Patient-Centered Outcomes Following COVID-19: Frailty and Disability Transitions in Critical Care Survivors*

Abstract

OBJECTIVES: As the pandemic advances, the interest in the long-lasting consequences of COVID-19 increases. However, a few studies have explored patient-centered outcomes in critical care survivors. We aimed to investigate frailty and disability transitions in COVID-19 patients admitted to ICUs. DESIGN: Prospective cohort study. SETTING: University hospital in Sao Paulo. PATIENTS: Survivors of COVID-19 ICU admissions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We assessed frailty using the Clinical Frailty Scale (CFS). We also evaluated 15 basic, instrumental, and mobility activities. Baseline frailty and disability were defined by clinical conditions 2–4 weeks before COVID-19, and post-COVID-19 was characterized 90 days (day 90) after hospital discharge. We used alluvial flow diagrams to visualize transitions in frailty status, Venn diagrams to describe the overlap between frailty and disabilities in activities of daily living, and linear mixed models to explore the occurrence of new disabilities following critical care in COVID-19. We included 428 participants with a mean age of 64 years, 57% males, and a median Simplified Acute Physiology Score-3 score of 59. Overall, 14% were frail at baseline. We found that 124/394 participants (31%) were frail at day 90, 70% of whom were previously non-frail. The number of disabilities also increased (mean difference, 2.46; 95% CI, 2.06–2.86), mainly in participants who were non-frail before COVID-19. Higher pre-COVID-19 CFS scores were independently associated with new-onset disabilities. At day 90, 135 patients (34%) were either frail or disabled. CONCLUSIONS: Frailty and disability were more frequent 90 days after hospital discharge compared with baseline in COVID-19 patients admitted to the ICU. Our results show that most COVID-19 critical care survivors transition to poorer health status, highlighting the importance of long-term medical follow-up for this population.

Association of Frailty, Organ Support, and Long-Term Survival in Critically Ill Patients With COVID-19

“…It is also worth mentioning that differently from previous studies ( 3 , 23 ), we determined the prognostic effect of frailty on 6-month mortality, incorporating aspects related to long-COVID complications. Exploring long-term survival is relevant as recent work has indicated that frailty increases the risk of patient-centered adverse outcomes (e.g., functional disability) in COVID-19 ICU survivors after hospital discharge ( 11 ).…”

“…Both CO-FRAIL and EPPICoV studies were reviewed and approved by HCFMUSP’s Research Ethics Committee (approval number 32037120.6.0000.0068 and 31382620.0.0000.0068) and registered in public databases (CO-FRAIL Study [Brazilian Clinical Trials Registry = RBR-7w5zhr] and EPICCoV Study [ClinicalTrials.gov = NCT04378582]). Recent analyses combining these two datasets have demonstrated the impact of COVID-19 on short-term patient-centered outcomes (e.g., frailty, functional disability) ( 11 ).…”

Frailty and risk of hospitalization from COVID-19 infection among older adults: evidence from the Dutch Lifelines COVID-19 Cohort study

“…More specifically, frailty could be a risk factor for the progress of COVID-19 infection because of the presence of excess weight, chronic diseases, and impaired respiratory function [ 27 ]. While the inflammatory reaction caused by COVID-19 infection may also exacerbate metabolic stress and muscle catabolism, resulting in malnutrition and physical inactivity, which could also cause frailty [ 28 , 29 ].…”

Tailoring treatments to older people in intensive care. A way forward

“…Mousai and colleagues innovated by presenting this whole picture as distinct phenotypes (Fig. 1), which could aid clinicians in conversations at the bedside on goals of care with patients and families (i.e., advanced care planning or decisions on withdrawing or withholding ICU treatments) [11][12][13].…”

“…Furthermore, their findings were based on ICU and 30-day mortality, arguably very short-term outcomes for this cohort of patients. Future research should focus on patient-centred outcomes, as quality of life and functional measures are the most relevant health aspects for older ICU patients [12].…”