Frailty and Long COVID in Older Adults: A Scoping Review

Introduction
Over 65 million people worldwide are estimated to have Long Covid following SARS-CoV-2 infection. UK population data flags under-recognition of symptoms in older people as a potential issue. Given known frailty prevalence in this age group, a meaningful proportion of those affected are likely to be living with frailty.

Long Covid is a complex multisystem condition of symptoms which persist/emerge three months after initial infection and is associated with over 200 reported symptoms. Many of these have similarities with frailty including fatigue, breathlessness, cognitive difficulties, pain and reduced exercise tolerance. A substantial subgroup will meet the diagnostic criteria for myalgic encephalomyelitis/ chronic fatigue syndrome (ME/CFS) and include post-exertional malaise/post-exertional symptom exacerbation (PEM/PESE): delayed and disproportionate symptom worsening following physical, cognitive or other exertion, often with prolonged and unpredictable recovery. 

Best practice for older people living with frailty recovering from acute illness includes effective rehabilitation based on a traditional activity based approach. However NICE guidance for ME/CFS explicitly advises against exercise based on deconditioning theories. Where frailty and Long Covid symptoms cannot be reliably distinguished, traditional geriatric rehabilitation approaches may therefore risk worsening symptoms rather than supporting recovery. This scoping review explored the relationship between frailty and Long Covid in older adults to inform safe clinical practice

Methods
A scoping review was conducted by two researchers using Joanna Briggs Institute methodology and reported in accordance with PRISMA-ScR framework. Databases (Medline, EMBASE and CINAHL) were searched for studies examining frailty and Long Covid /post-COVID condition in older adults (over 65s) and published in English between January 2020 and March 2026. Studies examining frailty after COVID-19 infection without explicit reference to Long Covid, post-COVID condition or persistent post-COVID symptoms were excluded.

Results

75 articles were identified through database searching, with a further nine through citation searching. Following title and abstract screening, 17 studies were reviewed in full; 10 met inclusion criteria (six observational studies, three narrative reviews and one guideline) and were analysed using narrative synthesis. Included studies were heterogeneous in design, follow-up duration, population and outcome measures. Most observational studies were retrospective and included predominantly white male populations from high-income countries. Frailty was often identified retrospectively using frailty indices applied to large datasets, with limited detail on clinical validation. Studies were not designed to differentiate frailty-related prolonged recovery from Long Covid and none examined Long Covid in relation to comprehensive geriatric assessment. Only two of the 10 included studies referenced PEM/PESE. The majority of excluded studies examined frailty after COVID-19 but did not consider or even mention Long Covid.

Conclusion

The evidence regarding frailty and Long Covid is limited, heterogeneous and gives little consideration to PEM/PESE. This gap has direct implications for rehabilitation safety. Access to appropriate recovery, rehabilitation and reablement for older people is paramount. However, without reliable means to distinguish frailty from Long Covid symptoms, standard deconditioning-based approaches risk harm.  Improved assessment tools and evidence-based interventions are needed to support safe, effective care for older people living with both frailty and Long Covid.