Date of Award

January 2022

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)

Department

School of Public Health

First Advisor

Evelyn Hsieh

Abstract

Background Older individuals are at high risk for musculoskeletal impairment following hospitalization due to decreased neuromuscular function and bone mineral density (BMD) arising from illness itself, and external factors such as immobilization and changes in nutritional status. To address the knowledge gap regarding the longitudinal impact of COVID-19 on musculoskeletal outcomes, this thesis aimed to study the relationship between COVID-19 severity and physical functional, incidence of falls and fractures in older adults. Secondarily, in a subset of patients we examined the relationship between COVID-19 severity and osteoporosis- and sarcopenia-related measures. Methods This study analyzed data from the VALIANT study and VALIANT MSK Sub-study. The VALIANT study included individuals who were over 60 years old and were hospitalized due to COVID-19 in the Yale New Haven Hospital System (YNHHS) from July 2020-July 2021. Virtual interviews were performed at the time of hospitalization, and 1, 3, and 6-months post-hospitalization and measured a range of sociodemographic, clinical and general health-related characteristics, physical function domains relevant to musculoskeletal health and mobility, and incident falls and fractures. Patients who consented to be re-contacted were invited to participate in the VALIANT MSK Sub-study and presented for an in-patient visit which included a survey, serum sample collection, a dual-energy x-ray absorptiometry test, the short physical performance battery and grip strength assessment. Descriptive statistics were used to evaluate primary and secondary outcomes, stratified by COVID-19 severity as defined by SOFA score, inpatient level of care, and inflammatory markers (high-sensitivity C-reactive protein and interleukin-6) at baseline and 6 months. Results Among 341 participants enrolled in the VALIANT parent study, the median age was 70.0 years (IQR 12) , with 49% female, and 72.5% White individuals while among the 62 participants in the VALIANT MSK Sub-Study, the median age was 67.0 years (IQR 10), with 49% females, and 64.2% White individuals. In the VALIANT cohort, when physical function status at 6 months was stratified by COVID-19 severity, multiple domains emerged as being significantly different. A higher proportion of patients who had a higher SOFA score (≥3) reported being unable to independently bathe (9.2% vs 2.4%, p<0.001), get in and out of a chair (5.8% vs 1.7%, p=0.017), use the toilet (3.8% vs 0.3%, p=0.006), shop (20.1% vs 11.6%, p=0.011), or walk flight of stairs (15.4% vs 8.2%, p=0.016). A significantly higher proportion of VALIANT participants with high inpatient hsCRP levels during hospitalization (≥97 mg/L) were unable to independently do housework (31.7% vs 21.1%, p= 0.013), shop (33.1% vs 19.7%, p=0.043), walk a quarter mile (28.5% vs 24.2%, p=0.009) and walk flights of stairs (37.0% vs 15.9%. p= 0.0114). In the VALIANT MSK Sub-study, a similar general trend was observed with a higher proportion of patients with SOFA scores ≥3 or hsCRP≥97 mg/L reporting that they were unable to independently perform certain physical function tasks. At baseline, 101/339 (29.8%) VALIANT participants reported a fall in the past year before COVID-19 compared with 15/62 (24.2%) of VALIANT MSK Sub-Study participants. At 6 months, 24.3% of VALIANT participants reported having an incident fall since COVID infection compared with 19.4% of VALIANT MSK participants. When participants of both groups were categorized based on COVID severity no significant differences were seen in the proportion of new falls in the 6 months. Seven participants overall reported having a fracture following COVID-19 hospitalization. Among the VALIANT MSK participants, 3 participants (5.2%) had osteoporosis and 22 participants (37.9%) had osteopenia. Mean femoral neck (FN) BMD was lower among patients with hsCRP ≥97 (0.79 vs 0.21, p<0.001). Five participants (8.1%) met criteria for probable sarcopenia. No participants met criteria for sarcopenia or severe sarcopenia. When examining individual sarcopenia assessment components, there was no statistically significant difference when categorized based on COVID severity. Conclusions Our study shows that a greater proportion of older adults presenting with severe COVID-19 as defined by SOFA, inpatient level of care, or high hsCRP and high IL-6 had worse physical functional status and lower FN BMD at six months. Further multivariable analyses should explore whether these associations remain when adjusted for key musculoskeletal health-related covariates, and how baseline status is associated with outcomes at 6 months. Attention to the rehabilitation needs of patients following COVID-19 hospitalization is important, as well as consideration for osteoporosis and sarcopenia screening for those with more severe disease.

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This is an Open Access Thesis.

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