Frailty and mortality in patients with COVID-19
Authors: Daniel Pan, Shirley Sze, Jatinder S Minhas, Iain B Squire, Manish Pareek
Journal: The Lancet Public Health (2020)

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 (466) Google Scholar 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. There are many reasons as to why frailty should be considered during the current pandemic. First, frailty is associated with atypical clinical presentations; in the context of COVID-19, this might lead to diagnostic delays and increases in community transmission.2Tay HS Harwood R Atypical presentation of COVID-19 in a frail older person.Age Ageing. 2020; 49: 523-524Crossref PubMed Scopus (68) Google Scholar Second, frailty is related to sarcopenia, a poor nutritional status, and underlying inflammation, all which predispose an individual to a poorer immune response to severe acute respiratory syndrome coronavirus 2.3Gingrich A Volkert D Kiesswetter E et al.Prevalence and overlap of sarcopenia, cachexia, frailty and malnutrition in older medical inpatients.Clin Nutr. 2016; 35: S54-S55Summary Full Text PDF Google Scholar This deficient immune response can lead to higher short-term mortality, a slower recovery, and a functional decline in patients who survive who are frail. Third, because of a weakened immune response in frail patients, a vaccine for COVID-19 might be less effective for them. Although this study shows the important prognostic information that frailty assessments can bring, we do not recommend using it as the overriding deciding component to rationing access to health care, for three main reasons. First, frailty assessment grades a patient's vulnerability, but does not consider a patient's resilience; for example, of two equally frail patients infected with COVID-19, one might only have mild symptoms, and the other might suffer from a critical illness. Second, frailty is a continuum rather than being dichotomous; it can be difficult to decide an appropriate cutoff of frailty status to decide access to interventions, such as intubation and ventilation. Third, the presence of frailty does not necessarily suggest a poor prognosis. A study of 210 older adult patients that were admitted to hospital suggests that mild frailty (Clinical Frailty Scale 5) is associated with a low 1 year mortality rate (8%).4Chong E Chan M Tan HN Lim WS COVID-19: use of the Clinical Frailty Scale for critical care decisions.J Am Geriatr Soc. 2020; 68: e30-e32Crossref PubMed Scopus (40) Google ScholarBecause of these reasons, withholding and rationing potentially life-saving treatment, mainly on the basis of a patient's frailty status, is not justified. Frailty assessments should form part of a patient-centred approach. Other factors such as comorbidities, disease severity, and the likelihood of medical interventions being successful should also be considered. Finally, although frailty might be associated with poor short-term outcomes in patients admitted to hospital with COVID-19, this population only represents a small proportion of those infected; most COVID cases are mild and are managed within the community. Frail patients have reduced reserve to respond to stressors; it is therefore necessary to also prevent these patients from exposure to the virus.5British Geriatrics SocietyBGS statement on the COVID-19 pandemic.https://www.bgs.org.uk/bgs-statement-on-the-covid-19-pandemicDate: 2020Date accessed: October 5, 2020Google Scholar Further research is required to understand the value of frailty assessments in the community and their role in triaging patients and preventing unnecessary admissions to hospital. MP reports personal fees from Gilead Sciences and Qiagen; and grants from Gilead Sciences. JSM reports grants from National Institute for Health Research Clinical Lectureship in Older People and Complex Health Needs. The views expressed in this publication are those of the author(s) and not necessarily those of the National Health Service, the National Institute for Health Research, or the Department of Health. All other authors declare no competing interests. Frailty and mortality in patients with COVID-19Frailty and mortality in patients with COVID-19 – Authors' replyThe effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort studyFrailty and mortality in patients with COVID-19