Impact of the first COVID-19 pandemic wave on hospitalizations and deaths caused by geriatric syndromes in France: a nationwide study

Impact de la première vague d’épidémie de COVID-19 sur les hospitalisations et la mortalité pour 10 syndromes gériatriques en France métropolitaine

Publié le 27 mars 2023

Preventive measures, especially lockdown and the fear of contracting COVID-19 during the health crisis, caused changes both in the way people live and the way the health system functions. These changes likely had an impact on the population’s health status, particularly among vulnerable groups. The elderly, quickly identified as being at risk of severe infection by SARS-CoV-2, were particularly targeted by strict lockdown measures. Several studies have reported on the psychological suffering associated with the isolation of older adults, whether living in the community or in an institution. But what is known today about the collateral damage of the first national lockdown regarding their health? Geriatric syndromes, conditions specific to this population, can be a sign of poor care and can have serious consequences in terms of functional decline, quality of life or mortality.

The article recently published in The Journals of Gerontology: Series A [1] is the first to provide national data regarding the impact of the first COVID-19 pandemic wave on hospitalizations and deaths caused by geriatric syndromes in France among people aged 65 years and over. 

3 questions for Marion Torres, Non-Communicable Diseases and Trauma Department,  Santé publique France

Marion thorres (Photo d'illustration)

Your study focuses on people aged 65 years and over in relation to the COVID-19 pandemic. Why did you target this particular population? What is at stake in terms of public health?

The fear of contracting COVID-19 and the measures put into place to manage the health crisis, more specifically during the first lockdown, had a profound impact both on people’s lifestyles (isolation, sedentary lifestyle, self-imposed restricted use of care, etc.) and on the way the health system functions. 

Numerous studies have shown that consultations and hospitalizations were either postponed or cancelled, which has likely affected the population’s health status, especially among vulnerable populations such as older adults. The elderly often cumulate physiological and psychological vulnerability factors, which puts them at particular risk of deteriorated health in times of crisis because of the difficulties they face in adapting. 

Our study aimed to investigate hospitalizations and mortality for ten geriatric syndromes (GS) at national level during the first COVID-19 wave up until September 2020, in comparison to previous years. The ten GS studied were those most frequently cited in the literature: dementia, cognitive decline, confusion/disorientation, depression, malnutrition, dehydration, bedsores, incontinence, fall and injury, with a specific focus on femoral neck fracture. Most of these conditions are avoidable and their apparition can reflect a lack of care (be it in the family, social or health sphere) that could have serious consequences in terms of functional decline, quality of life or mortality. 

In order to identify hospitalizations and mortality related to these ten GS, we exploited data from the National Health Data System (SNDS, Système national des données de santé: see box). We first identified the ICD-10 codes for each GS by gathering together data from the literature and expert opinions. These codes were then used in the hospital database of the Medical Information Systems Programme (PMSI, Programme de médicalisation des systèmes d’information) to estimate the incidence of new hospitalizations (all causes combined for each GS as a primary or related diagnosis) during the period in question. Hospitalizations for COVID-19 as a primary or related diagnosis were excluded. Mortality was assessed using the statistics database from the Centre for Epidemiology on the Medical Causes of Death (CépiDc, Centre d'épidémiologie sur les causes médicales de Décès – INSERM). 

The analysis was performed according to age, region, and place of residence for hospitalizations (home or institution) or place of death for mortality (home, institution, health facility or other).

What knowledge does your study bring? Are any syndromes more concerned than others in terms of impact? Do you notice disparities between regions?

Our study shows a very significant decrease of GS hospitalizations during the spring 2020 lockdown period (17 March– 2 May). This is conversely reflected by excess mortality for most of the motives, particularly at home and in institutions. 

Across France during this first lockdown, 314,421 persons aged 65 years and over were hospitalized for a cause other than COVID-19, which is below the average number of hospitalizations for the three previous years (approximately 557,033, representing -56%). Compared to the 2017–2019 period, hospitalizations diminished during the first lockdown for all GS included in our study. The extent of this decrease varied according to the GS: -59% for incontinence, -51% for depression, -49% for other cognitive disorders and symptoms, -43% for dementia, -37% for malnutrition, -37% for dehydration, -36% for bedsores, -30% for fall/injury, -18% for confusion/disorientation and -13% for femoral neck fractures. 

A dose-response relationship was observed in respect to the level of COVID-19 circulation: those regions most affected by the epidemic were also the ones with the greatest drop in hospitalizations. For instance, the decrease for dementia hospitalizations during the first lockdown was -61% in the regions most affected by COVID-19 (Île-de-France and Grand Est), compared to -40% in regions with a lower COVID-19 mortality rate (Occitania, Brittany and Nouvelle-Aquitaine). 

Moreover, during this first lockdown, excess mortality was observed for almost all GS compared to the 2015–2017 period. This represents COVID-19-related excess mortality among elderly people with GS but also, for most syndromes studied, an excess mortality unrelated to COVID-19: +74% of non-COVID-19-related deaths for confusion/disorientation, +44% for femoral neck fracture, +32% for depression, +20% for dehydration, +9% for malnutrition, +8% for fall/injury. This excess mortality was particularly notable for deaths occurring at home and in nursing homes. For instance, excess mortality for malnutrition during the first lockdown was +39% at home and +40% in institutions (nursing homes, long-term care facilities), compared to a -12% drop in mortality in hospitals.

This study underlines that the COVID-19 epidemic and the 2020 spring lockdown had immediate and significant negative impacts on elderly people’s health in France. It suggests these impacts were related to the saturation effect on the healthcare system, especially in regions hit hard by the epidemic, and to the isolation of persons aged 65 years or over, many of whom decided not to access health care even in areas where the virus was not circulating.

Do these indicators characterizing elderly people present an interest in the longer term regarding surveillance and prevention? Will they be useful for organizing prevention appointments among younger individuals, such as those the government is currently setting up?

These results underline how studying evolutions in health status among elderly people is important for understanding the impact of measures put into place to manage the health crisis. These impacts should be compared to the COVID-19-related morbidity and mortality that were avoided. 
Our study has established a robust system for monitoring the health status of elderly people and will enable further studies into the impacts of the pandemic in upcoming years. 

Combined with indicators of frailty1, indicators of geriatric syndromes will be valuable for monitoring the evolution of elderly people’s health status in future social, economic, environmental and sanitary contexts.

Geriatric syndromes are often avoidable. Their surveillance will also make it possible to evaluate the new prevention strategy, which includes free medical consultations offered at three key ages of life, including 65 years old. These prevention appointments aim to help prevent loss of autonomy by promoting physical activity, sport and a healthy diet, preventing certain cancers and addictions, and promoting mental and sexual health. It is never too late to act, even at 65 years or over, as frailty is largely reversible.

[1] Torres MJ, Coste J, Canouï-Poitrine F, Pouchot J, Rachas A, Carcaillon-Bentata L. Impact of the first COVID-19 pandemic wave on hospitalizations and deaths caused by geriatric syndromes in France: a nationwide study, The Journals of Gerontology: Series A, 2023; glad032.

Using SNDS data for public health purposes

The SNDS centralises and links France’s main national health databases, representing information on the health of more than 65 million French people. 

In this regard, the SNDS represents one of the largest health databases in the world, providing new opportunities for research on health and public health. 

Santé publique France is one the many users of the SNDS. The agency uses its data for a number of surveillance studies: antibiotic consumption in the primary care sector, vaccination coverage, hypertensive disorders in pregnancy, autism spectrum disorders, HIV screening, type 1 diabetes, hepatitis C treatment, etc.

Access to SNDS data is strictly regulated in order to preserve data confidentiality according to the fundamental rights of individuals and to guarantee that processing conforms to the purposes authorized by the law. 

Find out more about the SNDS:

1- The SFGG (French Society of Geriatrics and Gerontology) adopted in 2011 this definition for frailty: “Frailty is a clinical syndrome. It reflects a decrease in physiological reserve capacity which alters the mechanisms of adaptation to stress. Its clinical expression is modulated by comorbidities and psychological, social, economical and behavioural factors. The frailty syndrome is a risk factor for mortality and pejorative events, including disability, falls, hospitalization and entry into an institution. The age is a major determinant of frailty but does not explain entirely this syndrome. The care of frailty determinants can reduce or delay its consequences.  Thus, frailty would be part of a potentially reversible process.