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Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1091 (Published 26 March 2020) Cite this as: BMJ 2020;368:m1091

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Added vulnerability of frail older Population to COVID-19

Dear Editor,

The world is facing an immense threat from novel coronavirus disease 2019 commonly known as COVID-19. The study published by Chen and colleagues has highlighted that older persons infected with COVID-19 were the group with highest mortality rate[1]. In fact, another report from the Chinese Center for Disease Control and Prevention described the characteristics of the disease based on 72 314 cases, updated through February 11, 2020. We as geriatricians find the results alarming - as the older population was among the most affected by the virus. The study has reported that of the total cases, 3% (1408 cases) were older adults ≥80 years and the case-fatality rate (CFR) was 14.8% (208 of 1408) for this population. Older population aged 70-79 years had a CFR of 8.0% (312 of 3918). Subjects with pre-existing comorbid conditions such as cardiovascular disease, diabetes, chronic respiratory disease, hypertension, and cancer had the highest CFR, of which most of them are most likely to be older individuals. Similar findings have been reported even in the Italian population[3].

These findings are of immense concern to us, particularly because the number of older adults in China and other parts of the world has increased considerably in the last decade. Older people who are also widely known to be frail (i.e., a geriatric syndrome with increased vulnerability to stressors) or with multimorbidity (i.e., with multiple chronic conditions) are the most vulnerable population even in the absence of an epidemic disease. In fact, we could only speculate the psychological effect of the current situation relating them as the highest fatality rate group and reports of biased allocation of medical services for older patients[4]. For instance, evidence from the post-Severe Acute Respiratory Syndrome (SARS) study has shown older people to have a very high prevalence of psychological conditions such as post-traumatic stress disorder (PTSD)[5]. Furthermore, it is undeniable that during the current state of the COVID-19 epidemic, the majority of the older adults are locked indoors for the fear of becoming infected. Lack of proper physical exercise or social interaction (leading to loneliness) could have a huge negative impact on their health such as added vulnerability to conditions such as depression and frailty.

Lessons could be learned from the Chinese government initiatives such as online mental services to support older people [6], which is laudable. A similar approach to address physical inactivity such as online physical exercise training programs where applicable may be beneficial, particularly to boost their immunity. Older adults are known to have a weak immune system, hence, other strategies to maintain their immunity in older age such as advice on proper diet and healthy lifestyle may be disseminated through media (including in a non-epidemic scenario). Indeed, all older populations may not have access to online resources or may not have enough knowledge to use internet tools. Governments of the infected regions should mobilize resources to help these vulnerable populations, including in getting the correct information, assistance in meeting their other daily needs, and the most important is facilitate them in testing for the virus. Undeniably, such services will be difficult to be dispersed in many low and middle income countries[7].

There have been several reports of ongoing research to develop vaccines or therapeutics against COVID-19. Here we would like to bring the attention of the concerned agencies to prioritize the inclusion of older persons in clinical trials of such potential treatments. As clinical trials are largely known to be biased, recruiting mostly younger populations leaving the neediest still at risk[8]. Besides, suitable planning should be done to protect older people in long-term care facilities, which is a major concern for the geriatric community[9]. We welcome the recent NICE guideline of frailty assessment of older adults upon admission to hospital irrespective of age and COVID-19 status, to make proper use of available resources based on medical benefit[10].

Older populations represent the most vulnerable group for COVID-19 infection. Public health strategies in favor of the most disadvantaged and exposed older individuals should be a present global priority.

Conflict of interest: None

Role of funding source: None

References:
1 Chen T, Wu D, Chen H, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ 2020;368. doi:10.1136/bmj.m1091
2 Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA Published Online First: 24 February 2020. doi:10.1001/jama.2020.2648
3 Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? The Lancet 2020;0. doi:10.1016/S0140-6736(20)30627-9
4 Orecchio-Egresitz H. Faced with tough choices, Italy is prioritizing young COVID-19 patients over the elderly. That likely ‘would not fly’ in the US. Business Insider. https://www.businessinsider.com/prioritizing-covid-19-patients-based-age... (accessed 25 Mar 2020).
5 Lee TMC, Chi I, Chung LWM, et al. Ageing and psychological response during the post-SARS period. Aging Ment Health 2006;10:303–11. doi:10.1080/13607860600638545
6 Liu S, Yang L, Zhang C, et al. Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry Published Online First: 18 February 2020. doi:10.1016/S2215-0366(20)30077-8
7 Lloyd-Sherlock P, Ebrahim S, Geffen L, et al. Bearing the brunt of covid-19: older people in low and middle income countries. BMJ 2020;368. doi:10.1136/bmj.m1052
8 Chhetri JK. Immunisation of older adults: where are the frail? Lancet Public Health 2017;2:e449. doi:10.1016/S2468-2667(17)30155-X
9 Dosa D, Jump RLP, LaPlante K, et al. Long-Term Care Facilities and the Coronavirus Epidemic: Practical Guidelines for a Population at Highest Risk. Journal of the American Medical Directors Association 2020;0. doi:10.1016/j.jamda.2020.03.004
10 NICE publishes first rapid COVID-19 guidelines | News and features | News. NICE. https://www.nice.org.uk/news/article/nice-publishes-first-rapid-covid-19... (accessed 23 Mar 2020).

Competing interests: No competing interests

27 March 2020
Jagadish K Chhetri
Geriatrician
Prof. Piu Chan
National Clinical Research Center for Geriatric Disorders, Beijing, China
Xuanwu Hospital of Capital Medical University, Beijing Institute of Geriatrics, Beijing, China