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1.
Heart ; 2022.
Article in English | ProQuest Central | ID: covidwho-2020138

ABSTRACT

Introduction The marked heterogeneity in how ageing is experienced between individuals means that chronological age alone is insufficient for clinicians to identify patients who are at risk of a poor clinical outcome when they become unwell.1 Frailty describes vulnerability to poor resolution of homeostasis after a stressor event.1 It results from cumulative decline in multiple physiological systems, and is observed in 12%–24% of older adults.1 2 Frailty is particularly common in those with cardiovascular disease, and a combination of population ageing and increased survivorship of cardiovascular disease means that cardiologists will be caring for increasingly complex patients, who are living with varying degrees of frailty.3–5 Recognising that frailty is not a dichotomous variable is crucial;without that, frailty can become the polite face of ageism. In the UK, 1-year mortality for people aged 65 or older is 1.7% in those without frailty, 4.7% in those living with mild frailty, 10.6% in moderate frailty and 19.1% in severe frailty.6 Even after accounting for differences in age and sex, those living with mild frailty are almost twice as likely to die in the next year as their ‘fit’ counterparts—with a stepwise increase in mortality with increasing frailty: adjusted hazard ratio 1.92 (95% confidence interval (CI) 1.81 to 2.04) for mild frailty, 3.10 (95% CI 2.91 to 3.31) for moderate frailty and 4.52 (95% CI 4.16 to 4.91) for severe frailty.6 A similar pattern has been shown for the outcomes of hospitalisation and nursing home admission.6 Understanding the impact of frailty on our patients’ likely disease course and sharing this with them and their families is empowering, assists with expectation-management and makes a holistic management strategy more straightforward. How do we measure frailty? A systematic review identified that there are 67 instruments in use for identifying frailty,9 many of which have been used in studies of patients with cardiovascular disease.10 There is no consensus on which tool is recommended, but one of the easiest to use, either in screening or to summarise an assessment, is the Clinical Frailty Scale (CFS) (figure 2).11 Hospital clinicians in the UK have become familiar with the CFS during the COVID-19 pandemic, as it was recommended by the National Institute for Health and Care Excellence to assess baseline health and to inform discussions on treatment expectations within an individualised assessment. In a primary care cohort, prescription rates of oral anticoagulation are actually higher in people with frailty,20 and there is now evidence of similar efficacy of direct oral anticoagulants (DOACs) compared with warfarin in people with frailty, although we lack precise estimates of the bleeding risk associated with DOAC for patients with severe frailty.21 The population incidence of AF is increasing, in part, due to an increasing burden of cardiovascular risk factors and population ageing.22 Heart failure Frailty is common in people with heart failure and is associated with a poor prognosis.

2.
Lancet Healthy Longev ; 2(3): e119-e120, 2021 Mar.
Article in English | MEDLINE | ID: covidwho-2016336
3.
Trials ; 22(1): 865, 2021 Dec 02.
Article in English | MEDLINE | ID: covidwho-1551222

ABSTRACT

BACKGROUND: Most people living with dementia want to remain living in their own homes and are supported to do so by family carers. No interventions have consistently demonstrated improvements to people with dementia's life quality, functioning, or other indices of living as well as possible with dementia. We have co-produced, with health and social care professionals and family carers of people with dementia, a new intervention (NIDUS-family). To our knowledge, NIDUS-family is the first manualised intervention that can be tailored to personal goals of people living with dementia and their families and is delivered by facilitators without clinical training. The intervention utilizes components of behavioural management, carer support, psychoeducation, communication and coping skills training, enablement, and environmental adaptations, with modules selected to address dyads' selected goals. We will evaluate the effect of NIDUS-family and usual care on goal attainment, as measured by Goal Attainment Scaling (GAS) rated by family carers, compared to usual care alone at 12-month follow-up. We will also determine whether NIDUS-family and usual care is more cost-effective than usual care alone over 12 months. METHODS: A randomised, two-arm, single-masked, multi-site clinical trial involving 297 people living with dementia-family carer dyads. Dyads will be randomised 2:1 to receive the NIDUS-family intervention with usual care (n = 199) or usual care alone (n = 98). The intervention group will be offered, over 1 year, via 6-8 video call or telephone sessions (or face to face if COVID-19 restrictions allow in the recruitment period) in the initial 6 months, followed by telephone follow-ups every 1-2 months to support implementation, with a trained facilitator. DISCUSSION: Increasing the time lived at home by people living with dementia is likely to benefit lives now and in the future. Our intervention, which we adapted to include remote delivery prior to trial commencement due to the COVID-19 pandemic, aims to address barriers to living as well and as independently as possible that distress people living with dementia, exacerbate family carer(s) stress, negatively affect relationships, lead to safety risks, and frequently precipitate avoidable moves to a care home. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number ISRCTN11425138 . Registered on 7 October 2019.


Subject(s)
COVID-19 , Dementia , Caregivers , Cost-Benefit Analysis , Dementia/diagnosis , Dementia/therapy , Humans , Pandemics , Psychosocial Intervention , Quality of Life , SARS-CoV-2
4.
Chest ; 160(6): 2101-2111, 2021 12.
Article in English | MEDLINE | ID: covidwho-1271599

ABSTRACT

BACKGROUND: The extent to which the degree of baseline frailty, as measured using standardized multidimensional health assessments before hospital admission, predicts survival among older adults after admission to an ICU remains unclear. RESEARCH QUESTION: Is baseline frailty an independent predictor of survival among older adults receiving care in an ICU? STUDY DESIGN AND METHODS: Retrospective cohort study of community-dwelling older adults (age, ≥ 65 years) receiving public home services who were admitted to any ICU in Ontario, Canada, between April 1, 2009, and March 31, 2015. All individuals underwent an interRAI Resident Assessment Instrument-Home Care (RAI-HC) assessment completed within 180 days of ICU admission. These assessments were linked to hospital discharge abstract records. Patients were categorized using frailty measures each calculated from the RAI-HC: a classification tree version of the Clinical Frailty Scale; the Frailty Index-Acute Care; and the Changes in Health, End-Stage Disease, Signs, and Symptoms Scale. One-year survival models were used to compare their performance. Patients were stratified based on the receipt of mechanical ventilation in the ICU. RESULTS: Of 24,499 individuals admitted to an ICU within 180 days of a RAI-HC assessment, 26.4% (n = 6,467) received mechanical ventilation. Overall, 43.0% (95% CI, 42.4%-43.6%) survived 365 days after ICU admission. In general, among the overall cohort and both mechanical ventilation subgroups, mortality hazards increased with the severity of baseline frailty. Models predicting survival 30, 90, and 365 days after admission to an ICU that adjusted for one of the frailty measures were more discriminant than reference models that adjusted only for age, sex, major clinical category, and area income quintile. INTERPRETATION: Severity of baseline frailty is independently associated with survival after ICU admission and should be considered when determining goals of care and treatment plans for people with critical illness.


Subject(s)
Critical Illness/mortality , Critical Illness/nursing , Frail Elderly , Geriatric Assessment , Home Care Services , Aged , Female , Humans , Male , Ontario , Predictive Value of Tests , Reproducibility of Results , Retrospective Studies , Survival Analysis
5.
EClinicalMedicine ; 37: 100975, 2021 Jul.
Article in English | MEDLINE | ID: covidwho-1284051

ABSTRACT

BACKGROUND: The SARS-CoV-2 (Severe Acute Respiratory Syndrome coronavirus 2) has led to more than 165 million COVID-19 cases and >3.4 million deaths worldwide. Epidemiological analysis has revealed that the risk of developing severe COVID-19 increases with age. Despite a disproportionate number of older individuals and long-term care facilities being affected by SARS-CoV-2 and COVID-19, very little is understood about the immune responses and development of humoral immunity in the extremely old person after SARS-CoV-2 infection. Here we conducted a serological study to investigate the development of humoral immunity in centenarians following a SARS-CoV-2 outbreak in a long-term care facility. METHODS: Extreme aged individuals and centenarians who were residents in a long-term care facility and infected with or exposed to SARS-CoV-2 were investigated between April and June 2020 for the development of antibodies to SARS-CoV-2. Blood samples were collected from positive and bystander individuals 30 and 60 days after original diagnosis of SARS-CoV-2 infection. Plasma was used to quantify IgG, IgA, and IgM isotypes and subsequent subclasses of antibodies specific for SARS-CoV-2 spike protein. The function of anti-spike was then assessed by virus neutralization assays against the native SARS-CoV-2 virus. FINDINGS: Fifteen long-term care residents were investigated for SARS-CoV-2 infection. All individuals had a Clinical Frailty scale score ≥5 and were of extreme older age or were centenarians. Six women with a median age of 98.8 years tested positive for SARS-CoV-2. Anti-spike IgG antibody titers were the highest titers observed in our cohort with all IgG positive individuals having virus neutralization ability. Additionally, 5 out of the 6 positive participants had a robust IgA anti-SARS-CoV-2 response. In all 5, antibodies were detected after 60 days from initial diagnosis.

6.
Clin Interv Aging ; 16: 731-738, 2021.
Article in English | MEDLINE | ID: covidwho-1218451

ABSTRACT

The COVID-19 pandemic has disproportionately impacted frail older adults, especially residents of long-term care (LTC) facilities. This has appropriately led to prioritization of frail older adults and LTC residents, and those who care for them, in the vaccination effort against COVID-19. Older adults have distinct immunological, clinical, and practical complexity, which can be understood through a lens of frailty. Even so, frailty has not been considered in studies of COVID-19 vaccines to date, leading to concerns that the vaccines have not been optimally tailored for and evaluated in this population even as vaccination programs are being implemented. This is an example of how vaccines are often not tested in Phase 1/2/3 clinical trials in the people most in need of protection. We argue that geriatricians, as frailty specialists, have much to contribute to the development, testing and implementation of COVID-19 vaccines in older adults. We discuss roles for geriatricians in ten stages of the vaccine development process, covering vaccine design, trial design, trial recruitment, establishment and interpretation of illness definitions, safety monitoring, consideration of relevant health measures such as frailty and function, analysis methods to account for frailty and differential vulnerability, contributions in regulatory and advisory roles, post-marketing surveillance, and program implementation and public health messaging. In presenting key recommendations pertinent to each stage, we hope to contribute to a dialogue on how to push the field of vaccinology to embrace the complexity of frailty. Making vaccines that can benefit frail older adults will benefit everyone in the fight against COVID-19.


Subject(s)
Biomedical Research/organization & administration , COVID-19/epidemiology , Frailty/epidemiology , Geriatricians/organization & administration , Physician's Role , Aged , COVID-19/prevention & control , COVID-19 Vaccines , Frail Elderly/statistics & numerical data , Humans , Male , Pandemics , Public Health , SARS-CoV-2
7.
Age Ageing ; 50(4): 1406-1411, 2021 06 28.
Article in English | MEDLINE | ID: covidwho-1091263

ABSTRACT

BACKGROUND: the Clinical Frailty Scale (CFS) was originally developed to summarise a Comprehensive Geriatric Assessment and yield a care plan. Especially since COVID-19, the CFS is being used widely by health care professionals without training in frailty care as a resource allocation tool and for care rationing. CFS scoring by inexperienced raters might not always reflect expert judgement. For these raters, we developed a new classification tree to assist with routine CFS scoring. Here, we test that tree against clinical scoring. OBJECTIVE/METHODS: we examined agreement between the CFS classification tree and CFS scoring by novice raters (clerks/residents), and the CFS classification tree and CFS scoring by experienced raters (geriatricians) in 115 older adults (mean age 78.0 ± 7.3; 47% females) from a single centre. RESULTS: the intraclass correlation coefficient (ICC) for the CFS classification tree was 0.833 (95% CI: 0.768-0.882) when compared with the geriatricians' CFS scoring. In 93%, the classification tree rating was the same or differed by at most one level with the expert geriatrician ratings. The ICC was 0.805 (0.685-0.883) when CFS scores from the classification tree were compared with the clerk/resident scores; 88.5% of the ratings were the same or ±1 level. CONCLUSIONS: a classification tree for scoring the CFS can help with reliable scoring by relatively inexperienced raters. Though an incomplete remedy, a classification tree is a useful support to decision-making and could be used to aid routine scoring of the CFS.


Subject(s)
COVID-19 , Frailty , Aged , Female , Frail Elderly , Frailty/diagnosis , Geriatric Assessment , Humans , Male , SARS-CoV-2
9.
Age Ageing ; 50(1): 3-6, 2021 01 08.
Article in English | MEDLINE | ID: covidwho-772726

ABSTRACT

The COVID-19 pandemic has seen a proposal for frailty to be used as a rationing criterion. This commentary suggests circumstances under which that is defensible: in the face of lack of capacity to treat everyone, and as an alternative to age in stratifying risk. How best to stratify risk is likely to evolve and may include information about illness severity and dynamic measures. Current research must focus on mobilizing better, COVID-19-specific prognostic information, with a goal of best discriminating which lives are most and least likely to be saved should scarcity of resources dictate that not everyone can receive critical care.


Subject(s)
COVID-19 , Clinical Decision-Making , Frailty/diagnosis , Health Care Rationing , Health Resources , Patient Selection/ethics , Aged , COVID-19/epidemiology , COVID-19/therapy , Clinical Decision-Making/ethics , Clinical Decision-Making/methods , Critical Care/methods , Critical Care/organization & administration , Humans , Risk Assessment/methods , Risk Assessment/standards , SARS-CoV-2
10.
Can Geriatr J ; 23(3): 210-215, 2020 Sep.
Article in English | MEDLINE | ID: covidwho-750456

ABSTRACT

The key idea behind the Clinical Frailty Scale (CFS) is that, as people age, they are more likely to have things wrong with them. Those things they have wrong (health deficits) can, as they accumulate, erode their ability to do the high order functions which define their overall health. These high order functions include being able to: think and do as they please; look after themselves; interact with other people; and move about without falling. The Clinical Frailty Scale brings that information together in one place. This paper is a guide for people new to the Clinical Frailty Scale. It also introduces an updated version (CFS version 2.0), with revised level names (e.g., "vulnerable" becomes "living with very mild frailty") and minor edits to level descriptions. The key points discussed are that the Clinical Frailty Scale assays the baseline state, it is not widely validated in younger people or those with stable single-system disabilities, and it requires clinical judgement. The Clinical Frailty Scale is now commonly used as a triage tool to make important clinical decisions such as allocating scarce health care resources for COVID-19 management; therefore, it is important that the scale is used appropriately.

11.
Br J Anaesth ; 125(5): 730-738, 2020 11.
Article in English | MEDLINE | ID: covidwho-739780

ABSTRACT

BACKGROUND: A threshold Clinical Frailty Scale (CFS) of 5 (indicating mild frailty) has been proposed to guide ICU admission for UK patients with coronavirus disease 2019 (COVID-19) pneumonia. However, the impact of frailty on mortality with (non-COVID-19) pneumonia in critical illness is unknown. We examined the triage utility of the CFS in patients with pneumonia requiring ICU. METHODS: We conducted a retrospective cohort study of adult patients admitted with pneumonia to 170 ICUs in Australia and New Zealand from January 1, 2018 to September 31, 2019. We classified patients as: non-frail (CFS 1-4) frail (CFS 5-8), mild/moderately frail (CFS 5-6),and severe/very severely frail (CFS 7-8). We evaluated mortality (primary outcome) adjusting for site, age, sex, mechanical ventilation, pneumonia type and illness severity. We also compared the proportion of ICU bed-days occupied between frailty categories. RESULTS: 1852/5607 (33%) patients were classified as frail, including1291/3056 (42%) of patients aged >65 yr, who would potentially be excluded from ICU admission under UK-based COVID-19 triage guidelines. Only severe/very severe frailty scores were associated with mortality (adjusted odds ratio [aOR] for CFS=7: 3.2; 95% confidence interval [CI]: 1.3-7.8; CFS=8 [aOR: 7.2; 95% CI: 2.6-20.0]). These patients accounted for 7% of ICU bed days. Vulnerability (CFS=4) and mild frailty (CFS=5) were associated with a similar mortality risk (CFS=4 [OR: 1.6; 95% CI: 0.7-3.8]; CFS=5 [OR: 1.6; 95% CI: 0.7-3.9]). CONCLUSIONS: Patients with severe and very severe frailty account for relatively few ICU bed days as a result of pneumonia, whilst adjusted mortality analysis indicated little difference in risk between patients in vulnerable, mild, and moderate frailty categories. These data do not support CFS ≥5 to guide ICU admission for pneumonia.


Subject(s)
Betacoronavirus , Coronavirus Infections/epidemiology , Frail Elderly/statistics & numerical data , Geriatric Assessment/statistics & numerical data , Patient Outcome Assessment , Pneumonia, Viral/epidemiology , Aged , Australia/epidemiology , COVID-19 , Cohort Studies , Critical Illness , Female , Geriatric Assessment/methods , Humans , Length of Stay , Male , Middle Aged , New Zealand/epidemiology , Pandemics , Retrospective Studies , SARS-CoV-2
12.
Can Geriatr J ; 23(1): 152-154, 2020 Mar.
Article in English | MEDLINE | ID: covidwho-608092

ABSTRACT

BACKGROUND: The Canadian Geriatrics Society (CGS) fosters the health and well-being of older Canadians and older adults worldwide. Although severe COVID-19 illness and significant mortality occur across the lifespan, the fatality rate increases with age, especially for people over 65 years of age. The dichotomization of COVID-19 patients by age has been proposed as a way to decide who will receive intensive care admission when critical care unit beds or ventilators are limited. We provide perspectives and evidence why alternative approaches should be used. METHODS: Practitioners and researchers in geriatric medicine and gerontology have led in the development of alternative approaches to using chronological age as the sole criterion for allocating medical resources. Evidence and ethical based recommendations are provided. RESULTS: Age alone should not drive decisions for health-care resource allocation during the COVID-19 pandemic. Decisions on health-care resource allocation should take into consideration the preferences of the patient and their goals of care, as well as patient factors like the Clinical Frailty Scale score based on their status two weeks before the onset of symptoms. CONCLUSIONS: Age alone does not accurately capture the variability of functional capacities and physiological reserve seen in older adults. A threshold of 5 or greater on the Clinical Frailty Scale is recommended if this scale is utilized in helping to decide on access to limited health-care resources such as admission to a critical care unit and/or intubation during the COVID-19 pandemic.

14.
J Infect Dev Ctries ; 14(5): 428-432, 2020 05 31.
Article in English | MEDLINE | ID: covidwho-596261

ABSTRACT

Older adults have been disproportionately affected by the COVID-19 pandemic, with many outbreaks occurring in Long Term Care Facilities (LTCFs). We discuss this vulnerability among LTCF residents using an ecological framework, on levels spanning from the individual to families and caregivers, institutions, health services and systems, communities, and contextual government policies. Challenges abound for fully understanding the burden of COVID-19 in LTCF, including differences in nomenclature, data collection systems, cultural differences, varied social welfare models, and (often) under-resourcing of the LTC sector. Registration of cases and deaths may be limited by testing capacity and policy, record-keeping and reporting procedures. Hospitalization and death rates may be inaccurate depending on atypical presentations and whether or not residents' goals of care include escalation of care and transfer to hospital. Given the important contribution of frailty, use of the Clinical Frailty Scale (CFS) is discussed as a readily implementable measure, as are lessons learned from the study of frailty in relation to influenza. Biomarkers hold emerging promise in helping to predict disease severity and address the puzzle of why some frail LTCF residents are resilient to COVID-19, either remaining test-negative despite exposure or having asymptomatic infection, while others experience the full range of illness severity including critical illness and death. Strong and coordinated surveillance and research focused on LTCFs and their frail residents is required. These efforts should include widespread assessment of frailty using feasible and readily implementable tools such as the CFS, and rigorous reporting of morbidity and mortality in LTCFs.


Subject(s)
Betacoronavirus , Coronavirus Infections/epidemiology , Frailty , Long-Term Care , Pneumonia, Viral/epidemiology , COVID-19 , Health Policy , Humans , Pandemics , Resilience, Psychological , SARS-CoV-2 , Severity of Illness Index
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