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Background and Aim The aim of this systematic review was to quantify the association between frailty and COVID-19 in relation to mortality in hospitalised patients. Methods Medline, Embase, Web of Science and the grey literature were searched for papers from inception to 10 September 2020; the search was re-run in Medline up until the 9 December 2020. Screening, data extraction and quality grading were undertaken by two reviewers. Results were summarised using descriptive statistics, including a meta-analysis of overall mortality; the relationships between frailty and COVID-19 mortality were summarised narratively. Results A total of 2,286 papers were screened resulting in 26 being included in the review. Most studies were from Europe, half from the UK, and one from Brazil; the median sample size was 242.5, median age 73.1 and 43.5% were female. In total, 22/26 used the Clinical Frailty Scale; reported mortality ranged from 14 to 65%. Most, but not all studies showed an association between increasing frailty and a greater risk of dying. Two studies indicated a sub-additive relationship between frailty, COVID-19 and death, and two studies showed no association. Conclusions Whilst the majority of studies have shown a positive association between COVID-19-related death and increasing frailty, some studies suggested a more nuanced understanding of frailty and outcomes in COVID-19 is needed. Clinicians should exert caution in placing too much emphasis on the influence of frailty alone when discussing likely prognosis in older people with COVID-19 illness. [ABSTRACT FROM AUTHOR]

Background Early in the COVID-19 pandemic, many experts pointed to potential adverse mental health effects for older adults. By contrast, many studies in young to middle-aged adults found older age to be associated with reduced mental burden. However, a systematic review on older adults is missing. Objectives To comprehensively assess the pandemic's mental health impact on older adults. Data sources We searched nine databases from December 2019 to April 2022. Study selection We included longitudinal and repeated cross-sectional studies assessing pre- and/or peri-pandemic mental distress and/or positive mental health indicators (e.g. wellbeing) on at least two occasions. Data synthesis We identified 108 studies comprising 102,136 participants (≥60 years). After removal of outliers, there was a small increase in mental distress from pre-to-peri-pandemic assessments, standardised mean difference (SMD) = 0.10, 95% confidence interval (CI) [0.01, 0.18]. Furthermore, a small peri-pandemic decrease in anxiety symptoms was observed, whereas other symptoms remained unchanged. For positive mental health indicators, wellbeing and quality of life showed an initial decrease, whereas overall positive mental health increased during the pandemic, SMD = 0.08, 95% CI [0.01, 0.15]. Being female was related to larger peri-pandemic increases in mental distress. Conclusions Based on many studies, this review demonstrated small decreases in mental health during early stages of the pandemic in older adults, with evidence for later recovery. These findings are similar to those for younger adults and correct earlier claims that older adults are at particular risk for negative mental health consequences. The results ask for further research into resilience and adaptation processes in older adults. [ABSTRACT FROM AUTHOR]

Background Long-term care facilities (LTCFs) were high-risk settings for COVID-19 outbreaks. Objective To assess the impacts of the COVID-19 pandemic on LTCFs, including rates of infection, hospitalisation, case fatality, and mortality, and to determine the association between control measures and SARS-CoV-2 infection rates in residents and staff. Method We conducted a systematic search of six databases for articles published between December 2019 and 5 November 2021, and performed meta-analyses and subgroup analyses to identify the impact of COVID-19 on LTCFs and the association between control measures and infection rate. Results We included 108 studies from 19 countries. These studies included 1,902,044 residents and 255,498 staff from 81,572 LTCFs, among whom 296,024 residents and 36,807 staff were confirmed SARS-CoV-2 positive. The pooled infection rate was 32.63% (95%CI: 30.29 ~ 34.96%) for residents, whereas it was 10.33% (95%CI: 9.46 ~ 11.21%) for staff. In LTCFs that cancelled visits, new patient admissions, communal dining and group activities, and vaccinations, infection rates in residents and staff were lower than the global rate. We reported the residents' hospitalisation rate to be 29.09% (95%CI: 25.73 ~ 32.46%), with a case-fatality rate of 22.71% (95%CI: 21.31 ~ 24.11%) and mortality rate of 15.81% (95%CI: 14.32 ~ 17.30%). Significant publication biases were observed in the residents' case-fatality rate and the staff infection rate, but not in the infection, hospitalisation, or mortality rate of residents. Conclusion SARS-CoV-2 infection rates would be very high among LTCF residents and staff without appropriate control measures. Cancelling visits, communal dining and group activities, restricting new admissions, and increasing vaccination would significantly reduce the infection rates. [ABSTRACT FROM AUTHOR]

Background the negative consequences of COVID-19 distancing measures on older adults' mental health and ability to access services have been well documented. Online cognitive behavioural therapy and mindfulness interventions for older adults, carried out during the COVID-19 pandemic, have shown that these interventions are feasible and have potential mental health benefits. However, little research has been carried out on older adults' experiences of engaging with online psychological therapy, and specifically mindfulness therapy. Objectives to understand the experience of older adults engaging with online mindfulness therapy during the COVID-19 pandemic. Study design a qualitative analysis of four community-based focus groups. Participants thirty-six community dwelling older adults aged between 65 and 85 years were recruited via older adult organisations, charities and the local press. Nineteen percent had long-term physical health conditions, 25% had severe and enduring mental health difficulties and 19% had mild to moderate mental health difficulties. Results there was a strong sense of group cohesion and community from the participants. Three main themes were identified: reasons for applying, experience of the mindfulness therapy and connecting at home. Conclusions the majority of participants were positive about attending a mindfulness group online. This extended to the perceived psychological and social benefits as well as practical considerations. While some participants noted technological hurdles at the beginning of the course, the findings challenge previous studies that suggest older adults are reluctant to engage in online psychological therapies and has important implications for the future provision of psychological therapies to this population. [ABSTRACT FROM AUTHOR]

Background frailty imparts a higher risk for hospitalisation, mortality and morbidity due to COVID-19 infection, but the broader impacts of the pandemic and associated public health measures on community-living people with frailty are less known. Methods we used cross-sectional data from 23,974 Canadian Longitudinal Study on Aging participants who completed a COVID-19 interview (Sept–Dec 2020). Participants were included regardless of whether they had COVID-19 or not. They were asked about health, resource, relationship and health care access impacts experienced during the pandemic. Unadjusted and adjusted prevalence of impacts was estimated by frailty index quartile. We further examined if the relationship with frailty was modified by sex, age or household income. Results community-living adults (50–90 years) with greater pre-pandemic frailty reported more negative impacts during the first year of the pandemic. The frailty gradient was not explained by socio-demographic or health behaviour factors. The largest absolute difference in adjusted prevalence between the most and least frail quartiles was 15.1% (challenges accessing healthcare), 13.3% (being ill) and 7.4% (increased verbal/physical conflict). The association between frailty and healthcare access differed by age where the youngest age group tended to experience the most challenges, especially for those categorised as most frail. Conclusion although frailty has been endorsed as a tool to inform estimates of COVID-19 risk, our data suggest it may have a broader role in primary care and public health by identifying people who may benefit from interventions to reduce health and social impacts of COVID-19 and future pandemics. [ABSTRACT FROM AUTHOR]

Introduction residents of long-term care facilities (LTCFs) are at high risk of adverse outcomes from SARS-CoV-2. We aimed to estimate the vaccine effectiveness (VE) of one and two doses of BNT162b2 and ChAdOx-1 against SARS CoV-2 infection and COVID-19-related death in residents of LTCFs. Methods this observational study used testing, vaccination and mortality data for LTCF residents aged ≥ 65 years who were regularly tested regardless of symptoms from 8 December 2020 to 30 September 2021 in England. Adjusted VE, calculated as one minus adjusted hazard ratio, was estimated using time-varying Cox proportional hazards models for infection and death within 28 days of positive test result. Vaccine status was defined by receipt of one or two doses of vaccine and assessed over a range of intervals. Results of 197,885 LTCF residents, 47,087 (23.8%) had a positive test and 11,329 (5.8%) died within 28 days of a positive test during the study period. Relative to unvaccinated individuals, VE for infection was highest for ChAdOx-1 at 61% (40–74%) at 1–4 weeks and for BNT162b2 at 69% (52–80%) at 11–15 weeks following the second dose. Against death, VE was highest for ChAdOx-1 at 83% (58–94%) at 1–4 weeks and for BNT162b2 at 91% (75–97%) at 11–15 weeks following second dose. Conclusions compared with unvaccinated residents, vaccination with one dose of BNT162b2 or ChAdOx-1 provided moderate protection against infection and death in residents of LTCFs. Protection against death improved after two doses. However, some waning of protection over time was noted. [ABSTRACT FROM AUTHOR]

Background defining features of the COVID-19 pandemic in many countries were the tragic extent to which care home residents were affected and the difficulty in preventing the introduction and subsequent spread of infection. Management of risk in care homes requires good evidence on the most important transmission pathways. One hypothesised route at the start of the pandemic, prior to widespread testing, was the transfer of patients from hospitals that were experiencing high levels of nosocomial events. Methods we tested the hypothesis that hospital discharge events increased the intensity of care home cases using a national individually linked health record cohort in Wales, UK. We monitored 186,772 hospital discharge events over the period from March to July 2020, tracking individuals to 923 care homes and recording the daily case rate in the homes populated by 15,772 residents. We estimated the risk of an increase in case rates following exposure to a hospital discharge using multi-level hierarchical logistic regression and a novel stochastic Hawkes process outbreak model. Findings in regression analysis, after adjusting for care home size, we found no significant association between hospital discharge and subsequent increases in care home case numbers (odds ratio: 0.99, 95% CI: 0.82, 1.90). Risk factors for increased cases included care home size, care home resident density and provision of nursing care. Using our outbreak model, we found a significant effect of hospital discharge on the subsequent intensity of cases. However, the effect was small and considerably less than the effect of care home size, suggesting the highest risk of introduction came from interaction with the community. We estimated that approximately 1.8% of hospital discharged patients may have been infected. Interpretation there is growing evidence in the UK that the risk of transfer of COVID-19 from the high-risk hospital setting to the high-risk care home setting during the early stages of the pandemic was relatively small. Although access to testing was limited to initial symptomatic cases in each care home at this time, our results suggest that reduced numbers of discharges, selection of patients and action taken within care homes following transfer all may have contributed to the mitigation. The precise key transmission routes from the community remain to be quantified. [ABSTRACT FROM AUTHOR]

Background Sars-CoV-2 outbreaks resulted in a high case fatality rate in nursing homes (NH) worldwide. It is unknown to which extent presymptomatic residents and staff contribute to the spread of the virus. Aims To assess the contribution of asymptomatic and presymptomatic residents and staff in SARS-CoV-2 transmission during a large outbreak in a Dutch NH. Methods Observational study in a 185-bed NH with two consecutive testing strategies: testing of symptomatic cases only, followed by weekly facility-wide testing of staff and residents regardless of symptoms. Nasopharyngeal and oropharyngeal testing with RT-PCR for SARs-CoV-2, including sequencing of positive samples, was conducted with a standardised symptom assessment. Results 185 residents and 244 staff participated. Sequencing identified one cluster. In the symptom-based test strategy period, 3/39 residents were presymptomatic versus 38/74 residents in the period of weekly facility-wide testing (P -value < 0.001). In total, 51/59 (91.1%) of SARS-CoV-2 positive staff was symptomatic, with no difference between both testing strategies (P -value 0.763). Loss of smell and taste, sore throat, headache or myalga was hardly reported in residents compared to staff (P -value <0.001). Median Ct-value of presymptomatic residents was 21.3, which did not differ from symptomatic (20.8) or asymptomatic (20.5) residents (P -value 0.624). Conclusions Symptoms in residents and staff are insufficiently recognised, reported or attributed to a possible SARS-CoV-2 infection. However, residents without (recognised) symptoms showed the same potential for viral shedding as residents with symptoms. Weekly testing was an effective strategy for early identification of SARS-Cov-2 cases, resulting in fast mitigation of the outbreak. [ABSTRACT FROM AUTHOR]

Background epidemiological data on COVID-19 infection in care homes are scarce. We analysed data from a large provider of long-term care for older people to investigate infection and mortality during the first wave of the pandemic. Methods cohort study of 179 UK care homes with 9,339 residents and 11,604 staff. We used manager-reported daily tallies to estimate the incidence of suspected and confirmed infection and mortality in staff and residents. Individual-level electronic health records from 8,713 residents were used to model risk factors for confirmed infection, mortality and estimate attributable mortality. Results 2,075/9,339 residents developed COVID-19 symptoms (22.2% [95% confidence interval: 21.4%; 23.1%]), while 951 residents (10.2% [9.6%; 10.8%]) and 585 staff (5.0% [4.7%; 5.5%]) had laboratory-confirmed infections. The incidence of confirmed infection was 152.6 [143.1; 162.6] and 62.3 [57.3; 67.5] per 100,000 person-days in residents and staff, respectively. Sixty-eight percent (121/179) of care homes had at least one COVID-19 infection or COVID-19-related death. Lower staffing ratios and higher occupancy rates were independent risk factors for infection. Out of 607 residents with confirmed infection, 217 died (case fatality rate: 35.7% [31.9%; 39.7%]). Mortality in residents with no direct evidence of infection was twofold higher in care homes with outbreaks versus those without (adjusted hazard ratio: 2.2 [1.8; 2.6]). Conclusions findings suggest many deaths occurred in people who were infected with COVID-19, but not tested. Higher occupancy and lower staffing levels were independently associated with risks of infection. Protecting staff and residents from infection requires regular testing for COVID-19 and fundamental changes to staffing and care home occupancy. [ABSTRACT FROM AUTHOR]

Introduction Previous investigations have identified high rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among residents and staff in care homes reporting an outbreak of coronavirus disease 2019 (COVID-19). We investigated care homes reporting a single suspected or confirmed case to assess whether early mass testing might reduce risk of transmission during the peak of the pandemic in London. Methods Between 18 and 27 April 2020, residents and staff in care homes reporting a single case of COVID-19 to Public Health England had a nasal swab to test for SARS-CoV-2 infection by reverse transcription polymerase chain reaction and subsequent whole-genome sequencing. Residents and staff in two care homes were re-tested 8 days later. Results Four care homes were investigated. SARS-CoV-2 positivity was 20% (65/333) overall, ranging between 3 and 59%. Among residents, positivity ranged between 3 and 76% compared with 3 and 40% in staff. Half of the SARS-CoV-2-positive residents (23/46, 50%) and 63% of staff (12/19) reported symptoms within 14 days before or after testing. Repeat testing 8 days later in two care homes with the highest infection rates identified only two new cases. Genomic analysis demonstrated a small number of introduction of the virus into care homes, and distinct clusters within three of the care homes. Conclusions We found extensive but variable rates of SARS-CoV-2 infection among residents and staff in care homes reporting a single case of COVID-19. Although routine whole-home testing has now been adopted into practice, care homes must remain vigilant and should be encouraged to report a single suspected case, which should trigger appropriate outbreak control measures. [ABSTRACT FROM AUTHOR]

Background Frail older persons may have an atypical presentation of coronavirus disease 2019 (COVID-19). The value of real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) testing for identifying severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nursing homes (NHs) residents is not known. Objective To determine whether (i) atypical symptoms may predict rRT-PCR results and (ii) rRT-PCR results may predict immunisation against SARS-CoV-2 in NH residents. Design A retrospective longitudinal study. Setting Eight NHs with at least 10 rRT-PCR-positive residents. Subjects A total of 456 residents. Methods Typical and atypical symptoms recorded in residents' files during the 14 days before and after rRT-PCR testing were analysed. Residents underwent blood testing for IgG-SARS-CoV-2 nucleocapsid protein 6 to 8 weeks after testing. Univariate and multivariate analyses compared symptoms and immunisation rates in rRT-PCR-positive and negative residents. Results A total of 161 residents had a positive rRT-PCR (35.3%), 17.4% of whom were asymptomatic before testing. Temperature >37.8°C, oxygen saturation <90%, unexplained anorexia, behavioural change, exhaustion, malaise and falls before testing were independent predictors of a further positive rRT-PCR. Among the rRT-PCR-positive residents, 95.2% developed SARS-CoV-2 antibodies vs 7.6% in the rRT-PCR-negative residents. Among the residents with a negative rRT-PCR, those who developed SARS-CoV-2 antibodies more often had typical or atypical symptoms (P  = 0.02 and <0.01, respectively). Conclusion This study supports a strategy based on (i) testing residents with typical or unexplained atypical symptoms for an early identification of the first SARS-CoV-2 cases, (ii) rT-PCR testing for identifying COVID-19 residents, (iii) repeated wide-facility testing (including asymptomatic cases) as soon as a resident is tested positive for SARS-CoV-2 and (iv) implementing SARS-CoV-2 infection control measures in rRT-PCR-negative residents when they have unexplained typical or atypical symptoms. [ABSTRACT FROM AUTHOR]

Background There is little evidence about the utilisation of healthcare services and disease recognition in the older population, which was urged to self-isolate during the COVID-19 lockdown. Objectives We aimed to describe the utilisation of physician consultations, specialist referrals, hospital admissions and the recognition of incident diseases in Germany for this age group during the COVID-19 lockdown. Design Cross-sectional observational study. Setting 1,095 general practitioners (GPs) and 960 specialist practices in Germany. Subjects 2.45 million older patients aged 65 or older. Methods The number of documented physician consultations, specialist referrals, hospital admissions and incident diagnoses during the imposed lockdown in 2020 was descriptively analysed and compared to 2019. Results Physician consultations decrease slightly in February (−2%), increase before the imposed lockdown in March (+9%) and decline in April (−18%) and May (−14%) 2020 compared to the same periods in 2019. Volumes of hospital admissions decrease earlier and more intensely than physician consultations (−39 versus −6%, respectively). Overall, 15, 16 and 18% fewer incident diagnoses were documented by GPs, neurologists and diabetologists, respectively, in 2020. Diabetes, dementia, depression, cancer and stroke were diagnosed less frequently during the lockdown (−17 to −26%), meaning that the decrease in the recognition of diseases was greater than the decrease in physician consultations. Conclusion The data suggest that organisational changes were adopted quickly by practice management but also raise concerns about the maintenance of routine care. Prospective studies should evaluate the long-term effects of lockdowns on patient-related outcomes. [ABSTRACT FROM AUTHOR]

Background Frailty, increased vulnerability to physiological stressors, is associated with adverse outcomes. COVID-19 exhibits a more severe disease course in older, comorbid adults. Awareness of atypical presentations is critical to facilitate early identification. Objective To assess how frailty affects presenting COVID-19 symptoms in older adults. Design Observational cohort study of hospitalised older patients and self-report data for community-based older adults. Setting Admissions to St Thomas' Hospital, London with laboratory-confirmed COVID-19. Community-based data for older adults using the COVID Symptom Study mobile application. Subjects Hospital cohort: patients aged 65 and over (n  = 322); unscheduled hospital admission between 1 March 2020 and 5 May 2020; COVID-19 confirmed by RT-PCR of nasopharyngeal swab. Community-based cohort: participants aged 65 and over enrolled in the COVID Symptom Study (n  = 535); reported test-positive for COVID-19 from 24 March (application launch) to 8 May 2020. Methods Multivariable logistic regression analysis performed on age-matched samples from hospital and community-based cohorts to ascertain association of frailty with symptoms of confirmed COVID-19. Results Hospital cohort: significantly higher prevalence of probable delirium in the frail sample, with no difference in fever or cough. Community-based cohort: significantly higher prevalence of possible delirium in frailer, older adults and fatigue and shortness of breath. Conclusions This is the first study demonstrating higher prevalence of probable delirium as a COVID-19 symptom in older adults with frailty compared to other older adults. This emphasises need for systematic frailty assessment and screening for delirium in acutely ill older patients in hospital and community settings. Clinicians should suspect COVID-19 in frail adults with delirium. [ABSTRACT FROM AUTHOR]

Background SARS-CoV-2 has disproportionately affected nursing homes (NH). In Ireland, the first NH case COVID-19 occurred on 16 March 2020. A national point-prevalence testing programme of all NH residents and staff took place (18 April 2020 to 5 May 2020). Aims to examine characteristics of NHs across three Irish Community Health Organisations, proportions with COVID-19 outbreaks, staff and resident infection rates symptom profile and resident case fatality. Methods in total, 45 NHs surveyed, requesting details on occupancy, size, COVID-19 outbreak, outbreak timing, total symptomatic/asymptomatic cases and outcomes for residents from 29 February 2020 to 22 May 2020. Results surveys were returned from 62.2% (28/45) of NHs (2,043 residents, 2,303 beds). Three-quarters (21/28) had COVID-19 outbreaks (1,741 residents, 1,972 beds). Median time from first COVID-19 case in Ireland to first case in these NHs was 27.0 days. Resident incidence was 43.9% (764/1,741)—40.8% (710/1,741) laboratory confirmed, with 27.2% (193/710) asymptomatic and 3.1% (54/1,741) clinically suspected. Resident case fatality was 27.6% (211/764) for combined laboratory-confirmed/clinically suspected COVID-19. Similar proportions of residents in NHs with 'early-stage' (<28 days) versus 'later-stage' outbreaks developed COVID-19. Lower proportions of residents in 'early' outbreak NHs had recovered compared with those with 'late' outbreaks (37.4 versus 61.7%; χ2 = 56.9, P  < 0.001). Of 395 NH staff across 12 sites with confirmed COVID-19, 24.7% (99/398) were asymptomatic. There was a significant correlation between the proportion of staff with symptomatic COVID-19 and resident numbers with confirmed/suspected COVID-19 (Spearman's rho = 0.81, P  < 0.001). Conclusion this study demonstrates the significant impact of COVID-19 on the NH sector. Systematic point-prevalence testing is necessary to reduce risk of transmission from asymptomatic carriers and manage outbreaks in this setting. [ABSTRACT FROM AUTHOR]