Post-COVID functional limitations on daily living activities are associated with symptoms experienced at the acute phase of SARS-CoV-2 infection and internal care unit admission: A multicenter study
Authors: César Fernández-de-las-Peñas, José D. Martín-Guerrero, Esperanza Navarro-Pardo, Jorge Rodríguez-Jiménez, Oscar J. Pellicer-Valero
Journal: Journal of Infection (2021)

Evidence supports that almost 60% of COVID-19 survivors will experience post-COVID symptom during the first 6-months following the infection.[1]Fernández-de-las-Peñas C. Palacios-Ceña D. Gómez-Mayordomo V. Florencio L.L. Cuadrado M.L. Plaza-Manzano G. Navarro-Santana M. Prevalence of post-COVID-19 symptoms in hospitalized and non-hospitalized COVID-19 survivors: a systematic review and meta-analysis.Eur J Int Med. 2021; (S0953-6205): 00208-00209Google Scholar These symptoms lead to a decrease in health-related quality of life and decreased function.[2]Todt B.C. Szlejf C. Duim E. Clinical outcomes and quality of life of COVID-19 survivors: a follow-up of 3 months post hospital discharge.Respir Med. 2021; 184106453Google Scholar,[3]Jacobs L.G. Gourna Paleoudis E. Lesky-Di Bari D. Persistence of symptoms and quality of life at 35 days after hospitalization for COVID-19 infection.PLoS ONE. 2020; 15e0243882Google Scholar In a letter to the editor in Journal of Infection, Taboada et al. found that female sex, age, length of hospital stance and internal care unit (ICU) admission were associated with limitations in functional status.[4]Taboada M. Cariñena A. Moreno E. Post-COVID-19 functional status six-months after hospitalization.J Infect. 2021; 82: e31-e33Google Scholar These authors evaluated the Functional Status Scale (PCFS), a scale assessing global patient-functional limitation by using a 6-points scale.[5]Klok F.A. Boon G.J.A.M. Barco S. The post-COVID-19 functional status scale: a tool to measure functional status over time after COVID-19.Eur Respir J. 2020; 562001494Google Scholar The PCFS did not differentiate on which daily life activity the limitation is present since it uses a global score. Due to the complexity of COVID-19, it is possible that functional limitations and their associated risk factors are different depending on the type e.g., social, occupational, basic or instrumental, of daily living activity. In addition, previous studies have included limited numbers of participants (n < 300) recruited from just one single center.[2]Todt B.C. Szlejf C. Duim E. Clinical outcomes and quality of life of COVID-19 survivors: a follow-up of 3 months post hospital discharge.Respir Med. 2021; 184106453Google Scholar–[4]Taboada M. Cariñena A. Moreno E. Post-COVID-19 functional status six-months after hospitalization.J Infect. 2021; 82: e31-e33Google Scholar We describe a multicenter study investigating those risk factors associated with the presence of functional status differentiating occupational, leisure/social, basic or instrumental daily living activities in a sample of hospitalized COVID-19 survivors at a long-term follow-up period after hospital discharge. This multicenter study included patients hospitalized in five hospitals of Madrid (Spain) with a diagnosis of SARS-CoV-2 infection during the first wave of the pandemic. A sample of 400 individuals from each hospital was randomly selected for this study. Local Ethics Committee of each participating hospital approved the study (HUFA 20/126, HCSC20/495E, HSO25112020, HUIL/092-20, HUF/EC1517). All participants provided their informed consent. Clinical features (i.e., gender, age, height, weight, medical co-morbidities), symptoms at hospital admission, and hospitalization data (days at hospital, ICU admission) were collected from medical records. Participants were scheduled for a telephone interview conducted by experienced healthcare professionals to evaluate the functional status of the patient. Participants were asked for self-perceived limitations in occupational, leisure/social activities, instrumental, and basic daily living activities. They s were asked for determining their functional status at the moment of the interview (post-COVID) in comparison with their previous status before hospitalization. Mean and standard deviation (SD) or percentages were calculated. Missing values were imputed using median imputation. Multivariate logistic regressions were conducted to analyze associations between clinical and hospitalization variables with the presence of limitations in occupational, leisure/social activities, instrumental, and basic activities of daily living (dependent variables) using Python's library statsmodels 0.11.1. Adjusted odds ratio (OR) with their confidence intervals (95%CI) were calculated. From 2000 patients randomly selected from the five hospitals and invited to participate, a total of 1969 (46% women, age: 61, SD: 16 years) were assessed a mean of 8.4 months (SD 1.5) after hospital discharge. Fever (74.6%), dyspnea (31.5%) and myalgia (30.7%) were the most prevalent symptoms at hospital admission (Table 1). The mean number of COVID-19 symptoms at hospital admission was 2.2. (SD 0.8). Almost 57.5% of patients (n = 1133) reported at least one comorbidity. The mean number of medical co-morbidities was 0.8 (SD 0.9). Hypertension (26.2%), diabetes (12.0%), and cardiovascular disorders (11.9%) were the most common medical comorbidities (Table 1). Between 20 and 30% of participants reported limitations during at least one daily living activity (Table 1).Table1Clinical, hospitalization and functional status data of the sample (n = 1969).Age, mean (SD), years61 (16)Gender, male/female (%)1054 (53.5%) / 915 (46.5%)Weight, mean (SD), kg.75 (15)Height, mean (SD), cm.165 (16.5)Main Symptoms at hospital admission, n (%)FeverdyspneaMyalgiaCoughHeadachediarrhoeaAnosmiaThroat PainAgeusiaVomiting1469 (74.6%)620 (31.5%)604 (30.7%)549 (27.9%)332 (16.9%)210 (10.7%)167 (8.5%)102 (5.2%)66 (33.5%)55 (2.8%)Medical co-morbiditiesHypertensionDiabetesCardiovascular DiseaseAsmaObesityChronic Obstructive Pulmonary DiseaseStrokeRheumatological DiseaseOther (Cancer, Kidney Disease)514 (26.1%)236 (12.0%)234 (11.9%)126 (6.4%)88 (4.5%)77 (3.9%)38 (2.0%)31 (1.6%)332 (16.9%)Stay at the hospital, mean (SD), days11.3 (11.4)Intensive Care Unit (ICU) admissionYes/No, n (%)130 (6.6%) / 1839 (93.4%)Functional Limitations n (%)Limitation in Occupational ActivitiesLimitation in Leisure/Social ActivitiesLimitation in Basic Activities of Daily LifeLimitation in Instrumental Activities of Daily Life418 (21.2%)604 (30.6%)542 (27.5%)389 (19.7%) Open table in a new tab The regression model revealed that the number of COVID-19 symptoms at hospital admission (occupational activities: OR1.51, 95%CI 1.14–2.01, P = 0.004; leisure/social activities: OR1.59, 95%CI 1.25–2.03, P < 0.001; basic daily live activities: OR1.61, 95%CI 1.21–2.13, P < 0.001; instrumental daily live activities: OR1.57, 95%CI 1.22–2.01, P < 0.001) and ICU admission (occupational activities: OR1.79, 95%CI 1.16–2.78, P = 0.009; leisure/social activities: OR1.83, 95%CI 1.22–2.73, P = 0.003; basic daily living activities: OR3.30, 95%CI 2.16–5.05, P < 0.001; instrumental daily living activities: OR2.37, 95%CI 1.57–3.58, P < 0.001) were significantly with limitations in all activities. Additionally, age was also associated with limitation in leisure/social activities (OR1.009, 95%CI 1.003–1.016, P = 0.006), limitations basic daily living activities (OR1.016, 95%CI 1.008–1.024, P < 0.001), and limitations in instrumental daily living activities (OR1.020, 95%CI 1.013–1.028, P < 0.001). Female sex was only associated with limitations in leisure and social activities (OR1.46, 95%CI 1.13–1.89, P = 0.003) and limitations instrumental daily living activities (OR1.66, 95%CI 1.28–2.16, P < 0.001). Our multicenter study found that at least 20% of COVID-19 survivors self-reported limitations on daily living activities eight months after hospitalization. Current data agree with previous studies[2]Todt B.C. Szlejf C. Duim E. Clinical outcomes and quality of life of COVID-19 survivors: a follow-up of 3 months post hospital discharge.Respir Med. 2021; 184106453Google Scholar–[4]Taboada M. Cariñena A. Moreno E. Post-COVID-19 functional status six-months after hospitalization.J Infect. 2021; 82: e31-e33Google Scholar; nevertheless, we differentiated the type of activity perceived as limited, a distinction that is not commonly conducted in former post-COVID literature. Identification of risk factors is needed for an early identifying and monitoring of patients at a high risk of developing post-COVID sequelae.[6]Iqbal F.M. Lam K. Sounderajah V. Clarke J.M. Ashrafian H. Darzi A. Characteristics and predictors of acute and chronic post-COVID syndrome: a systematic review and meta-analysis.EClinicalMedicine. 2021; 36100899Google Scholar This multicenter study found that a higher number of symptoms at hospital admission and ICU admission were associated with functional limitations at all daily living activities. Our findings the assumption that a higher symptom load at the acute phase of the infection leads to a greater likelihood of suffering long-term functional disability at least in hospitalized COVID-19 survivors. We also observed that other risk factors, e.g., female sex and age, which have been associated with post-COVID symptoms,[7]Yong S.J. Long COVID or post-COVID-19 syndrome: putative pathophysiology, risk factors, and treatments.Infect Dis. 2021; https://doi.org/10.1080/23744235.2021.1924397Google Scholar were associated with the limitations of daily living activities, although clinical relevance of age could be questioned due to their lower adjusted OR. Our findings agree with those found by Taboada et al. except for the longer hospital stay.[4]Taboada M. Cariñena A. Moreno E. Post-COVID-19 functional status six-months after hospitalization.J Infect. 2021; 82: e31-e33Google Scholar Increasing evidence suggests that post-COVID fatigue, probably one of the symptoms most associated with functional status, is not associated with the severity of the initial infection[8]Townsend L. Dyer A.H. Jones K. Dunne J. Mooney A. Gaffney F. Persistent fatigue following SARS-CoV-2 infection is common and independent of severity of initial infection.PLoS ONE. 2020; 15e0240784Google Scholar or damage in lung function at 3- and 6-month after.[9]Stylemans D. Smet J. Hanon S. Schuermans D. Ilsen B. Vandemeulebroucke J. Vanderhelst E. Verbanck S. Evolution of lung function and chest CT 6 months after COVID-19 pneumonia: real-life data from a Belgian University Hospital.Respir Med. 2021; 182106421Google Scholar It would be probably that hospitalization data can exert less influence on the development of post-COVID sequelae than expected. Although our study provides further evidence to the current literature about post-COVID functional status with a large, multicenter design evaluating specific daily living activities, potential weaknesses should be considered. First, only hospitalized COVID-19 patients participated. Second, the number of patients requiring ICU admission was small. Third, the cross-sectional design did not permit to determine cause -and-effect association between suffering COVID-19 and functional status. Fourth, we did not collect objective data of COVID-19 disease and measures of lung damage, although these factors seem to be not related to post-COVID sequelae.[8]Townsend L. Dyer A.H. Jones K. Dunne J. Mooney A. Gaffney F. Persistent fatigue following SARS-CoV-2 infection is common and independent of severity of initial infection.PLoS ONE. 2020; 15e0240784Google Scholar,[9]Stylemans D. Smet J. Hanon S. Schuermans D. Ilsen B. Vandemeulebroucke J. Vanderhelst E. Verbanck S. Evolution of lung function and chest CT 6 months after COVID-19 pneumonia: real-life data from a Belgian University Hospital.Respir Med. 2021; 182106421Google Scholar César Fernández-de-las-Peñas: Conceptualization, Data curation, Investigation, Methodology, Project administration, Resources, Validation, Visualization, Writing – original draft, Writing – review & editing. José D. Martín-Guerrero: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Software, Validation, Visualization, Writing – original draft, Writing – review & editing. Esperanza Navarro-Pardo: Conceptualization, Data curation, Investigation, Methodology, Resources, Validation, Visualization, Writing – original draft, Writing – review & editing. Jorge Rodríguez-Jiménez: Conceptualization, Data curation, Investigation, Methodology, Validation, Visualization, Writing – original draft, Writing – review & editing. Oscar J. Pellicer-Valero: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. None. No funds were received for this study.