by Heather Sanders
The COVID-19 pandemic has had a disproportionate impact on older people, in terms of the number of lives lost as well as the effects of social isolation. SFU professor of mental health and aging Theodore D. Cosco is working to understand and learn from these impacts. Since the age of 12 when he began volunteering at a long-term care facility, he has had a life-long passion for gerontology and the aging process.
Cosco is a Chartered Psychologist and epidemiologist, and a Research Fellow at the Oxford Institute of Population Ageing at the University of Oxford. He studies a range of factors that promote healthy aging and resilience in older people – from digital interventions to physical activity. He also leads Precision Mental Health, a community-engaged research project based at the SFU Gerontology Research Centre that leverages technology and big data to support the mental wellbeing of older adults.
“I’ve long been advocating for the use of technology to help isolated seniors foster social connections,” says Cosco. “When the pandemic started, I had a bit of an ‘I told you so’ moment, as we all pushed to connect with our parents, grandparents, aunts and uncles online. One of the rare silver linings of the pandemic was the push for greater technology adoption for socially isolated older adults, as well as seeing more funding driven to this area.”
For his recent study, Cosco collaborated with researchers from SFU, University College London, the University of Leicester, and Sheffield Teaching Hospital, including Simon Conroy and Daniel Davies who are both geriatricians. They examined studies related to frailty and mortality in older, hospitalized COVID patients. Their paper, What is the relationship between validated frailty scores and mortality for adults with COVID-19 in acute hospital care? A systematic review, provides insights into how frailty may or may not influence health outcomes specific to COVID-19.
The term frailty is used in clinical settings to describe a state of decreased reserve and diminished resistance to stressors. Age-related frailty increases the risk of adverse health outcomes, including cognitive impairment, disability and death. Physicians use a number of accepted ranking systems to determine frailty, such as the Clinical Frailty Scale.
The researchers screened thousands of papers published in Medline, Embase and Web of Science databases from the onset of the pandemic to September 2020, and selected 26 original peer-reviewed articles to study. The patients were all diagnosed with COVID, their median age was 73.1 years and 43.5 percent were female. Mortality varied widely across the studies, ranging from 14 to 65 percent and the studies reported mortality at different times, between five and 60 days.
The majority of studies showed that in older people hospitalized with COVID-19, frailty was associated with COVID-19-related mortality in most patients, but not all. Some studies presented a more complex interaction between frailty and COVID-19 status. For example, two studies found that mortality in severely frail people was not as high as expected, while observing higher mortality among those deemed to be relatively healthier.
Taken altogether, the findings suggest a more nuanced understanding of frailty and COVID-19 outcomes is needed. The researchers recommend that physicians use caution when considering frailty in their prognosis, take into account all factors, and consider many factors in determining the appropriate approaches to treatment. “We encourage health practitioners to use frailty as one of the tools to determine treatment escalation – not the only tool,” says Cosco.
He adds that the transmissibility of COVID made it unique to other viruses. “Care homes were hit especially hard because they are community settings,” Cosco confirms, “and then you bring in visitors, staff, and caregivers. Older adults are both more vulnerable because of transmissibility in community settings as well as via increased frailty which may lead to decreased capacity to fend off disease.”
Cosco et al. also suggest that the transmissibility of COVID may have altered people’s behavior. Many may have chosen to avoid hospitals or delay moving aging relatives into care facilities, and to manage at home. This may have resulted in only the very ill arriving at hospitals.
The study noted that paradoxically, in persons over 60, a one percent decrease in mortality from all causes is associated with a four percent increase in the COVID death rate. This is thought to be related to the unhealthy survivor effect – individuals experiencing longevity at the price of dependency and susceptibility – such as seen in care home settings.
Since completing the paper, Cosco and colleagues, along with the British Geriatrics Society have continued to maintain a live web-repository of COVID and frailty studies at: www.bgs.org.uk/covidfrailty. They encourage people to contribute their work, as it’s the most comprehensive source of this research. They have also compiled updated clinical guidance on frailty and COVID, as well as other resources at: www.criticalcarenice.org.uk.
Cosco continues his research and advocacy regarding the mental and physical well-being of the older population. He is a Co-Investigator on the Canadian Longitudinal Study on Aging, and is identifying strategies and resources that older adults can use to foster greater resilience. He’s currently finalizing a sub-study of 30,000 participants on the effects that decreased social and physical activity during the pandemic lockdown had on the mental well-being of older adults.
“As we continue to add years to life, my research focuses on adding life to those years,” says Cosco. “The pandemic has been an especially challenging time for older adults and I hope that the lessons learned from it can help us identify new ways to promote wellbeing at the individual, societal and policy levels. Understanding the challenges that older people face can help improve their quality of life and their health outcomes, and will ultimately benefit all of us.”