To our knowledge, this is the first study to report long-term impact of COVID-19 on HR-QoL and functional status in older people.
More than half of the study participants reported a clinically relevant decline in HR-QoL six months after hospitalisation due to COVID-19, compared to before hospital admission. One out of three patients reported decline in mobility and the ability to carry out activities of daily living. We found no difference in functional decline six months after hospitalisation due to COVID-19 when comparing patients aged 75 years or older with patients aged under 75 years. Still, the oldest patients reported lower functional status, possibly increasing their risk of permanent care needs and loss of independence following hospitalisation due to COVID-19. The results of our study suggest awareness of long-term functional decline in older COVID-19 patients, and sends the message to prevent both the disease and its complications in this vulnerable group of patients.
Reports about persistent symptoms among patients who have suffered from COVID-19 are emerging, and studies of long-term consequences of the disease are highly warranted (21). So far, knowledge on HR-QoL in survivors is very sparse (16), and we are not aware of any studies that have studied older patients with this regard.
In a recently published paper, Huang, et al, reported persistent symptoms among patients with a median age of 57 years, after hospitalisation due to COVID-19 in China (12). Interestingly, the mean EQ 5D-5L VAS at six months was much lower in our study compared to in the patients in China (65.8 vs. 80.9), and very few patients in the Chinese study had problems with mobility or ADL. The most likely explanations for these differences are the much higher mean age, more comorbidity, and a higher proportion of patients with severe disease and ICU treatment, in our study. Patients who had experienced severe COVID-19 had the largest decline in HR-QoL in our study. The results suggest that special attention regarding long-term reduction of HR-QoL and functional decline should be drawn to the oldest patients and patients with severe COVID-19.
Functional loss during hospitalisation due to acute illness is common in older people. It reduces their ability to live independently, and increases the risk of nursing home admission and needs of community care (22–24). In a recently published study that included 346 patients aged 65 years and older with confirmed seasonal influenza and other acute respiratory illness, 18% experienced persistent functional decline 30 days after discharge from hospital (11). The functional losses were equivalent between patients with influenza and other acute respiratory illnesses. Whether COVID-19 might cause more severe long-term reduction in HR-QoL and functional capacity compared to other acute conditions, remains an unanswered question that should be addressed in further studies.
Many patients with COVID-19 require long-term oxygen treatment, and both persistent hypoxemia and isolation measures might promote immobilisation and delirium. Immobilisation due to acute illness increases the risk of acute sarcopenia and loss of physical function (8). Sarcopenia is furthermore associated with negative impact on HR-QoL (25). Emerging evidence suggest that older patients with COVID-19 are at high risk of developing delirium, a condition associated with both increased mortality and long-term cognitive impairment and dementia (26, 27).
Prevention of hospital admission due to COVID-19 with vaccination of older people might be an effective measure to prevent long-term functional decline. Furthermore, management of complications such as immobilisation and delirium, might prevent long-term functional loss, and should be implemented subsequently in older patients hospitalised with COVID-19.
Strengths and limitations
The main strengths of this study is the long follow-up generating new knowledge about the persisting impact of the lives of older people who have survived severe COVID-19. Furthermore, the study population represents a high proportion of older survivors after hospitalisation due to COVID-19 in Norway. Also, the multicentre design supports the generalisability of our result.
This study has some limitations. We made use of the EQ 5D-5L response form, which was scored retrospectively for the premorbid status at six months. The response in premorbid status might be influenced by experiences during hospitalisation, the patient’s current health status or the psychosocial effect of the pandemic situation in itself, leading to under- or over reporting of symptoms. To prevent potential bias from patients reporting only small changes in the EQ 5D VAS scale, we chose a cut-off value of 7 points as the minimally clinically important difference when comparing scores before and after discharge from hospital (20).
Patients were evaluated at a single point follow-up at six months. We experienced that some patients with a high degree of comorbidity or anamnestic great loss of function after COVID-19 were unwilling to participate in the study because of the resources demanded in meeting at the hospital. Home visits or institutional consultations were arranged to include as many of these patients as possible, but we still suspect that the frailest group is underrepresented in our study, potentially leading to underestimation of both symptoms and the magnitude of functional decline at 6 months.