Frailty may hint at COVID-19 mortality risk

Frailty may indicate an increased risk of death from COVID-19, results of the COPE* study showed.

“[W]e showed that patients classed as frail by the Clinical Frailty Scale (CFS) are more likely to die from COVID-19 and are discharged from hospital less quickly than those who are not frail … independent of age and comorbidities,” noted the researchers.

“These results support the use of the CFS in the decision-making process [about appropriate allocation of healthcare resources in the urgent setting of the COVID-19 pandemic] and it could be considered for adoption in other countries,” they said. However, frailty should not be the sole marker in decision making, they added.

The observational study, conducted in the UK (10 hospitals) and Italy (one hospital), involved 1,564 adults (median age 74 years, 57.7 percent male) hospitalized with COVID-19. Using the CFS, patients were categorized as fit (1–2), vulnerable, but not frail (3–4), initial signs of frailty but with some degree of independence (5–6), or severe or very severe frailty (7–9), based on status 2 weeks prior to hospitalization. At data cut-off, 27.2 percent of patients (n=425) had died, while 727 were discharged after a median 9 days of hospitalization.

Almost half of the patients (49.4 percent, n=772) were categorized as frail (CFS 5–8), while 27 were deemed terminally ill (CFS 9).

Increasing level of frailty was tied to increased mortality (time from hospital admission to death; adjusted hazard ratio [adjHR], 1.55, 95 percent confidence interval [CI], 1.00–2.41; p=0.052 for CFS 3–4, adjHR, 1.83, 95 percent CI, 1.15–2.91; p=0.011 for CFS 5–6, and adjHR, 2.39, 95 percent CI, 1.50–3.81; p<0.0002 for CFS 7–9 compared with CFS 1–2). [Lancet Public Health 2020;doi:10.1016/S2468-2667(20)30146-8]

Other factors tied to increased mortality risk were older age (adjHR, 2.58 and 2.92 for age 65–79 and ≥80 years; p<0.0001 for both vs age <65 years), C-reactive protein (CRP) >40 mg/dL (adjHR, 2.61; p<0.0001), and estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² (adjHR, 1.43; p=0.0007).

The risk of in-hospital mortality by day 7 since admission also increased in a step-wise manner according to degree of frailty, though was only significant for CFS 7–9 (adjusted odds ratio [adjOR], 1.22, 95 percent CI, 0.63–2.38; p=0.56 for CFS 3–4, adjOR, 1.62, 95 percent CI, 0.81–3.26; p=0.17 for CFS 5–6, and adjOR, 3.12, 95 percent CI, 1.56–6.24; p<0.0012 for CFS 7–9 compared with CFS 1–2).

Patients with CFS 5–6 and 7–9 also had longer duration of hospitalization compared with those with CFS 1–2 (time to discharge; adjHR, 0.70, 95 percent CI, 0.54–0.91; p=0.0084 and adjHR, 0.66, 95 percent CI, 0.50–0.87; p=0.0035, respectively). Duration of hospitalization was also increased in patients aged 65–79 and ≥80 years (adjHR, 0.82; p=0.047 and adjHR, 0.62; p<0.0001, respectively, vs age <65 years) and those with CRP >40 mg/dL (adjHR, 0.73; p<0.0002).

“[P]eople with high frailty scores probably require longer to recover and rehabilitate from COVID-19 and require more complex discharge planning,” the researchers said, though these outcomes were not examined in the present study. These results are also only applicable to hospitalized patients.

“Our findings suggest that contracting COVID-19 is probably more severe for frail people and adds empirical substance to the widely held belief that a poor outcome is associated with increased age or increased frailty,” they noted.