Frailty and mortality in patients with COVID-19
Authors: Michaël R. Laurent
Journal: The Lancet Public Health (2020)

The COVID-19 in Older People (COPE) study by Jonathan Hewitt and colleagues1Hewitt J Carter B Vilches-Moraga A et al.The effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort study.Lancet Public Health. 2020; 5: e444-e451Summary Full Text Full Text PDF PubMed Scopus (412) Google Scholar supports the use of the Clinical Frailty Scale (CFS) for prognostication. These findings support our recently published single-center experience.2De Smet R Mellaerts B Vandewinckele H et al.Frailty and mortality in hospitalized older adults with COVID-19: retrospective observational study.J Am Med Dir Assoc. 2020; 21 (32.e1): 928Summary Full Text Full Text PDF PubMed Scopus (123) Google Scholar However, several aspects of this study deserve clarification. COPE included patients aged between 20 and 101 years old. Frailty is a geriatric concept, although it might originate in midlife, and UK guidelines specify that the CFS should not be applied to younger people.3National Institute for Health and Care ExcellenceCOVID-19 rapid guideline: critical care in adults. NICE guideline [NG159].https://www.nice.org.uk/guidance/ng159Date: March 20, 2020Date accessed: April 24, 2020Google Scholar Frailty predicted mortality in our exclusively geriatric cohort (≥65 years).2De Smet R Mellaerts B Vandewinckele H et al.Frailty and mortality in hospitalized older adults with COVID-19: retrospective observational study.J Am Med Dir Assoc. 2020; 21 (32.e1): 928Summary Full Text Full Text PDF PubMed Scopus (123) Google Scholar Judging from the COPE data, frailty does not appear to be associated with mortality in patients younger than 65 years. The methods do not specify whether biomarkers were measured on admission or during their hospital stay.1Hewitt J Carter B Vilches-Moraga A et al.The effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort study.Lancet Public Health. 2020; 5: e444-e451Summary Full Text Full Text PDF PubMed Scopus (412) Google Scholar In our study, C-reactive protein concentrations at admission were not associated with mortality, with median values less than 40 mg/L in both patients who survived and those who did not.2De Smet R Mellaerts B Vandewinckele H et al.Frailty and mortality in hospitalized older adults with COVID-19: retrospective observational study.J Am Med Dir Assoc. 2020; 21 (32.e1): 928Summary Full Text Full Text PDF PubMed Scopus (123) Google Scholar Could the authors report the median C-reactive protein concentrations in their groups? Many studies on COVID-19 use Cox proportional hazard models, which consider both mortality and its timing (early or late). I wonder whether such models are appropriate for an acute life-threating illness. In that regard, I question the validity of mortality on day 7 of treatment in hospital as an appropriate outcome. Finally, the authors of the COPE study suggest that the CFS could be used for shared decision making. However, CFS by itself has insufficient sensitivity and specificity to be useful in clinical practice.2De Smet R Mellaerts B Vandewinckele H et al.Frailty and mortality in hospitalized older adults with COVID-19: retrospective observational study.J Am Med Dir Assoc. 2020; 21 (32.e1): 928Summary Full Text Full Text PDF PubMed Scopus (123) Google Scholar Indeed, luckily, most frail older adults that have been treated in hospital survive COVID-19. Given that the adjusted hazard ratios in the COPE study are similarly low as in our report, I believe that the predictive use would be similarly restricted. I report personal fees from Alexion Pharma, Amgen, Kyowa Kirin, Menarini, Sandoz, Takeda, Union Chimique Belge, and Will-Pharma. Frailty and mortality in patients with COVID-19 – Authors' replyWe thank all the research teams who have submitted letters in response to our frailty and COVID-19 paper.1 This study has generated discussion in scientific journals, lay press, and social media. We welcome the opportunity to further discuss our methods and results. Full-Text PDF Open AccessThe effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort studyIn a large population of patients admitted to hospital with COVID-19, disease outcomes were better predicted by frailty than either age or comorbidity. Our results support the use of CFS to inform decision making about medical care in adult patients admitted to hospital with COVID-19. Full-Text PDF Open AccessFrailty and mortality in patients with COVID-19We read with interest the study by Jonathan Hewitt and colleagues,1 investigating the association of frailty with mortality in 1564 patients diagnosed with COVID-19. We are interested in how treatment varied between patients in different frailty categories. Although the outcomes were adjusted for baseline patient factors, including age and comorbidities, we note that neither illness severity nor important process measures after admission to hospital, such as intensive care unit admission or mechanical ventilation, were reported. Full-Text PDF Open AccessFrailty and mortality in patients with COVID-19Jonathan Hewitt and colleagues1 found, in a multicentre cohort study, that frailty strongly predicts mortality in patients with COVID-19. We would like to further comment on their study. 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