The New Strain SARS-COV-2 Meets a Frailty Endemics
Older adults rank in the most at-risk segment of the population because the basal
functional resilience, meant as the ability to cope with physical trauma and psychological
stressors, is fading (Cesari et al., 2017). Aging is physiologically associated with
cognitive decline and impaired stress response (Bishop et al., 2010), with the spinal
circuitry degeneration leading to progressive alterations of motor performance (Borzuola
et al., 2020). This reduced resilience and cognitive impairment intimately coexist
in the rampant -definitely endemics- frailty syndrome (Ofori-Asenso et al., 2019),
which is known to be associated with disability, traumatic falls, and hospital admission
(Eeles et al., 2012). Regrettably, the wearisome settings of hospital wards provide
poor incitements to the oldest minds and often oversee the abilities of individuals,
who cope with progressive restlessness, dietary impoverishment, and nutrition-related
or activity-related sarcopenia (Eeles et al., 2012; Ligthart-Melis et al., 2020).
Multidisciplinary interventions, such as the HEPAS approach (Healthy Eating, Physical
Activity, and Sleep), are models for dealing with multiple issues simultaneously (Briguglio
et al., 2020c). Despite this knowledge, contemporary society, and health services
put the older adults in the background. From the most complex digitization of services
to the simplest use of public transport, there is “No Country for Old Men” (Ethan
and Joel Coen, 2007). It is therefore not surprising that when the new strain coronavirus
SARS-CoV-2 (Severe Acute Respiratory Syndrome-Coronavirus of 2019) spilled out to
infect humans found not only fertile ground -a population of old people- but also
countries ready to choose treating people with more life expectancy. After the outbreak
of viral pneumonia in Wuhan, China, (December 2019), SARS-CoV-2 spread rapidly in
Europe. Italy resulted among the worst-hit countries with 214.457 infected and 29.684
deaths (May 7, 2020, WHO situation report 108). The northern region of Lombardy accounted
for the overall 52.3% of the deaths (May 7, 2020, Italian SARS-CoV-2 Surveillance
Group), with the older adults suffering from chronic cardiovascular diseases and malnutrition
counting the highest case-fatality ratio (Briguglio et al., 2020b). Considering that
the region counted 128.528 subjects over 60 years of age at the beginning of the past
year (Annual Italian Census of 2019), we can say that the north of Italy lost over
10% of its older population. This rapid increase of infected severe cases led to a
rapid saturation of health facilities in March-April 2020 and public health interventions
focused on social isolation, travel restraints, and at-home confinement. Containment
measures have been applied with different degrees of restriction in different Italian
regions, but the northern regions -the worst-hit- have suffered the most severe lockdown
measures. In Lombardy, almost 100.000 older adult residents locked themselves up in
the house.
Public Health Interventions Amid COVID-19: Locking up in Fear Pandemic
Leaving the house was permitted, but only for proven health or job reasons. Interregional
travel was also banned. Most commercial activities were shut down, few have been minimized.
Buying necessities was allowed, but only one individual per family wearing masks and
gloves. To respect social distancing, supermarkets regulated the entrances eventually
forming long queues, with people possibly waiting for hours. Priority tickets could
be booked online, as well as masks that were sold out by pharmacies but available
on various web sites at inflated prices. Eventually, these measures contributed to
reduce the impact on health services and the risk of severe illness (Steffens, 2020).
Although reasonable and essential, the social lockdown has affected both the bourgeois
and the less well-off classes of the population. However, are the vulnerable groups
-the older adults- who will be carrying the worse future debt of disability? In the
pre-COVID-19 era, over 50% of older adults were known to be at risk of loneliness
(with associated morbid events) (Fakoya et al., 2020) and this feature fused with
reduced health care capacity during the pandemic. In the COVID-19 era, most medical
clinics closed or adhered to special hours and the reorganization of the health system
led to a significant reduction in clinical and surgical assistance. These restrictions
prevented the older adults from having a continuity of care for their co-existing
chronic conditions. The decline in social relations combined with reduced support
increase the disability debt, with the reaching of the “social frailty.” Results from
a Chinese -another worst-hit country- online survey proved over 50% of respondents
rating the psychological impact of COVID-19 moderate-to-severe, with depressive and
anxiety symptoms being prevalent (Wang et al., 2020). Dramatic events, such as the
loss of a kin, but also anxiety from the fear of being infected and the inability
to do something can further compromise the mental health. On one hand, the Italian
daily newscast informed the public about the disease severity, reporting hundreds
of daily deaths. On the other hand, the indirect fear inherent in those who were watching
has been a major side effect. Frailty therefore acquired a mental nature, becoming
“psychological frailty” (Gobbens et al., 2012). Older adults require increasing cognitive
demand to perform any motor task (Seidler et al., 2010). The COVID-19 restrictions
have been not only associated with psychological derangements, but also with an increasing
“bed-kitchen-sofa” lifestyle. Low environmental information-processing was consequently
prevalent during daytime, with further impairment of age-associated spatial disorientation,
proprioception, disequilibrium, and incoordination (Dunsky, 2019). At-home confinement
easily led to sarcopenia. The sedentary lifestyle associated with constant stress
that decreased the desire to eat. Either reduced food security or food supply reduced
energy intake, leading to nutritional deficits (Briguglio et al., 2020b). Sarcopenia
easily became osteosarcopenia. After 2 months (end of March, April, and early May)
of confinement, the perceived loss of balance inherits the fear of falling. The “physical
frailty” reaches its peak.
End of Isolation: Looking up for Fear Consequences
The easing of COVID-19 lockdown on the older population has possibly brought effects
comparable to the hospital-associated deconditioning. The disability debt earned during
the lockdown will require an augmented need for care for older individuals suffering
from the abovementioned geriatric conditions -functional disability- and psychosocial
disorders, mainly isolation. The surviving older individuals who have not been infected
with SARS-CoV-2 are definitely more fragile, malnourished, and more ill than the pre-COVID-19
era. Those who have been infected will encounter permanent disabilities, such as pulmonary
fibrosis and impaired liver function. Indeed, reduced respiratory capacity has been
observed for the survivors after SARS-CoV-1 (Ngai et al., 2010). Permanent affections
could be also mental, with long-term neuropsychiatric consequences being characteristics
of neurotrophic coronaviruses (Briguglio et al., 2020a; De Felice et al., 2020). We
expect the frail older adults to be exposed to an increased risk of traumatic events
amid restrictions (Clegg et al., 2013). This worsening of the three-dimension frailty
may therefore transduce into more hospital admissions. Frail older adults encounter
a 1.2- to 2.8-fold risk for falls and fractures and 1.2- to 1.8-fold risk for hospitalization
(Vermeiren et al., 2016). Even though COVID-19-associated admissions are known to
be flattening, it is also known that most fractures occur in the home and the prolonged
restrictions may expose orthopedic hospitals to a different kind of saturation post-COVID-19.
During the pandemic, the choice of operating older adult subjects who have suffered
a falling trauma was a matter of debate. In the worst-hit countries, the experience
of Chinese (Mi et al., 2020) and Spanish (Munoz Vives et al., 2020) authors would
suggest delaying the surgical treatment of fractured patients with SARS-CoV-2 as they
have observed excessive mortality rates. The Italian experience would suggest instead
to treating the fracture as soon as possible in order to stabilize the patient (Catellani
et al., 2020). Anyhow, it is a fact that elective orthopedic surgery has been delayed,
but there may be also a debt of traumatic fractures that must be bridged. It is also
possible that many lonely seniors who fell into the house during the restricted period
have not yet been established: fall not reported? While there was over a halving of
emergency room accesses for high energy fractures in Italy during the pandemic (Fojut,
2020; Magro et al., 2020), on the other hand, low energy/fragility fractures did not
substantially reduce (Benazzo et al., 2020; Jain et al., 2020). This highlights the
lack of home prevention measures for the elderly that certainly has exposed them to
an increased risk of risk of hospital-acquired SARS-CoV-2 infection.
Discussion
In the post-COVID-19 era, the saturation of health services may only be the tip of
the iceberg in relation to the restriction-derived burden of frailty. During confinement,
the diminished state of resilience in elderly people may have worsened all age-associated
conditions, such as a mild high blood pressure, glucose intolerance, basal immune
dysfunction, inflammaging, and mental liability with anxiety-depressive traits. The
dynamics of “frailty” renders its transition to a worse level more common than improvement
(Morley et al., 2013), and this COVID-19 pandemic may have spin the loop of a decline
of decreasing functional ability, increasing frailty, greater risk of traumatic falls,
and higher hospital admissions for fragility fractures in the near future (Figure
1). Since it is difficult to predict when SARS-CoV-2 will become a secondary problem,
it is also important to ponder the possibility of a second wave of infections since
this prolonged social isolation has created a population with fewer anti-viral immune
defenses (Cole et al., 2015). Homeless and people with disabilities should also be
a matter of concern (Mesa Vieira et al., 2020). It is therefore mandatory to get prepared
for pandemic consequences with appropriate interventions, being both public health-oriented
and patient-oriented. This pandemic has not only underlined the public health challenges
to guarantee that older population can access the services they need, but it has also
shown new opportunities to be seized, such as an expanded workforce specialized in
aging (Morrow-Howell et al., 2020), a promotion of intergenerational solidarity (Brooke
and Jackson, 2020), or practical community participations, such as the dropping off
of groceries (Fraser et al., 2020). In clinical settings, the confronting with a fast-growing
geriatric population suffering from multiple comorbidities needs a multidisciplinary
approach like the orthogeriatric co-management model of care, with orthopedic doctors
and geriatricians prioritizing the patients' needs and aiming at clinical as well
as cost-benefit advantages for older adults (Gosch et al., 2016). Valuable and tailored
patient-oriented solutions have been proposed after COVID-19 pandemic restriction-associated
isolation to cope with social, psychological, and physical frailty. Both the procurement
of health care assistance and the reduction of loneliness to older adults that who
have suffered from isolation should be a priority for social frailty handling. For
instance, remote interventions via online systems may be valuable (Patel and Clark-Ginsberg,
2020) but an appropriate utility assessment and training in the use of technological
services should be provided. Psychological frailty should be counteracted through
older adult engagement and motivation, possibly via phone contact with health professionals
(Armitage and Nellums, 2020) or by broadcasting television entertaining with premeditated
programs (Jawaid, 2020). Also, symptoms such as fear and sleeping disturbances should
be properly identified and addressed (Berg-Weger and Morley, 2020). Physical frailty
can be resolved through educational videos and recorded physical activity sessions
(Angulo et al., 2020). Actually, online technologies are the most valuable support
systems, but have to be appropriately planned for older minds (Meinert et al., 2020).
Of note, prioritized interventions should be established for low and middle income
countries where family dynamics are different, a large number of older adults are
illiterate, and proper health care assistance is limited (Lloyd-Sherlock et al., 2020).
Figure 1
Tendencies of the consequences of the COVID-19 pandemic on the health of the elderly
and the risk of hospital admissions after lockdown easing. The severe acute respiratory
syndrome coronavirus that was discovered in Hubei province, China at the end of December
2019 (SARS-CoV-2) burst a pandemic that shut down the world. Under normal circumstances,
the older adults must deal with a diminished functional ability and progressive establishment
of geriatric fragility. If a healthy status is present, recovery from any trauma is
discreet even if it is not associated with full pre-trauma functionality. Although
restrictive measures were necessary for public health during the pandemic, they have
exposed older individuals to confinement that has worsened their physical and mental
health. Upon easing of the lockdown, the older person will suffer a disability debt,
which will make him highly vulnerable to the risk of falling. Orthopedic hospitals
that recorded a halving of traumatic admissions could contrariwise encounter a surge
in accesses for traumas amid lockdown easing.
To conclude, we can say that:
The new coronavirus SARS-CoV-2 met a population of frail elderly
The restrictions due to the COVID-19 pandemic generated a more fragile class of older
adults
The health system should re-organize for efficiently managing the surge of frailty
fractures
Long-term psychological consequences amid COVID-19 pandemic and associated restrictions
should be considered, especially for the oldest fragile minds.
Author Contributions
MB formulated the hypothesis and wrote the first draft of the manuscript together
with RG. BD, MC, MP, FL, GB, and GMP revised the first draft and contributed to manuscript
sections. All authors contributed to manuscript revision, read and approved the submitted
version.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.