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.

Keywords: COVID-19; Long-Term Care; biomarker; frailty; older adult.

Conflict of interest statement

MKA and SAM report grant funding from the Public Health Agency of Canada through Service Canada, Canadian Institutes of Health Research, and Canadian Immunization Research Network in the conduct of the Serious Outcomes Surveillance Network. MKA reports funding and honoraria from the Canadian Frailty Network, Sanofi, GSK, and Pfizer outside the submitted work. JEM’s institution has received honoraria for consultancies with GSK, Sanofi, Merck, Pfizer, Medicago and RestorBio, outside of the submitted work. SAM reports funding and honoraria from GSK, Merck, Pfizer and Sanofi outside the submitted work. KR founded and is Chief Science Officer of DGI Clinical, which has several contracts with pharma and medical device manufacturers. He developed the CFS and has asserted copyright through Dalhousie University; it is made available for free clinical and academic use including through a downloadable App. SDS, BC and DJK report no conflict of interest

Copyright (c) 2020 Melissa Andrew, Samuel D Searle, Janet E McElhaney, Shelly A McNeil, Barry Clarke, Kenneth Rockwood, David J Kelvin.