Does determining the degree of frailty help pandemic decision-making when resources are scarce?
Authors: Samuel D Searle, Kenneth Rockwood
Journal: The Lancet Healthy Longevity (2021)

In general, and never without nuance, the more frail an older person is, the worse their health outcomes with COVID-19, compared with those who are fitter, or less frail.1Pranata R Henrina J Lim MA et al.Clinical frailty scale and mortality in COVID-19: a systematic review and dose-response meta-analysis.Arch Gerontol Geriatr. 2021; 93104324Crossref PubMed Scopus (110) Google Scholar, 2Cosco TD Best J Davis D et al.What is the relationship between validated frailty scores and mortality for adults with COVID-19 in acute hospital care? A systematic review.Age Ageing. 2021; (published online Jan 14.)https://doi.org/10.1093/ageing/afab008Crossref PubMed Scopus (29) Google Scholar In a multicentre, European, COVID-19 study published in The Lancet Healthy Longevity, Roos Sablerolles and colleagues3Sablerolles RSG Lafeber M van Kempen JAL et al.Association between Clinical Frailty Scale score and hospital mortality in adult patients with COVID-19 (COMET): an international, multicentre, retrospective observational cohort study.Lancet Healthy Longev. 2021; (published online Feb 9.)https://doi.org/10.1016/S2666-7568(21)00006-4Summary Full Text Full Text PDF PubMed Scopus (56) Google Scholar report that a higher score on the Clinical Frailty Scale (CFS) was associated with greater risk of hospital mortality. Frailty tools were developed because informal assessments for frailty are poor and over-emphasise the indubitable effect of age on worse outcomes. Older people, when acutely ill, can seem to be frail when unwell and immobile in a hospital bed. This can reinforce an ageism that is subconscious, not rare, and even exacerbated by COVID-19.4Skoog I COVID-19 and mental health among older people in Sweden.Int Psychogeriatr. 2020; 32: 1173-1175Crossref PubMed Scopus (17) Google Scholar The CFS is an efficient clinical tool studied and developed for older adults.5Rockwood K Theou O Using the clinical frailty scale in allocating scarce health care resources.Can Geriatr J. 2020; 23: 210-215Crossref PubMed Google Scholar It has good validity for inpatient populations and when used by various health-care professionals,5Rockwood K Theou O Using the clinical frailty scale in allocating scarce health care resources.Can Geriatr J. 2020; 23: 210-215Crossref PubMed Google Scholar, 6Brummel NE Girard TD Pandharipande PP et al.Prevalence and course of frailty in survivors of critical illness.Crit Care Med. 2020; 48: 1419-1426Crossref PubMed Scopus (27) Google Scholar, 7Hubbard RE Maier AB Hilmer SN Naganathan V Etherton-Beer C Rockwood K Frailty in the face of COVID-19.Age Ageing. 2020; 49: 499-500Crossref PubMed Scopus (64) Google Scholar, 8Darvall JN Bellomo R Bailey M et al.Frailty and outcomes from pneumonia in critical illness: a population-based cohort study.Br J Anaesth. 2020; 125: 730-738Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar and has been recommended for many settings,5Rockwood K Theou O Using the clinical frailty scale in allocating scarce health care resources.Can Geriatr J. 2020; 23: 210-215Crossref PubMed Google Scholar, 7Hubbard RE Maier AB Hilmer SN Naganathan V Etherton-Beer C Rockwood K Frailty in the face of COVID-19.Age Ageing. 2020; 49: 499-500Crossref PubMed Scopus (64) Google Scholar making it widely used. Major components of the CFS include exercise, comorbidities, symptom control, disability, and mobility. Based on a theory of how age-associated health deficits accumulate, these components are ordered to reflect the various degrees of fitness and frailty.5Rockwood K Theou O Using the clinical frailty scale in allocating scarce health care resources.Can Geriatr J. 2020; 23: 210-215Crossref PubMed Google Scholar The nine-point CFS includes a category for people who are understood to be terminally ill.5Rockwood K Theou O Using the clinical frailty scale in allocating scarce health care resources.Can Geriatr J. 2020; 23: 210-215Crossref PubMed Google Scholar Reflecting the complexity of frailty, scoring the CFS relies on observer judgment. Raters must take a history—the scale is designed to be scored on the basis of the health of the individual 2 weeks before the current state. This 2-week criterion is empirical and reflects how much energy it takes to get back even to baseline health. Recovery requires not just repair, but reversing the inertia of decline.9Farrell SG Mitnitski AB Rockwood K Rutenberg AD Network model of human aging: Frailty limits and information measures.Phys Rev E. 2016; 94052409Crossref PubMed Scopus (33) Google Scholar, 10Stolz E Hoogendijk EO Mayerl H Freidyl W Frailty changes predict mortality in four longitudinal studies of aging.J GerontolBiol Sci Med Sci. 2020; (published online Oct 26.)https://doi.org/10.1093/gerona/glaa266Crossref Scopus (16) Google Scholar The evidence generally supports evaluating frailty as part of managing frail individuals who are acutely ill, especially if age is the alternative measure.1Pranata R Henrina J Lim MA et al.Clinical frailty scale and mortality in COVID-19: a systematic review and dose-response meta-analysis.Arch Gerontol Geriatr. 2021; 93104324Crossref PubMed Scopus (110) Google Scholar, 2Cosco TD Best J Davis D et al.What is the relationship between validated frailty scores and mortality for adults with COVID-19 in acute hospital care? A systematic review.Age Ageing. 2021; (published online Jan 14.)https://doi.org/10.1093/ageing/afab008Crossref PubMed Scopus (29) Google Scholar The use of a frailty evaluation is also supported specifically in COVID-19-related presentations. Frailty identification is a starting point to understanding patients who are at risk for death, disability, and loss of independence. Management of patients who are frail is not always part of the training provided to health-care workers in acute care, which often means that important information about the breadth of existing social and health issues is ignored, or even derided.11Granger K Ninan S Stopford E The patient presenting with 'acopia'.Acute Med. 2013; 12: 173-177PubMed Google Scholar So-called atypical presentations, such as delirium, functional decline, and falls are often the only signs of a serious acute illness in patients who are frail.12Zazzara MB Penfold RS Roberts AL et al.Probable delirium is a presenting symptom of COVID-19 in frail, older adults: a cohort study of 322 hospitalised and 535 community-based older adults.Age Ageing. 2021; 50: 40-48Crossref PubMed Scopus (61) Google Scholar Crucially, frailty exists on a spectrum. Categorising people as being frail and using a standard care plan discussion that does not distinguish between those living with mild frailty and those living with very severe frailty, means that patients will not be properly informed or provided with appropriate care. Following frailty identification (eg, with the CFS) a comprehensive assessment is required to create a realistic, patient-centred treatment strategy that targets reversible contributors to frailty as well as the inciting health issue. So-called long COVID, although not unique to people who had been living with frailty, might serve to prompt closer attention to specific clinical measures thus far not studied other than an expected longer functional recovery after illness. Pandemic medicine seems to have accommodated, alongside care for patients, the ethical mandate to ensure that health-care systems are maintained.5Rockwood K Theou O Using the clinical frailty scale in allocating scarce health care resources.Can Geriatr J. 2020; 23: 210-215Crossref PubMed Google Scholar Does this mean that people who live with frailty would be lesser candidates for more traditionally intensive management or be a higher burden to the health-care system? This question must consider outcomes other than mortality: for many people, death is not the worst result of intensive treatment. When the system is under extreme pressure, estimations are needed for whether frail patients take up more health resources than other patients. Sablerolles and colleagues3Sablerolles RSG Lafeber M van Kempen JAL et al.Association between Clinical Frailty Scale score and hospital mortality in adult patients with COVID-19 (COMET): an international, multicentre, retrospective observational cohort study.Lancet Healthy Longev. 2021; (published online Feb 9.)https://doi.org/10.1016/S2666-7568(21)00006-4Summary Full Text Full Text PDF PubMed Scopus (56) Google Scholar have extended their use of the frailty construct to include people younger than 65 years. In these patients, the concept of frailty is less well validated than in older patients.1Pranata R Henrina J Lim MA et al.Clinical frailty scale and mortality in COVID-19: a systematic review and dose-response meta-analysis.Arch Gerontol Geriatr. 2021; 93104324Crossref PubMed Scopus (110) Google Scholar, 5Rockwood K Theou O Using the clinical frailty scale in allocating scarce health care resources.Can Geriatr J. 2020; 23: 210-215Crossref PubMed Google Scholar, 7Hubbard RE Maier AB Hilmer SN Naganathan V Etherton-Beer C Rockwood K Frailty in the face of COVID-19.Age Ageing. 2020; 49: 499-500Crossref PubMed Scopus (64) Google Scholar Despite their findings, which are similar to those of a larger study of outcomes of respiratory infection before the pandemic,8Darvall JN Bellomo R Bailey M et al.Frailty and outcomes from pneumonia in critical illness: a population-based cohort study.Br J Anaesth. 2020; 125: 730-738Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar caution is still needed in applying the CFS to younger populations. That is because disability (including mobility disability) in particular has a different meaning when it is life-long than when it arises in older age. In older people, single system disability is not common. Instead, disability arises from the coalescence of several age-related health deficits.13Theou O Rockwood MRH Mitnitski A Rockwood K Disability and co-morbidity in relation to frailty: how much do they overlap?.Arch Gerontol Geriatr. 2012; 55: e1-e8Crossref PubMed Scopus (151) Google Scholar The importance of disabilities in frailty and CFS scoring lies in ability of the scale to integrate a lot of information that is relevant to mortality risk.9Farrell SG Mitnitski AB Rockwood K Rutenberg AD Network model of human aging: Frailty limits and information measures.Phys Rev E. 2016; 94052409Crossref PubMed Scopus (33) Google Scholar From a life course perspective, the mutual information of frailty and mortality is lower among younger people, in whom death is less common (equally it declines in the tenth decade of life onwards, when the risk of death is high, even for people who are fit). This contrasts with younger people, in whom disability more often reflects single-system, non-ageing related processes (eg, spinal cord injury) or conditions present since early in life (eg, cerebral palsy or intellectual disability). In these people, the mechanisms for functional impairment differ from those that arise from the accumulation of health deficits in ageing. In short, the CFS score in a younger person need not confer the same risk that it does in an older person. This is not to say that the degree of frailty does not accelerate after severe illness. Notably, this acceleration can follow acute illness requiring intensive care.6Brummel NE Girard TD Pandharipande PP et al.Prevalence and course of frailty in survivors of critical illness.Crit Care Med. 2020; 48: 1419-1426Crossref PubMed Scopus (27) Google Scholar Additionally, a major stroke, together with the multiple contributory factors that commonly accompany it, can accelerate the development of premorbid, baseline frailty due to the cumulative impact across multiple organ and regulatory systems: new deficits beget more deficits.10Stolz E Hoogendijk EO Mayerl H Freidyl W Frailty changes predict mortality in four longitudinal studies of aging.J GerontolBiol Sci Med Sci. 2020; (published online Oct 26.)https://doi.org/10.1093/gerona/glaa266Crossref Scopus (16) Google Scholar In this regard, two important questions must be addressed. Does disability accelerate frailty after acute illness? When symptoms persist, what is the best way to determine a newly established baseline frailty state in the still recovering patient? For the former question, it seems likely that even before the age of 65 years, progression of disability is related to the degree of frailty. For example, in a study of people aged 50 years and older who lived with intellectual disabilities, the degree of frailty was related to the risk of incident impairment in activities of daily living.14Schoufour JD Mitnitski A Rockwood K Hilgenkamp TIM Evenhuis HM Echteld MA Predicting disabilities in daily functioning in older people with intellectual disabilities using a frailty index.Res Dev Disabil. 2014; 35: 2267-2277Crossref PubMed Scopus (29) Google Scholar As for the second question, at the moment, too little information is available on relevant health and frailty trajectories in younger people. This important question should motivate additional inquiry. In older adults, a growing body of evidence, to which the study by Sablerolles and colleagues adds, suggests that the degree of frailty can inform the estimate of mortality risk in people with COVID-19 who are severely ill enough to be considered for intensive care. Caution must be taken about extending the understanding of lifelong disability to equate it with disability as a manifestation of age-related frailty. Until we understand if frailty accelerates following disability and whether ageing and non-ageing related disability are similar in their relationship with adverse outcomes, we need to be cautious in applying the CFS to younger populations. Rather, we will need to rely on careful clinical judgement, comprehensive assessments, and be conscious of not discriminating against age or anyone with a disability. KR has asserted copyright of the Clinical Frailty scale; use is free for research, educational, and not-for-profit care, users are asked not to change or commercialise it. KR is also President and cofounder of Ardea Outcomes, which offers software and training for individualised outcome measurement to pharmaceutical companies, device manufacturers, and academic institutions, and has had private sector contracts in the past 3 years with EIP Pharma, Hollister, Novartis, Nutricia, Roche, Shire, and Takeda, all outside the submitted work. KR receives career support from the Dalhousie Medical Research Fund as the Kathryn Allen Weldon Professor of Alzheimer's Research, philanthropic programme support from the Fountain Family Innovation Fund (Queen Elizabeth II Health Sciences Centre Foundation), and holds research grants from the Canadian Institutes of Health Research (Canadian Frailty Network), all outside the submitted work. SDS receives fellowship support from the Dalhousie Medical Research Foundation and University Internal Medicine Research Foundation at Dalhousie University, outside the submitted work. Association between Clinical Frailty Scale score and hospital mortality in adult patients with COVID-19 (COMET): an international, multicentre, retrospective, observational cohort studyThe results of this study suggest that CFS score is a suitable risk marker for hospital mortality in adult patients with COVID-19. However, treatment decisions based on the CFS in patients younger than 65 years should be made with caution. Full-Text PDF Open Access