or potentially inappropriate medications among older adults with COVID-19 in a secondary hospital in China and their association with mortality

Elderly patients with multiple concomitant chronic diseases are the particularly vulnerable during the Coronavirus disease 2019 (COVID-19) epidemic, which accounts for a large number of COVID-19-related deaths. The purpose of the study was to investigate the impact of polypharmacy and potentially inappropriate medications (PIMs) on in-hospital mortality in a secondary hospital in China. A cross-sectional, retrospective study was conducted using electronic medical data collected from Shanghai Gonghui Hospital from April 2022 to June 2022. Two types of PIMs were adopted, involving the evaluation of the PIM status of older patients with COVID-19 (age ≥ 60 years) identified by AGS/Beers Criteria (PIM-Beers) and the PIM related to Covid-19 antiviral NMV/r (Nirmatrelvir/ritonavir) (PIM-NMV/r). Multivariate logistic regression was used to identify the risk factors associated with PIM use and in-hospital mortality. A total of 617 older COVID-19 inpatients were included in the study. The prevalence of polypharmacy and excessive polypharmacy were 24.6% and 19.1%, respectively. The prevalence of PIMs, PIM-Beers, and PIM-NMV/r were 25.8%, 22.5%, and 60.8%, respectively. Multivariate regression demonstrated that male (OR: 0.57 [95% CI: 0.33-0.98], p = 0.044), diabetes (OR: 2.05 [95% CI: 1.11-3.80], p = 0.023), the more number of medications (OR: 1.44 [95% CI: 1.20-1.72], p < 0.001) and given NMV/r (OR: 3.67 [95% CI: 1.48-9.10], p = 0.005) were influencing factors associated with PIM use. A multivariate logistic regression demonstrated that severe COVID-19 (OR: 6.56 [95% CI: 1.13-38.03], p = 0.036), polypharmacy (OR: 15.43 [95% CI: 3.20-74.29], p = 0.001), excessive polypharmacy (OR: 51.09 [95% CI: 5.23-499.52], p = 0.001), and long-term hospitalization (OR: 0.08 [95% CI: 0.02-0.32], p < 0.001) were influencing factors associated with in-hospital mortality in older COVID-19 inpatients. The polypharmacy and drug-drug interactions of NMV/r were observed in many older COVID-19 inpatients. Older patients with severe COVID-19, a higher number of medications and long-term hospitalization had a higher in-hospital mortality. This result highlights the importance of conducting clinical pharmacists-led medication reviews to identify PIMs of NMV/r and collaboratively working with the physicians to ensure medication appropriateness.

Association between Clinical Frailty Scale and mortality 24 months after hospitalisation in adult patients with COVID-19

Background

The clinical frailty scale (CFS) was used as a triage tool for medical decision making during the COVID-19 pandemic. The CFS has been posed as a suitable risk marker for in-hospital mortality in COVID-19 patients. We evaluated whether the CFS is associated with mortality 24 months after hospitalisation for COVID-19.

Methods

The COvid MEdicaTion (COMET) study is an international, multicentre, observational cohort study, including adult patients hospitalised for COVID-19 between March 2020-July 2020. Patients' characteristics, prescribed medication, clinical characteristics, and CFS were collected at admission, survival data were collected 24 months after hospitalisation. Multivariable cox proportional hazard models stratified by age (<65 and ≥65 years), and adjusted for covariates (age, sex, number of drugs, and types of drug class as a proxy for comorbidities) were used to study the association between the CFS and 24-month mortality after hospitalisation.

Results

In this study, 1238 fit (CFS 1-3), 478 mildly frail (CFS 4-5), and 235 frail (CFS 6-9) patients were included for baseline analysis (median age 68 years (IQR 58-78); 58.5 % male). Frailty was associated with an increased risk of 24-month mortality after hospitalisation in older patients (HR 1.91, 95 % CI [1.17-3.12]), in younger adults a trend was seen (HR 3.13, 95 % CI [0.86-11.36]).

Conclusion

The results suggest that the CFS is an indicator for mortality 24 months after hospitalisation in COVID-19 patients.

One-year mortality and associated factors in older hospitalized COVID-19 survivors: a Nationwide Cohort Study in Korea

This study aimed to evaluate the 1-year mortality rate among older patients with COVID-19 discharged from hospital and to identify risk factors associated with this outcome. Using a COVID-19 dataset from the Korean National Health Insurance System, this study's evaluation period spanned from October 8, 2020, through December 31, 2021. The primary outcome was the 1-year mortality rate following hospital discharge. A logistic regression model was employed for multivariable analysis to estimate the odds ratios for the outcomes, and the Kaplan-Meier method was used to analyze differences in 1-year survival rates. Among the 66,810 COVID-19 patients aged 60 years or older who were hospitalized during the study period, the in-hospital mortality rate was 4.8% (n = 3219). Among the survivors (n = 63,369), the 1-year mortality rate was 4.9% (n = 3093). Non-survivors, compared to survivors, were significantly older (79.2 ± 9.5 vs. 68.9 ± 7.8, P < 0.001) and exhibited a lower rate of COVID-19 vaccination (63.0% vs. 91.7%, P < 0.001). Additionally, non-survivors experienced a higher incidence of organ dysfunction, along with a greater proportion of required mechanical ventilation (14.6% vs. 1.0%, P < 0.001) and extracorporeal membrane oxygenation (4.0% vs. 0.1%, P < 0.001). Multivariable logistic regression analysis identified older age, male sex, cardiovascular disease, immunosuppression, organ dysfunction, illness severity, and corticosteroid use during hospitalization as factors associated with death within 1 year after hospital discharge. However, vaccination was found to have a long-term protective effect against death among COVID-19 survivors. The 1-year mortality rate after hospital discharge for older COVID-19 patients was comparable to the in-hospital mortality rate for these patients in Korea. The long-term mortality rate among hospitalized older COVID-19 patients was influenced by demographic factors and the severity of illness experienced during hospitalization.

Long-Term Mortality in Very Old Survivors of COVID-19

OBJECTIVES

This report aimed to describe mortality at 18 months in older survivors of the first wave of COVID-19.

DESIGN

Observational cohort study.

SETTING AND PARTICIPANTS

Patients aged ≥65 years hospitalized for COVID-19 in the acute geriatric wards of 2 centers.

METHODS

Characteristics of deceased and survivors were compared by Fisher exact, Mann-Whitney U, or 2-tailed t tests. Survival rates were analysed by Cox proportional hazards regression models.

RESULTS

Of a total of 323 patients admitted during the first wave, 196 survived the acute phase, with 34 patients who died in the 18 months after hospital discharge (17.3%). Higher mortality was observed in patients living in nursing homes (P = .033) and in those who were hospitalized after discharge during the follow-up period (97.1% vs 72.8%, P = .001). There was no difference in survival curves according to age, sex, presence of dyspnea, and dementia. Living in a nursing home significantly increased the mortality rates in the multivariate model adjusted for age and sex (hazard ratio 3.07, 95% CI 1.47-6.40; P = .007).

CONCLUSIONS AND IMPLICATIONS

No excess mortality was observed during 18 months in older survivors of COVID-19. Living in a nursing home was associated with decreased survival rates.

Causes of deaths in long-term care and hospice care facilities during the first year of COVID-19 pandemic: a snapshot of Italy during 2020

BACKGROUND

Older adults living in long-term care facilities (LTCF) have been severely affected by COVID-19. Hospice care (HC) facilities and palliative care are essential in treating patients dying from COVID-19. In Italy, little is known about the impact of COVID-19 on deaths in LTCF and the care provided in HC to COVID-19 patients.

AIM

To assess overall and case-specific mortality in 2020 in LTC and HC facilities in comparison to the previous five years (2015-2019).

METHODS

We performed a descriptive study using data derived from the Italian national "Cause of Death" registry-managed by the Italian National Institute of Statistics-on deaths occurred in LTC and HC facilities during 2020 and the period 2015-2019.

RESULTS

Number of deaths significantly increased in 2020 compared with 2015-2019 in LTCF (83,062 deaths vs. 59,200) and slightly decreased in hospices (38,788 vs. 39,652). COVID-19 caused 12.5% of deaths in LTCF and only 2% in hospices. Other than COVID-19, in 2020, cancer accounted for 77% of all deaths that occurred in HC, while cardiovascular diseases (35.6%) and psychotic and behavioral disorders (10%) were the most common causes of death in LTCF. Overall, 22% of the excess mortality registered in Italy during 2020 is represented by the deaths that occurred in LTCF.

DISCUSSION AND CONCLUSION

LTCF were disproportionally affected by COVID-19, while the response to the pandemic in HC was limited. These data can help plan strategies to limit the impact of future epidemics and to better understand residential care response to COVID-19 epidemic.

One-Year Adverse Outcomes Among US Adults With Post-COVID-19 Condition vs Those Without COVID-19 in a Large Commercial Insurance Database

Importance

Many individuals experience ongoing symptoms following the onset of COVID-19, characterized as postacute sequelae of SARS-CoV-2 or post-COVID-19 condition (PCC). Less is known about the long-term outcomes for these individuals.

Objective

To quantify 1-year outcomes among individuals meeting a PCC definition compared with a control group of individuals without COVID-19.

Design, Setting, and Participants

This case-control study with a propensity score-matched control group included members of commercial health plans and used national insurance claims data enhanced with laboratory results and mortality data from the Social Security Administration's Death Master File and Datavant Flatiron data. The study sample consisted of adults meeting a claims-based definition for PCC with a 2:1 matched control cohort of individuals with no evidence of COVID-19 during the time period of April 1, 2020, to July 31, 2021.

Exposures

Individuals experiencing postacute sequelae of SARS-CoV-2 using a Centers for Disease Control and Prevention-based definition.

Main Outcomes and Measures

Adverse outcomes, including cardiovascular and respiratory outcomes and mortality, for individuals with PCC and controls assessed over a 12-month period.

Results

The study population included 13 435 individuals with PCC and 26 870 individuals with no evidence of COVID-19 (mean [SD] age, 51 [15.1] years; 58.4% female). During follow-up, the PCC cohort experienced increased health care utilization for a wide range of adverse outcomes: cardiac arrhythmias (relative risk [RR], 2.35; 95% CI, 2.26-2.45), pulmonary embolism (RR, 3.64; 95% CI, 3.23-3.92), ischemic stroke (RR, 2.17; 95% CI, 1.98-2.52), coronary artery disease (RR, 1.78; 95% CI, 1.70-1.88), heart failure (RR, 1.97; 95% CI, 1.84-2.10), chronic obstructive pulmonary disease (RR, 1.94; 95% CI, 1.88-2.00), and asthma (RR, 1.95; 95% CI, 1.86-2.03). The PCC cohort also experienced increased mortality, as 2.8% of individuals with PCC vs 1.2% of controls died, implying an excess death rate of 16.4 per 1000 individuals.

Conclusions and Relevance

This case-control study leveraged a large commercial insurance database and found increased rates of adverse outcomes over a 1-year period for a PCC cohort surviving the acute phase of illness. The results indicate a need for continued monitoring for at-risk individuals, particularly in the area of cardiovascular and pulmonary management.

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.

Performance status: A key factor in predicting mortality in the first wave of COVID-19 in South-East Scotland

BACKGROUND

COVID-19 mortality risk factors have been established in large cohort studies; long-term mortality outcomes are less documented.

METHODS

We performed multivariable logistic regression to identify factors associated with in-patient mortality and intensive care unit (ICU) admission in symptomatic COVID-19 patients admitted to hospitals in South-East Scotland from 1st March to 30th June 2020. One-year mortality was reviewed.

RESULTS

Of 726 patients (median age 72; interquartile range: 58-83 years, 55% male), 104 (14%) required ICU admission and 199 (27%) died in hospital. A further 64 died between discharge and 30th June 2021 (36% overall 1-year mortality). Stepwise logistic regression identified age >79 (odds ratio (OR), 4.77 (95% confidence interval (CI), 1.96-12.75)), male sex (OR, 1.83 (95% CI, 1.21-2.80)) and higher European Cooperative Oncology Group/World Health Organization performance status as associated with higher mortality risk.

DISCUSSION

Poor functional baseline was the predominant independent risk factor for mortality in COVID-19. More than one-third of individuals had died by 1 year following admission.

The Short- and Long-Term Clinical, Radiological and Functional Consequences of COVID-19

As with the rapid increase of the number of patients who have recovered from COVID-19 globally, there needs to be a major shift of the focus from rapid pathogen detection, treatment and prevention to the promotion of better recovery. Notwithstanding the scarcity of our understandings, recent studies have unraveled a plethora of pulmonary and systemic consequences which require medical attention. These consequences remained as of the end of follow-up which ranged from 1 month to 1 year. Here, we review the consequences of COVID-19 in terms of the residual symptoms, radiological and functional manifestations, and identify the potential risk factors that contribute to a prolonged recovery. We also summarize the benefits of clinical interventions (particularly the pulmonary rehabilitation program), and address several undetermined concerns and key future research directions.