The decision-making process of selection in the clinical pathway for COVID-19: The recommendations for older patients

Older people are at a higher risk of serious illness and death from the COVID-19 disease due to physiological changes of ageing and potential underlying health conditions. In the last years, there has been an increase in the elderly population admitted to the intensive care unit (ICU) and the proportion of the very old (85 years or over) critically ill patients is very high especially during the COVID-19 crisis. The care of older patients often determines ethical and practical challenges both before and during admission to intensive care. Therefore a decision-making process of selection in the clinical pathway is necessary. This decision-making process requires some skills like remarkable knowledge of ageing and its consequences on the normal function of organs, competence in comprehensive geriatric assessment and good communication ability with the family and other caregivers. For these reasons, an approach based on comprehensive geriatric assessment (CGA) and the identification of levels of "frailty" becomes essential in the decision-making process to guarantee the most appropriate levels of care both in a critical area and in the long-term or palliative care in accordance, when it is possible, with the wishes and individual needs of the older patient. The mission of Geriatrics is to identify and to treat older patients maximally benefiting of goal-oriented, tailored, multidisciplinary interventions and to identify patients at risk of poor outcomes such as the "very frail" elderly to guarantee the best possible quality of life and avoid unnecessary treatment. When no benefit of treatments can be obtained, palliative care should be considered. © Springer Nature Switzerland AG 2020.

Older People Hospitalized for COVID-19: Prognostic Role of Multidimensional Prognostic Index and Other Prognostic Scores.

During the SARS-CoV-2 pandemic, frailty and patients' poor outcomes seem to be closely related. However, there is no clear indication of the significance of this connection and the most adequate risk index in clinical practice. In this study, we compared a short version of MPI (multidimensional prognostic index) and other two prognostic scores for COVID-19 as potential predictors of poor patient outcomes. The patients were consecutively enrolled in the hospital of Palermo for COVID-19. The accuracy of Brief-MPI, 4C score and COVID-GRAM score in points was evaluated using the area under the curve (AUC) with 95% CI, taking mortality or sub-ICU admission as outcome. The study included 112 participants (mean age 77.6, 55.4% males). During a mean of 16 days of hospitalization, Brief-MPI significantly increased by 0.03 ± 0.14 (p = 0.04), whilst COVID-GRAM did not. Brief-MPI, 4C score and COVID-GRAM scores had good accuracy in predicting negative outcomes (AUC > 0.70 for all three scores). Brief-MPI was significantly associated with an increased mortality/ICU admission risk, indicating the importance of multidimensional impairment in clinical decision-making with an accuracy similar to other prognostic scores commonly used in COVID-19 study, providing information regarding domains for which interventions can be proposed.

GP-led adapted comprehensive geriatric assessment for frail older people: a multi-methods evaluation of the 'Living Well Assessment' quality improvement project in Scotland.

BACKGROUND: Evidence to support comprehensive geriatric assessment (CGA) in primary care for frail older people is limited. AIM: To evaluate a GP-led adapted CGA quality improvement project. DESIGN & SETTING: Multi-methods evaluation in a large practice in Midlothian in Scotland. METHOD: The intervention was conducted by 10 GPs in a practice of approximately 11 000 patients, initially in the patient's home, and then remotely (by telephone or video consultation) during the COVID-19 pandemic. Evaluation included a patient questionnaire, and qualitative interviews with GPs delivering the Living Well Assessment (LWA), analysed by thematic analysis. RESULTS: A total of 165/220 (75%) patients responded to the survey, of which 86% reported a 'very good experience' of the LWA. The method of delivery did not significantly influence this although most (58%) stated a preference for face-to-face consultation. For the 31% who preferred remote LWA, most (23%) preferred telephone to video consultation (8%). Problems in remote consultations related to technical issues (video), poor vision (video), or deafness (telephone or video). GPs felt that home-based LWAs had real benefits but switching to remote during the pandemic had proven feasible. Concerns included potential increase in GP workload owing to the LWA and whether it was an efficient use of GPs' time. CONCLUSION: GP-led adapted CGA was feasible in a large practice, even during the pandemic, and highly valued by frail patients. Questions regarding efficient use of GPs' time, effectiveness in terms of important patient outcomes and impact, and cost-effectiveness, requires further investigation in a larger study.

Comprehensive Geriatric Assessment in a Mexican Long-term Care Facility During a COVID-19 Outbreak

Objective: The Coronavirus disease-2019 (COVID-19) pandemic has greatly affected long-term care facilities worldwide. In Mexico, there are no studies that assess the impact between COVID-19 and the comprehensive geriatric assessment (CGA). This article aims to investigate the effect on the geriatric assessment before and after COVID-19 infection had in residents of a long-term care facility, as well as the factors that influenced the virus transmission and its associated mortality. Materials and Methods: This is a prospective observational study that included 90 older adults during an outbreak of COVID-19 in a long-term care facility in Monterrey, Nuevo León, Mexico. Participants' geriatric assessments were designed using their history records, comorbidities and Barthel index, Folstein's mini-mental state examination, geriatric depression scale, mini nutritional assessment, and polypharmacy. Results: When comparing the CGA before and after the COVID-19, Barthel index median was 90 vs 57.7 (p=0.001), the mini-mental state examination median was 23 vs 19 (p=0.001), the geriatric depression scale median was 4 vs 5 (p=0.007), the weight mean was 59.63 vs 56.95 (p=0.001), the body mass index mean was 23.9 vs 23.19 (p=0.009), and the mini nutritional assessment median was 23 vs 21.5 (p=0.001). Mortality in positive residents of COVID-19 was significantly higher in those with a polypharmacy >8 and mini-mental state examination <10 points. Conclusion: This study highlights the vulnerability of older adults to COVID-19 infection associated with high mortality and their global deterioration in the post-infection stage. Likewise, mortality in our population was higher in those with polypharmacy and cognitive impairment. These results guide us to create preventive measures that improve the quality and survival of geriatric COVID-19 patients. © Copyright 2022 by the Academic Geriatrics Society / European Journal of Geriatrics and Gerontology published by Galenos Publishing House.

A multidimensional approach to older patients during COVID-19 pandemic: a position paper of the Special Interest Group on Comprehensive Geriatric Assessment of the European Geriatric Medicine Society (EuGMS).

PURPOSE: The COVID-19 pandemic has been a dramatic trigger that has challenged the intrinsic capacity of older adults and of society. Due to the consequences for the older population worldwide, the Special Interest Group on Comprehensive Geriatric Assessment (CGA) of the European Geriatric Medicine Society (EuGMS) took the initiative of collecting evidence on the usefulness of the CGA-based multidimensional approach to older people during the COVID-19 pandemic. METHODS: A narrative review of the most relevant articles published between January 2020 and November 2022 that focused on the multidimensional assessment of older adults during the COVID-19 pandemic. RESULTS: Current evidence supports the critical role of the multidimensional approach to identify older adults hospitalized with COVID-19 at higher risk of longer hospitalization, functional decline, and short-term mortality. This approach appears to also be pivotal for the adequate stratification and management of the post-COVID condition as well as for the adoption of preventive measures (e.g., vaccinations, healthy lifestyle) among non-infected individuals. CONCLUSION: Collecting information on multiple health domains (e.g., functional, cognitive, nutritional, social status, mobility, comorbidities, and polypharmacy) provides a better understanding of the intrinsic capacities and resilience of older adults affected by SARS-CoV-2 infection. The EuGMS SIG on CGA endorses the adoption of the multidimensional approach to guide the clinical management of older adults during the COVID-19 pandemic.

Frailty trajectories in community-dwelling older adults during COVID-19 pandemic: The PRESTIGE study.

BACKGROUND: Frailty has been recognized as potential surrogate of biological age and relevant risk factor for COVID-19 severity. Thus, it is important to explore the frailty trajectories during COVID-19 pandemic and understand how COVID-19 directly and indirectly impacts on frailty condition. METHODS: We enrolled 217 community-dwelling older adults with available information on frailty condition as assessed by multidimensional frailty model both at baseline and at one-year follow-up using Multidimensional Prognostic Index (MPI) tools. Pre-frail/frail subjects were identified at baseline as those with MPI score >0.33 (MPI grades 2-3). Frailty worsening was defined by MPI difference between 12 months follow-up and baseline ≥0.1. Multivariable logistic regression was modelled to identify predictors of worsening of frailty condition. RESULTS: Frailer subjects at baseline (MPI grades 2-3 = 48.4%) were older, more frequently female and had higher rates of hospitalization and Sars-CoV-2 infection compared to robust ones (MPI grade 1). Having MPI grades 2-3 at baseline was associated with higher risk of further worsening of frailty condition (adjusted odd ratio (aOR): 13.60, 95% confidence interval (CI): 4.01-46.09), independently by age, gender and Sars-CoV-2 infection. Specifically, frail subjects without COVID-19 (aOR: 14.84, 95% CI: 4.26-51.74) as well as those with COVID-19 (aOR: 12.77, 95% CI: 2.66-61.40, p = 0.001) had significantly higher risk of worsening of frailty condition. CONCLUSIONS: Effects of COVID-19 pandemic among community-dwelling frailer individuals are far beyond the mere infection and disease, determining a significant deterioration of frailty status both in infected and non-infected subjects.

Can the Multidimensional Prognostic Index Improve the Identification of Older Hospitalized Patients with COVID-19 Likely to Benefit from Mechanical Ventilation? An Observational, Prospective, Multicenter Study.

OBJECTIVE: Data on prognostic tools for indicating mechanical ventilation in older people with COVID-19 are still limited. The aim of this research was to evaluate if the Multidimensional Prognostic Index (MPI), based on the Comprehensive Geriatric Assessment (CGA), may help physicians in identifying older hospitalized patients affected by COVID-19 who might benefit from mechanical ventilation. DESIGN: Longitudinal, multicenter study. SETTINGS AND PARTICIPANTS: 502 older people hospitalized for COVID-19 in 10 European hospitals. METHODS: MPI was calculated using 8 different domains typical of the CGA. A propensity score, Cox's regression analysis was used for assessing the impact of mechanical ventilation on rehospitalization/mortality for 90 days' follow-up, stratified by MPI = 0.50. The accuracy of MPI in predicting negative outcomes (ie, rehospitalization/mortality) was assessed using the area under the curve (AUC), and the discrimination with several indexes like the Net Reclassification Improvement (NRI) and the Integrated Discrimination Improvement (IDI). RESULTS: Among 502 older people hospitalized for COVID-19 (mean age: 80 years), 152 were treated with mechanical ventilation. In the propensity score analysis, during the 90-day follow-up period, there were 44 rehospitalizations and 95 deaths. Mechanical ventilation in patients with MPI values ≥ 0.50, indicating frailer participants, was associated with a higher risk of rehospitalization/mortality (hazard ratio 1.56, 95% CI 1.09-2.23), whereas in participants with MPI values < 0.50 this association was not significant. The accuracy of the model including age, sex, respiratory parameters, and MPI was good (AUC = 0.783) as confirmed by an NRI of 0.2756 (P < .001) and an IDI of 0.1858 (P < .001), suggesting a good discrimination of the model in predicting negative outcomes. CONCLUSIONS AND IMPLICATIONS: MPI could be useful for better individualizing older people hospitalized by COVID-19 who could benefit from mechanical ventilation.

Models of hospital care during COVID-19 pandemic in Italy: results from a survey of physicians

During COVID-19 pandemic, COVID Hospitals were created throughout Italy and several different models of care for COVID-19 patients were implemented. Methods. We conducted a survey on physicians dedicated to the care of COVID-19 patients with the aim of describing specific models of hospital care that were implemented during the first wave of the pandemic in Italy. The survey included seven questions with an estimated response time of approximately 5 minutes. The questionnaire went through a face validation process and pilot testing. The final version of the questionnaire was disseminated through a national limited social platform for physicians involved in the care of COVID-19 patients. Results. In the time period between May 1st, 2020 and July 1st, 2020, 350 physicians from all over the Country participated to the survey. In most cases, old departments were transformed to COVID units, and new units dedicated to COVID-19 patients were created. A multidisciplinary team of specialists was available in half of the models of care described. The geriatrician was always part of the mulridisciplinary team. Over one third of the multidisciplinary teams for the care of COVID-19 patients also included infectious diseases specialists and pulmonologists. Conclusions. According to findings from our survey, co-management of care and multidisciplinary models were available for half of COVID-19 patients during the first wave of pandemic. Such models may offer significant advantages in terms of favourable outcomes and mortality, especially in complex older adults. © by Società Italiana di Gerontologia e Geriatria (SIGG).

Promoting early management of frailty in the new normal: An updated software tool in addressing the need of virtual assessment of frailty at points of care.

Introduction: Frailty is a state of diminished physiological reserve and can be assessed using the frailty index. Early management of frailty is crucial for preventing adverse outcomes. Intended for assessing home-living older adults, the initial release of the eFI-CGA software was prior to the coronavirus disease 2019 (COVID-19) pandemic. Methods: In addressing the increased need of virtual assessment, the eFI-CGA was upgraded to version 3.0. In this paper, we introduce the updated electronic frailty assessment tool, reporting the newly developed features and validating its use. Results: End-user experiences with the previous versions are discussed. The updated features include a search function to resume disrupted assessments. The improved user interface enabled clinicians to record care management details. Conclusion: This study represents an example of software solutions in moving from disruption to transformation, benefiting healthcare for older adults during this challenging time.

Validation and implementation of telephone-administered version of the Multidimensional Prognostic Index (TELE-MPI) for remote monitoring of community-dwelling older adults.

BACKGROUND: During the recent lockdown measures adopted by national authorities to contain the COVID-19 pandemic, many vulnerable older patients with chronic conditions, normally followed in ambulatory setting, needed to be monitored and managed in alternative ways, including telemedicine. AIMS: In the framework of a telemedicine program, we aimed to validate and implement a telephone-administered version of the Multidimensional Prognostic Index (TELE-MPI) among community-dwelling older outpatients. METHOD: From March 9 to May 11, 2020, 131 older patients (82.1 years; 74% females) were interviewed using a telephone-based survey to calculate the TELE-MPI. The standard MPI was performed face-to-face three months apart. The Bland-Altman methodology measured the agreement between the two tools. Multivariate logistic regression models were built to ascertain the prognostic value of TELE-MPI and TELE-MPI classes (low, moderate, or severe risk) on negative outcomes occurring during the lockdown period. RESULTS: Mean MPI and TELE-MPI values were 0.523 and 0.522, respectively. Lower and upper 95% limits of agreement were - 0.122 and + 0.124, respectively, with only 4.6% of observations outside the limits. Each 0.1 increase of TELE-MPI score was significantly correlated with higher incidence of psychiatric disorders [odd ratio (OR): 1.57; 95% confidence interval (CI) 1.27, 1.95] and falls (OR: 1.41; 95% CI 1.08, 1.82) in community-dwelling-older adults. DISCUSSION: TELE-MPI showed a strong agreement with the standard MPI and was able to predict psychiatric disorders and falls during lockdown period. CONCLUSION: TELE-MPI may represent a useful way to follow by remote the health status of older adults.

Aging-Related Concerns of People Living with HIV Referred for Geriatric Consultation.

PURPOSE: People with HIV (PWH) are living longer lives and likely experiencing accentuated aging. Comprehensive geriatric assessment (CGA) has been proposed as a way to identify and help meet each individual patient's needs. PATIENTS AND METHODS: We performed a retrospective review of the results of CGA in an HIV clinic in New York City. CGA included assessment of basic and instrumental activities of daily living, screens for depression, anxiety, frailty, cognition, and quality of life, along with general discussion of concerns and goals. We compared the group of PWH referred for CGA to those of comparable age who were not referred to determine the factors that were associated with referral. We carried out a descriptive analysis of those undergoing CGA, along with regression to determine factors associated with poorer PHQ-2 depression scores and higher VACS score. RESULTS: A total of 105 patients underwent full CGA during the study period. Mean age of referred patients was 66.5 years, ranging from 50 to 84 years (SD 7.99). More than 92% were virally suppressed. Compared with their non-referred counterparts over 50, referred patients were older and had more functional comorbidities like cerebrovascular disease, neuropathy, and urinary incontinence. More than half complained of fatigue, and 2/3 noted poor memory. Almost 60% were frail or prefrail. Ninety patients were asked about their goals, and the most commonly cited were related to health or finances; fifteen patients were unable to articulate any goals. Having fewer goals and noting weight loss or fatigue were predictive of higher scores on the PHQ-2 depression screen. CONCLUSION: Although most older PWH undergoing CGA can manage their ADL, many have concerns and deficits beyond their comorbidities. CGA offers an important window into the psychosocial concerns and needs of older PWH.

Mortality attributable to COVID-19 in nursing home residents: a retrospective study.

AIM: Coronavirus-19 disease (COVID-19) is a widespread condition in nursing home (NH). It is not known whether COVID-19 is associated with a higher risk of death than residents without COVID-19. Therefore, the aim of this study was to assess whether COVID-19 is associated with a higher mortality rate in NH residents, considering frailty status assessed with the Multidimensional Prognostic Index (MPI). METHODS: In this retrospective study, made in 31 NHs in Venice, Italy, the presence of COVID-19 was ascertained with a nasopharyngeal swab. Frailty was evaluated using the MPI, modified according to the tools commonly used in our NHs. A Cox's regression analysis was used reporting the results as hazard ratios (HRs) with 95% confidence intervals (CIs), using COVID-19 as exposure and mortality as outcome and stratified by MPI tertiles. Similar analyses were run using MPI tertiles as exposure. RESULTS: Overall, 3946 NH residents (median age = 87 years, females: 73.9%) were eligible, with 1136 COVID-19 + . During a median follow-up of 275 days, higher values of MPI, indicating frailer people, were associated with an increased risk of mortality. The incidence of mortality in COVID-19 + was more than doubled than COVID-19- either in MPI-1, MPI-2 and MPI-3 groups. The presence of COVID-19 increased the risk of death (HR = 1.85; 95% CI 1.59-2.15), also in the propensity score model using MPI as confounder (HR = 2.48; 95% CI 2.10-2.93). CONCLUSION: In this retrospective study of NH residents, COVID-19 was associated with a higher risk of all-cause mortality than those not affected by COVID-19 also considering the different grades of frailty.

The multidimensional prognostic index (MPI) for the prognostic stratification of older inpatients with COVID-19: A multicenter prospective observational cohort study.

BACKGROUND: The topic of prognosis in COVID-19 research may be important in adopting appropriate clinical decisions. Multidimensional prognostic index (MPI) is a frailty assessment tool widely used for stratifying prognosis in older people, but data regarding inpatients, affected by COVID-19, are not available. OBJECTIVES: To evaluate whether MPI can predict in-hospital mortality and the admission to intensive care unit (ICU) in older inpatients hospitalized for COVID-19 infection. METHODS: In this longitudinal, Italian, multi-center study, older patients with COVID-19 were included. MPI was calculated using eight different domains typical of comprehensive geriatric assessment and categorized in three groups (MPI 1 ≤ 0.33, MPI 2 0.34-0.66, MPI 3 > 0.66). A multivariable Cox's regression analysis was used reporting the results as hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS: 227 older patients hospitalized for SARS-CoV-2 infection were enrolled (mean age: 80.5 years, 59% females). Inpatients in the MPI 3 were subjected less frequently than those in the MPI 1 to non-invasive ventilation (NIV). In the multivariable analysis, people in MPI 3 experienced a higher risk of in hospital mortality (HR = 6.30, 95%CI: 1.44-27.61), compared to MPI 1. The accuracy of MPI in predicting in hospital mortality was good (Area Under the Curve (AUC) = 0.76, 95%CI: 0.68-0.83). People in MPI 3 experienced a significant longer length of stay (LOS) in hospital compared to other participants. No association between MPI and ICU admission was found. CONCLUSIONS: Frailty- as assessed by high MPI score - was associated with a significant higher risk of in-hospital mortality, longer LOS, and lower use NIV, whilst the association with ICU admission was not significant. These findings suggest that prognostic stratification by using the MPI could be useful in clinical decision making in older inpatients affected by COVID-19.