COVID-19, frailty and long-term care: Implications for policy and practice

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.

Frailty and SARS-CoV-2 infection. A population-based study in a highly endemic village

“…Some reports argued that frail individuals may develop more severe COVID-19 disease [ 3 , 4 ]. However, data is inconsistent as it has also been suggested that there may be a sort of resilience by which certain frail subjects remain asymptomatic [ 5 ]. To our knowledge, there are no studies addressing if frail subjects are more prone to acquire SARS-CoV-2 infection in endemic communities, independently of risk factors inherent to aging or other comorbidities.…”

Susceptibility to Coronavirus (COVID-19) in Occupational Settings: The Complex Interplay between Individual and Workplace Factors

“…Additionally, worldwide reports have confirmed the high risk of severe illness from COVID-19, including the need for hospitalization, intensive care and death, in older adults, particularly in those with comorbidities (e.g., cardiovascular and respiratory diseases, morbid obesity, diabetes, chronic kidney disease, cancer, gastrointestinal, skin, muscleskeletal, and immune diseases) [8][9][10][11][12][13].…”

System models for resilience in gerontology: application to the COVID-19 pandemic

“…Disease spread increases when staff are required to re-use personal protective equipment because of shortages, when staff work at more than one facility; and when training level is low. Andrew et al, (2020) point to the socio-environmental policy level, in order to understand system-level problems. These include COVID-19 testing ability, availability of personal protective equipment, resident and congregate room size, staff training in infectious disease, and synchronized administrative organization for mitigation strategies, all of which can be highly variable across health care jurisdictions and facilities [147].…”

“…Andrew et al, (2020) point to the socio-environmental policy level, in order to understand system-level problems. These include COVID-19 testing ability, availability of personal protective equipment, resident and congregate room size, staff training in infectious disease, and synchronized administrative organization for mitigation strategies, all of which can be highly variable across health care jurisdictions and facilities [147]. There is also potential for applying or adapting communication technology that can be used by residents to stay connected with family and friends.…”