Long Covid: An Age-old concept?

Dr Krishanthi Sathanandan is a newly appointed Consultant Geriatrician at Whipps Cross Hospital, Barts Health NHS Trust and a member of the BGS Clinical Quality Group.

With over 69 million reported cases of COVID-19 worldwide¹, we have all experienced rapid and dramatic changes to our healthcare services over the last 12 months. Older people have been disproportionately affected by a greater severity of disease and mortality, detrimental psychological, cognitive and physical outcomes from necessary social distancing, as well as age discrimination. 

Public and professional bodies are now concerned about the impact of “long COVID”.  A recent review² defined symptoms lasting beyond 12 weeks as “chronic COVID”. In addition to breathlessness and cough, commonly reported symptoms from surveys like the UK COVID symptom study³ include fatigue, muscle weakness and neurocognitive difficulties (such as “brain fog, poor attention, depression and insomnia).^3-5 This particular study reports that around 10% of people have continued to report ongoing symptoms three weeks after a presumed COVID infection, with a smaller proportion reporting symptoms for several months.³ Other studies^5-6 have reported higher rates, especially post-hospitalisation. Increasing age and co-morbidity in particular are associated with higher rates of “long COVID”.^5-6

Protracted recovery of patients is familiar territory for any geriatrician, and the functional impact of illness and hospitalisation on older adults is well documented. People who have hip fractures represent some of our frailest patients.  Even with robust orthogeriatric services, maximal cognitive and physical recovery can take up to 6 months, and although a small proportion of patients continue to report gains thereafter, less than half reach their pre-fracture functioning.⁷

Similarly, after admission for acute medical illness, around a third of older patients are discharged at lower functional levels. Post-discharge mortality is high, with only 30% of survivors achieving full functional recovery after a year. Some experience ongoing decline despite being discharged at their functional baseline.⁸ Even before the advent of COVID-19, acute respiratory illnesses in older patients placed a major burden on acute healthcare services. Almost a fifth of hospitalised patients with influenza, pneumonia or other acute respiratory illness experience functional loss, and frailty plays a major role in this continued decline.⁹

During the pandemic, frailty and co-morbidity became established risk factors for developing more severe disease with significantly higher mortality.  Frailty has long been reported to be associated with delayed recovery after illness. So is it really surprising that we are seeing “long COVID” in the older population? This brings forth the question of whether this really is a distinct clinical entity, or rather has the already recognised recovery trajectory of our patients been brought into the spotlight due to the sheer volume of infection cases.

The UK guideline on the management of long term effects of COVID-19, a collaborative effort from NICE, SIGN and the RCGP, has now been published. Given that older people are more likely to have delayed recovery after COVID, involvement of geriatricians to influence the structure of these rehabilitation programmes is vital.

During this pandemic, geriatricians have found themselves repeatedly compelled to step forward to advocate for fair access to care and resources for their vulnerable patient groups. The pan-European EU-COGER study is underway to identify the optimal strategies for recovery in older patients specifically. Whilst COVID-19 continues to remain the priority for most clinicians at this time, it is important in the coming years to sustain this drive for research and fair access to acute and rehabilitation resources for our patient group, regardless of the nature of their illness.

References:

1. WHO Coronavirus Disease (COVID-19) Dashboard. World Health Organisation. https://covid19.who.int/. Accessed 12.12.20

2. Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026. doi: 10.1136/bmj.m3026.

3. Sudre C, Murray B, Varsavsky T et al. Attributes and predictors of long-COVID: analysis of COVID cases and their symptoms collected by the Covid Symptoms Study app. medRxiv. 2020; published online Oct 21.) (preprint). https://doi.org/10.1101/2020.10.19.20214494

4. Assaf G, Davis H, McCorkell L, et al. An analysis of the prolonged COVID-19 symptoms survey by Patient-Led Research Team. Patient Led Research, 2020. https://patientresearchcovid19.com/. Accessed 12.12.20

5. Tenforde MW, Kim SS, Lindsell CJ, Rose EB, Shapiro NI, Clark Files D et al. Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network - United States, March-June 2020. Morbidity and Mortality Weekly Report. 2020 Jul;69(30):993-998. https://doi.org/10.15585/MMWR.MM6930E1

6. Arnold DT, Hamilton FW, Milne A, Morley AJ, Viner J, Attwood M, Noel A, Gunning S, Hatrick J, Hamilton S, Elvers KT, Hyams C, Bibby A, Moran E, Adamali HI, Dodd JW, Maskell NA, Barratt SL. Patient outcomes after hospitalisation with COVID-19 and implications for follow-up: results from a prospective UK cohort. Thorax. 2020 Dec 3:thoraxjnl-2020-21608 doi: 10.1136/thoraxjnl-2020-216086.

7. Magaziner J, Hawkes W, Hebel JR, Zimmerman SI, Fox KM, Dolan M, Felsenthal G, Kenzora J. Recovery from hip fracture in eight areas of function. J Gerontol A Biol Sci Med Sci. 2000 Sep;55(9):M498-50 doi: 10.1093/gerona/55.9.m498. PMID: 10995047.

8. Boyd CM, Landefeld CS, Counsell SR, Palmer RM, Fortinsky RH, Kresevic D, Burant C, Covinsky KE. Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc. 2008 Dec;56(12):2171-9. doi: 10.1111/j.1532-5415.20002023.x.

9. Andrew MK, MacDonald S, Godin J, McElhaney JE, LeBlanc J, Hatchette TF, Bowie W, Katz K, McGeer A, Semret M, McNeil SA. Persistent Functional Decline Following Hospitalization with Influenza or Acute Respiratory Illness. J Am Geriatr Soc. 2020 Dec 8. doi: 10.1111/jgs.16950.