Frailty and COVID-19: why, what, how, where and when?

The information on this page is also available here as a downloadable PDF, including links.

Key point: clinicians should not place too much emphasis on frailty alone when discussing prognosis in older people with COVID-19 infection.

Why is this important?

Rapid NICE guidance produced in response to the COVID-19 outbreak clearly outlined the importance of identifying and grading frailty using the Clinical Frailty Scale (CFS). At that time, there had been no studies examining the role of the CFS specifically in older people with COVID-19. Since, there have been many studies that have shown an association between an increased risk of COVID-19 related death and increasing frailty, but other studies demonstrate a more nuanced understanding of frailty and outcomes in COVID-19 is needed.

Analysis of all people aged 75+ years admitted with COVID-19 (whether PCR confirmed or clinically diagnosed) in England indicates that those with greater frailty risk may actually have lower all-cause mortality. This may relate to immunosenesence and a less marked cytokine storm, which is thought to underpin poor outcomes in COVID-19 infections.

What should you be doing?

You should always use a holistic assessment to guide clinical decision making – no one tool should be used in isolation. Frailty considerations, alongside other risk scores such as the 4C Mortality Score can form part of a holistic assessment to inform a shared decision making process. Frailty can be useful in identifying the risk of COVID-19 related complications such as delirium and deconditioning.

Outwith the context of COVID-19, frailty is associated with increased mortality, fewer people returning home and poorer quality of life following a critical care episode. These outcomes have not been studied in older people with COVID-19 to date.

How should i use the cfs?

DON’T use the CFS in isolation to direct your clinical decision making.

DO remember that the CFS has only been validated in older people; it has not been widely validated in younger populations (below 65 years of age), or in those with learning disability. It may not perform as well in people with stable long term disability such as cerebral palsy, whose outcomes might be very different compared to older people with progressive disability.

• The CFS can be undertaken by any appropriately trained health or social care professional (doctor, nurse, health care assistant, therapist etc.) with training and support BUT decision makers using the CFS to inform clinical management MUST check the score  themselves to ensure that it is accurate.

• Ask the patient, their carer/next of kin/paramedics/care home staff what their capability was TWO weeks ago.

• DO NOT base your assessment on how the patient appears before you today.

• DO be careful about differentiating between CFS 6 and 7:

  • CFS 6 (need help with outdoor activities and some help with basic activities) – all  cause mortality during admission to acute hospital = 6% (NOT COVID-19 specific data)

  • CFS 7 (completely dependent for personal care) – all cause mortality during  admission to acute hospital = 11% (NOT COVID-19 specific data)

When?

The CFS should be assessed in Emergency Department triage, or any first point of contact with acute care (including by paramedics), alongside National Early Warning Scores (NEWS). It should be reassessed after two weeks if clinically relevant in environments where stable patients are being observed for progress over a longer time-frame.

Resources

• A CFS app is now available for both Apple and Android devices

• Specific training on the use of the CFS in the urgent care context is available here.

• A general overview of frailty with tips on using the CFS can be found here.

References

1. National Institute for Clinical Excellence. COVID-19 rapid guideline: critical care in adults. NICE guideline 2020([NG159])

2. Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people.[see comment]. CMAJ Canadian Medical Association Journal 2005;173(5):489-95.

3. Cosco TD, Best J, Bryden 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. medRxiv 2020:2020.11.13.20231365. doi: 10.1101/2020.11.13.20231365

4. Li X, Geng M, Peng Y, et al. Molecular immune pathogenesis and diagnosis of COVID-19. Journal of Pharmaceutical Analysis 2020 doi: https://doi.org/10.1016/j.jpha.2020.03.001

5. McElvaney OJ, McEvoy N, McElvaney OF, et al. Characterization of the Inflammatory Response to Severe COVID-19 Illness. American Journal of Respiratory and Critical Care Medicine;0(ja):null. doi: 10.1164/rccm.202005-1583OC

6. Knight SR, Ho A, Pius R, et al. Risk stratification of patients admitted to hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: development and validation of the 4C Mortality Score. BMJ 2020;370:m3339. doi: 10.1136/bmj.m3339

7. Marengoni A, Zucchelli A, Grande G, et al. The impact of delirium on outcomes for older adults hospitalised with COVID-19. Age and Ageing 2020 doi: 10.1093/ageing/afaa189

8. Zazzara 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 and Ageing 2020 doi: 10.1093/ageing/afaa223

9. Steinmeyer Z, Vienne-Noyes S, Bernard M, et al. Acute Care of Older Patients with COVID-19: Clinical Characteristics and Outcomes. Geriatrics (Basel, Switzerland) 2020;5(4) doi: 10.3390/geriatrics5040065 [published Online First: 2020/10/01]

10. Flaatten H, Beil M, Guidet B. Prognostication in older ICU patients: mission impossible? British Journal of Anaesthesia 2020;125(5):655-57. doi: 10.1016/j.bja.2020.08.005

11. Muscedere J, Waters B, Varambally A. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Med 2017;43(8):1105–22.

USING CFS IN PRACTICE

Rockwood Clinical Frailty Scale