Age should not be the only criterion
The question of prioritisation in the health services has become far more relevant as a result of the COVID-19 pandemic. We believe that using age as the only criterion for setting priorities is not appropriate. Older people who belong to the fittest subgroup in their age range may have the same life expectancy as an ill and vulnerable younger person. It is thus essential to assess frailty and comorbidity in the acutely ill in order to determine their treatment level. In geriatric medicine we normally have both the time and resources needed to decide such priorities with the aid of a broad, interdisciplinary geriatric assessment (4). Most likely, we will not have the same opportunity if a large number of older people fall ill at the same time.
Typical characteristics of frail patients are weight loss, cognitive impairment, reduced mobility and decline in the functions of daily living. As an aid in assessing frailty we propose the use of a structured instrument. The Clinical Frailty Scale (CFS) is available in Norwegian translation (5), takes little time to complete and is already being used to some extent in acute and intensive care medicine. It has proven to be useful both as an aid in making treatment decisions (6) and for assessment of prognosis in emergency admissions (7).
Treatment decisions must be made in nursing homes, in accident and emergency departments and in hospital wards with no access to specialist competencies in geriatrics, or a geriatric team. Some will claim that nursing home patients with COVID-19 should not be admitted to hospital. However, the nursing home population is very heterogeneous. Some are relatively fit older people who are on short-term stay for rehabilitation, while others suffer from severe dementia and need help with all activities of daily living. There is also considerable local variation in the nursing homes' capacity to treat seriously ill patients. Therefore, there may be good reasons to admit acutely ill frail patients, with or without COVID-19, to hospitals, even when they will not need treatment in the intensive-care ward. Individual assessments must thus be made, and we recommend advance care planning for all patients in nursing homes.