Study Finds Higher In-Hospital Mortality Risk for Older Patients With Frailty, COVID-19

Among patients admitted to the intensive care unit (ICU) for COVID-19, patients with frailty had higher risk of in-hospital and in-ICU mortality despite spending fewer days in the ICU vs patients without frailty, according to a study published in Critical Care Explorations.

“Patients with frailty were more likely to die in the ICU (unadjusted mortality, 26.8% vs 17.9%; P = .044) and in hospital (unadjusted mortality, 65.2% vs 41.8%; P < 0.001),” the authors said.

They collected individual patient data from 2001 patients across 7 studies published between December 1, 2019, and February 28, 2021. Of this group, 19.4% were considered frail. All studies focused on patients admitted to the ICU for COVID-19 infection with a documented Clinical Frailty Scale (CFS). For this study, patients ere considered nonfrail if they had a CFS score of 1 to 4 and frail if they had a CFS score of 5 to 8.

The primary outcome was hospital mortality, and secondary outcomes were organ support within the ICU (mechanical ventilation [MV], noninvasive ventilation, renal replacement therapy, vasoactive infusion, extracorporteal membrane oxygenation), length of ICU and hospital stay, ICU bed days, and discharge destination.

After adjusting for age and sex, frailty status was shown to have an independent association with just in-hospital mortality, and younger patients and patients without frailty were more likely to be put on MV. Overall, among patients put on MV, both frail and nonfrail, frailty status had a higher risk of in-hospital mortality, at 65.2% vs 41.8%

Additionally, patients with frailty status also spent less time on MV, with a median (interquartile range) of 9 days (5-16) compared with 11 (6-18) days for patients without frailty, and they accounted for only 12.3% of total ICU bed days

“Even before the COVID-19 pandemic began, frailty was recognized as a predictive factor for adverse outcomes, such as mortality, hospitalizations, and readmission,” they explained. “Consequently, frailty was proposed as an important aspect of patient assessment early in the pandemic.”

Independent predictors of death in patients were increasing age and Sequential Organ Failure Assessment score, CFS of at least 4, invasive MV use, dialysis and vasopressors, and high or rising lactate. History of hypertension was associated with a lower likelihood of mortality.

The authors also noted that patients with frailty were more likely to present with delirium; to have accompanying acute kidney injury; to have higher rates of lymphopenia, a marker for poor COVID-19 prognosis, especially in younger patients; and to have a higher neutrophil-to-lymphocyte ratio compared with nonfrail patients. However, nonfrail patients were more likely to present with fever and myalgia or lethargy.

Secondary analyses showed a significant association between frailty and hospital mortality, independent of age, body mass index, and neutrophil-to-lymphocyte ratio.

Consistent with past research, this study showed that MV was used more often among younger and nonfrail patients with COVID-19.

“Frailty captures risks beyond other known risk factors in those with COVID-19 admitted to the ICU,” the authors concluded. “Future studies should consider incorporating frailty into the patient assessment process alongside other commonly used measures (age, sex, comorbidities, illness acuity) to support clinicians in making better decisions for severe forms of COVID-19.”

Reference

Subramaniam A, Anstey C, Curtis JR, et al. Characteristics and outcomes of patients with frailty admitted to ICU with coronavirus disease 2019: an individual patient data meta-analysis. Crit Care Explor. Published online January 18, 2022. doi:10.1097/CCE.0000000000000616