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Covid-19 HSE Clinical Guidance and Evidence

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Informing Use of Frailty criteria as prognostic indicators for older people during COVID-19 pandemic

Informing use of frailty criteria as prognostic indicators for older people during COVID-19 pandemic (CD19-067 / 08.04.20)


Recent international guidance on prognostic indicators to inform decision making on critical care escalation in older people during the COVID-19 pandemic have identified frailty and its measurement based on specific instruments such as the Clinical Frailty Scale (CFS) [Rockwood et al., 2005] as having potential utility (NICE, 2020; BESEDIM, 2020). In order to inform national guidance in the Irish context, an expert group was formed to advise relevant professional bodies and policy.

Frailty is a multi-dimensional, age-related condition characterised by decreased resilience to stressors predisposing individuals to higher risk of adverse outcomes including death [Clegg et al., 2013]. The COVID-19 pandemic has disproportionately affected older adults with high mortality rates reported in Wuhan, China [Chen et al., 2020; Wu et al., 2020] and Italy [Lazzerini and Putoto, 2020]. Frail older adults appear most susceptible, possibly secondary to impaired immune responses [Wu et al., 2020]. The roles of other possible risk factors remain unclear at present, pending urgent research. Preliminary data from Italy suggests that higher mortality rates relate to infections among older and predominantly male patients with co-morbidities [Onder, Rezza & Brusaferro, 2020]. Data are, however, preliminary and pathophysiological mechanisms and the impact of differential management strategies on the course of the disease among older adults remain uncertain [Wu et al., 2020]. Further, the prevalence of frailty among those diagnosed, admitted or dying is not reported at present

Frailty as a prognostic tool in emergency and critical care

Outside the current COVID-19 pandemic, the measurement of frailty in older adults has been shown to potentially inform prognostic outcomes in critical care including mortality and institutionalisation [Muscedere et al., 2017]. Frailty is also a predictor of adverse outcomes from in-hospital cardiopulmonary resuscitation (CPR) (Wharton, 2019).

The CFS [Rockwood et al., 2005] measures frailty on a scale from 1 (very fit) to 9 (terminally ill). Service evaluations and research studies (outside the COVID-19 context) have shown that the CFS is a significant independent predictor of adverse outcomes in older people in emergency and critical care settings, suggesting that this tool may be able to aid decision making by clinicians. However, it is not perfect - acute illness, for example, can lead to overestimates of frailty severity [Flaatten and Clegg, 2018] - and should not be used in isolation to direct clinical decision making (NHS, 2020).  

Up to now, the CFS has largely been deployed by those with training in care of older people where the mix of functional decline, comorbidity and / or cognitive change in later life are identified within a multidimensional assessment. However, in an impending COVID-19 scenario with multiple critically ill older patients presenting simultaneously, the availability and access to geriatric-trained staff will be very limited.

The CFS can be undertaken by any healthcare professional (doctor, nurse, healthcare assistant, therapist etc.) with training and support. There are concerns about the potential for over-estimation of frailty when the CFS is applied by inexperienced raters.  In particular, it is essential that all using this scale have an understanding of the nuances required in its use and interpretation.

General recommendations regarding care escalation decisions

A range of possible care escalation decisions (from hospital admission to and including intubation / ventilation) may need to be made during the current pandemic. In emergency care settings in particular, assessments may need to be made and decisions taken very quickly. Nevertheless, a number of general principles remain important:

Clinical decision making with individual patients should involve consideration of several factors including:

  • Acute illness severity – based upon objective markers of disease severity (e.g. SOFA score).

  • The potential for recovery as suggested by the presence of active co-morbidities and disabilities in progressive decline - including how well they are managed and their severity – this can be assessed by existing risk-prediction tools such as the CFS.

  • The person’s current, or if not available previous, preferences and values.

An amalgam or composite picture of these dimensions as they relate to the individual will be more informative and aid discussion more than any single scoring system.

Advanced care planning, based on the principles of shared decision making and requiring proactive, transparent communication with patients, is essential to avoiding unnecessary admissions and cardiac arrest calls (the latter posing potentially the highest risk to healthcare workers during the COVID-19 pandemic).

It is becoming clear that, in those receiving intensive care as a result of COVID-19, prolonged ventilation often in the prone position, is usually required.   This needs to be considered in discussions and decision making, especially in frailer cohorts, as there may be significant potential for additional functional decline and worse outcomes in such patients as a result. 

Sensitive communication is also key if it is necessary to explain to a patient, or to those close to the patient, that escalation to critical care will not be effective or suitable. 

If limitations in the resources available, rather than purely clinical factors, are an important factor in decision making regarding critical care escalation, this should be documented and acknowledged openly. 

Decisions regarding escalation of care are sometimes difficult, and it is important that mechanisms are in place to support resolution of differences of opinion where they occur. The importance of contemporaneous documentation remains very important in this regard.

Specific recommendations regarding use of Clinical Frailty Scale
  • Who and when to assess with the Clinical Frailty Scale  (CFS)?

On admission to hospital, clinicians caring for older adults (typically aged 65 and older), irrespective of COVID‑19 status, should naturally continue to obtain the clinical history, collateral history when appropriate, and perform the clinical examination and the relevant functional assessments. This forms the basis of the geriatric assessment required to use frailty tools such as the Clinical Frailty Scale (CFS). If frailty tools are used, the scoring rationale and result should be recorded in the patient’s chart, alongside all the other information gathered (e.g. acuity of illness, patient preferences).

Assessing patients using the CFS always requires knowledge of their baseline status (usually about 2 weeks) prior to their acute illness.  If this information is not immediately available from the patient, an informant who knows the patient well or from the medical records, assessment with the CFS should be deferred.

  • Uses and limitations of the CFS

The CFS is a helpful predictor of outcomes for older people but it should not be used in isolation to direct clinical decision making.

Staff using the CFS should have an adequate understanding of the uses and limitations of this tool, and it should not be used be used in isolation to determine care.  

This online course provides guidance to learners about frailty and how to accurately determine a person's Clinical Frailty Scale score based on their specific circumstances: There is also an open access CME article on frailty scoring on 

  • It is important that staff using the CFS are aware of the following points:

  • It should only be used in older adults (typically 65 and older) and has only been adequately assessed in this population.

  • In particular, the CFS should not be used in younger people, people with stable long-term disabilities, intellectual disabilities, autism or cerebral palsy. An individualised assessment is recommended in all cases where the CFS is not appropriate.

  • CFS judgements should be guided by the text descriptors of each frailty grade rather than relying on the pictorial representations included with the scale or making snap judgements based on ‘eyeballing’ the person.  

  • The baseline status of the individual, prior to onset of acute illness, must form the basis of the score rather than the current, immediate status. 

  • This baseline status situation should be considered as being gradually progressive, not obviously remediable, and not expected to improve. It is not appropriate, for example, to identify someone as frail while they are recovering from surgery or from an injury.

  • Interpreting the CFS​

The CFS must always be interpreted in the context of underlying pathologies, comorbidities, severity of acute illness and patient preferences and in awareness of the limitations of this tool.  Decision makers using the CFS to inform clinical management MUST check the score to ensure that it is accurate.  The following rough guidance may be helpful:  

  • Older people with a CFS of 4 or less are non-frail.  If they agree and require it, referral to critical care teams to discuss possible admission to critical care is usually appropriate. 

  • Older people with a CFS of 5 or 6 have mild and moderate frailty respectively.  Uncertainty regarding the potential benefit of critical care escalation is most common in such patients, and further assessment by senior clinical decision makers and advice from critical care teams may be needed to help the decision about treatment.

  • Older people with a CFS of 7 to 9 have severe levels of frailty. Outcomes are often poor in such patients, and critical care escalation is often more harmful than beneficial. This may be particularly true in the context of a COVID-19 illness requiring prolonged ventilation, but there is currently no data to support this. These issues should be explained to and discussed with patients and those close to them by a senior decision maker.  If there is uncertainty about the best option for an individual patient, or disagreement about the goals of care, a second opinion or discussion with the critical care team may be helpful.

  • BESEDIM. Ethical principles and guidance with regard to ethical decisions in pre-hospital and emergency medicine in Belgium during the COVID-19 pandemic. A joint statement of the Belgian Society of Emergency and Disaster Medicine and the Belgian Resuscitation Council. Published date: 22 March 2020.

  • Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507-513.

  • Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752-762.

  • Flaatten H, Clegg A. Frailty: we need valid and reliable tools in critical care. Intensive Care Med. 2018;44(11):1973-1975.

  • Lazzerini M, Putoto G. COVID-19 in Italy: momentous decisions and many uncertainties. Lancet Glob Health. 2020.

  • Muscedere J, Waters B, Varambally A, et al. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Med. 2017;43(8):1105-1122.

  • NICE. COVID 19: Rapid Guideline: Critical Care; NICE guideline [NG159]; Published date: March 2020.

  • NHS. Identification of Frailty in Over 65 Year Olds in an Urgent Care Setting. March 2020.

  • Onder G, Rezza G, Brusaferro S. Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. JAMA. 2020.

  • Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489-495.

  • Wallis et al, QJM, 2015, 943–949.  

  • Wharton C, King E, MacDuff A. Frailty is associated with adverse outcome from in-hospital cardiopulmonary resuscitation. Resuscitation. 2019;143:208-211.

  • Wu C, Chen X, Cai Y, et al. Risk Factors Associated with Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med. 2020.

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