Impact of frailty on long-term survival in patients discharged alive from hospital after an ICU admission with COVID-19 <sup>☆</sup>

Author(s): Ashwin Subramaniam , MBBS MMed FRACP FCICM PhD ^a ^, ^b ^, ^c ^, ^d ^, ^∗ , Ryan Ruiyang Ling , Dr MBBS ^e , David Pilcher , MBBS MRCP(UK) FRACP FCICM ^d ^, ^f ^, ^g

Publication date (Electronic): 14 December 2023

Journal: Critical Care and Resuscitation

Publisher: Elsevier

Keywords: ANZICS adult patient database, COVID-19, Clinical frailty scale, Frailty, CFS, Long-term survival

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Abstract

Objective

Though frailty is associated with mortality, its impact on long-term survival after an ICU admission with COVID-19 is unclear. We aimed to investigate the association between frailty and long-term survival in patients after an ICU admission with COVID-19.

Design, Setting and Participants

This registry-based multicentre, retrospective, cohort study included all patients ≥16 years discharged alive from the hospital following an ICU admission with COVID-19 and documented clinical frailty scale (CFS). Data from 118 ICUs between 01/01/2020 through 31/12/2020 in New Zealand and 31/12/2021 in Australia were reported in the Australian and New Zealand Intensive Care Society Adult Patient Database. The patients were categorised as ‘not frail’ (CFS 1-3), ‘mildly frail’ (CFS 4-5) and ‘moderately-to-severely frail’ (CFS 6-8).

Main Outcome Measures

The primary outcome was survival time up to two years, which we analysed using Cox regression models.

Results

We included 4028 patients with COVID-19 in the final analysis. ‘Moderately-to-severely frail’ patients were older (66.6 [56.3–75.8] vs. 69.9 [60.3–78.1]; p < 0.001) than those without frailty (median [interquartile range] 53.0 [40.1–64.6]), had higher sequential organ failure assessment scores (p < 0.001), and less likely to receive mechanical ventilation (p < 0.001) than patients without frailty or mild frailty. After adjusting for confounders, patients with mild frailty (adjusted hazards ratio: 2.31, 95%-CI: 1.75–3.05) and moderate-to-severe frailty (adjusted hazards ratio: 2.54, 95%-CI: 1.89–3.42) had higher mortality rates than those without frailty.

Conclusions

Frailty was independently associated with shorter survival times to two years in patients with severe COVID-19 in ANZ following hospital discharge. Recognising frailty provides individualised patient intervention in those with frailty admitted to ICUs with severe COVID-19.

Clinical trial registration

Not applicable.

Related collections

Most cited references 30

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Frailty is the most problematic expression of population ageing. It is a state of vulnerability to poor resolution of homoeostasis after a stressor event and is a consequence of cumulative decline in many physiological systems during a lifetime. This cumulative decline depletes homoeostatic reserves until minor stressor events trigger disproportionate changes in health status. In landmark studies, investigators have developed valid models of frailty and these models have allowed epidemiological investigations that show the association between frailty and adverse health outcomes. We need to develop more efficient methods to detect frailty and measure its severity in routine clinical practice, especially methods that are useful for primary care. Such progress would greatly inform the appropriate selection of elderly people for invasive procedures or drug treatments and would be the basis for a shift in the care of frail elderly people towards more appropriate goal-directed care. Copyright © 2013 Elsevier Ltd. All rights reserved.

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There is no single generally accepted clinical definition of frailty. Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians. We aimed to develop a tool that would be both predictive and easy to use. We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging (CSHA). We followed this cohort prospectively; after 5 years, we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools. The CSHA Clinical Frailty Scale was highly correlated (r = 0.80) with the Frailty Index. Each 1-category increment of our scale significantly increased the medium-term risks of death (21.2% within about 70 mo, 95% confidence interval [CI] 12.5%-30.6%) and entry into an institution (23.9%, 95% CI 8.8%-41.2%) in multivariable models that adjusted for age, sex and education. Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition, function or comorbidity in assessing risk for death (area under the curve 0.77 for 18-month and 0.70 for 70-month mortality). Frailty is a valid and clinically important construct that is recognizable by physicians. Clinical judgments about frailty can yield useful predictive information.

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Long covid—mechanisms, risk factors, and management

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Since its emergence in Wuhan, China, covid-19 has spread and had a profound effect on the lives and health of people around the globe. As of 4 July 2021, more than 183 million confirmed cases of covid-19 had been recorded worldwide, and 3.97 million deaths. Recent evidence has shown that a range of persistent symptoms can remain long after the acute SARS-CoV-2 infection, and this condition is now coined long covid by recognized research institutes. Studies have shown that long covid can affect the whole spectrum of people with covid-19, from those with very mild acute disease to the most severe forms. Like acute covid-19, long covid can involve multiple organs and can affect many systems including, but not limited to, the respiratory, cardiovascular, neurological, gastrointestinal, and musculoskeletal systems. The symptoms of long covid include fatigue, dyspnea, cardiac abnormalities, cognitive impairment, sleep disturbances, symptoms of post-traumatic stress disorder, muscle pain, concentration problems, and headache. This review summarizes studies of the long term effects of covid-19 in hospitalized and non-hospitalized patients and describes the persistent symptoms they endure. Risk factors for acute covid-19 and long covid and possible therapeutic options are also discussed.

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Author and article information

Contributors

Ashwin Subramaniam: Twitter icon

@catchdrash

Journal

Journal ID (nlm-ta): Crit Care Resusc

Journal ID (iso-abbrev): Crit Care Resusc

Title: Critical Care and Resuscitation

Publisher: Elsevier

ISSN (Print): 1441-2772

ISSN (Electronic): 2652-9335

Publication date PMC-release: 14 December 2023

Publication date Collection: March 2024

Publication date (Electronic): 14 December 2023

Volume: 26

Issue: 1

Pages: 16-23

Affiliations

[a ]Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia

[b ]Department of Intensive Care, Dandenong Hospital, Monash Health, Dandenong, Victoria, Australia

[c ]Peninsula Clinical School, Monash University, Frankston, Victoria, Australia

[d ]Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

[e ]Yong Loo Lin School of Medicine, National University of Singapore, Singapore

[f ]Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia

[g ]Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Victoria, Australia

Author notes

[∗ ]Corresponding author at: Intensive Care Specialist, Department of Intensive Care, Dandenong Hospital, Dandenong, Victoria 3175, Australia. Tel.: +61 3 9784 7422. ashwin.subramaniam@ 123456monash.edu Twitter icon

@catchdrash

Article

Publisher Item ID: S1441-2772(23)02224-X

DOI: 10.1016/j.ccrj.2023.11.001

PMC ID: 11056397

PubMed ID: 38690183

SO-VID: d0aadcf0-3aa8-40aa-8703-f6fb530b7f1e

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).