Manage frailty effectively or manage decline – your choice and responsibility!

Br J Cardiol 2019;26(1)doi:10.5837/bjc.2019.001 Leave a comment
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First published online 31st January 2019

Over the last few decades there has been a steady increase in life-expectancy leading to an increase in the ageing population, placing significant demands on health and social care.1 Among the several healthcare issues that confront older people, frailty has emerged as an important entity, and tackling frailty has assumed greater significance.2 There is currently no single agreed definition of frailty, but it is widely accepted as a condition characterised by reduced response to stressors consequent to decline in multiple physiological systems associated with ageing. Prevalence of frailty in community-dwelling older adults is estimated to be around 10–14%, but figures between 4% and 49% have been quoted in various populations.3,4 Prevalence also varies with age, with around 7% in adults over 65 years, increasing up to 25% in those aged 80 years and above.5 There are a number of tools to detect frailty, and the most commonly used tool is the criteria proposed by Fried and colleagues based on data from the Cardiovascular Health Study, which assesses five domains, namely weight loss (≥5% weight loss in the past year), exhaustion (effort required for activities), slow walking speed (>6–7 s per 15 feet), weakness as measured by grip strength and decreased physical activity (kilocalories/week: male <383, female <270), with the presence of three or more of these fulfilling the criteria for frailty.5

Frailty elderly care

Frailty is strongly associated with cardiovascular disease (CVD) and, while the precise pathophysiological mechanisms linking frailty and CVD remain to be elucidated, it is likely that this association is bi-directional.4,6,7 Loss of muscle mass and function (sarcopaenia), insulin resistance and chronic low-level inflammation observed in the frailty state can predispose to CVD. On the other hand, the presence of CVD can lead to reduced activity, muscle loss and exhaustion, thus, predisposing to frailty. Large cross-sectional and longitudinal studies have shown that those with CVD were up to two to three times more likely to be frail than those without CVD.5,8-10 Moreover, the association between CVD and frailty extends across the whole spectrum of CVD from subclinical CVD to those with established heart failure.11-14 In addition to its association with CVD, frailty is also an important prognostic marker for risk of falls, increased hospitalisation, reduced quality of life and mortality.15,16

In patients undergoing cardiac procedures and surgery, frailty has been shown to be associated with increased risk of short- and medium-term mortality.17-21 Frail individuals have nearly five times the risk of major cardiac events compared with those who are not frail,22 and addition of frailty assessment to the existing risk scores, such as EUROSCORE II or the STS risk score, significantly enhances peri-operative risk prediction.23,24

Impact

How does this understanding of the relationship between frailty and CVD impact clinical decision-making? Despite its growing importance in managing older patients, assessment of frailty has largely been confined to geriatricians working within hospitals, and this specialty has appropriately claimed a great deal of ownership of this condition.25 However, with a growing number of older patients presenting with CVD, frailty assessment should form part of the standard care for older patients within all healthcare sectors, including primary care and cardiology specialist services.25,26 In the UK, GPs are now being actively encouraged to look for frailty in those aged 65 years and over, and new work is emerging in diabetes, a major risk factor for CVD, that proposes important changes to frailty assessment and outcome that might influence the way the Quality Outcomes Framework (QOF) in primary care is applied in relation to frailty.27

The growing importance of frailty as a major determinant of health outcome has particular relevance while considering cardiac interventions and surgery, where frailty and functional status may modulate the level of health benefits obtained.28 Identification of frailty may also have other advantages. Frailty often precedes disability, and the recognition of frailty can help direct patients to appropriate interventions that can prevent further deterioration. These could include lifestyle changes and a more proactive approach towards managing cardiovascular risk factors, especially in those who are pre-frail.29,30 Individualisation of care and involving patients in decision-making will ultimately improve the quality of life, as well as reduce unnecessary health expenditure.31

While there has been considerable progress in our understanding of frailty and CVD, there are several important aspects that still require further attention. Although there are several tools to assess frailty in routine clinical practice, such as the clinical frailty scale, electronic frailty index (eFI), and the FRAIL score,32 there is at present no consensus about what tool is best under a given set of circumstances, e.g. emergency room, general surgical wards, outpatient clinics, and so on. In the context of CVD, a simple test, such as gait speed, may be a useful test, and is supported by studies that have shown that slow gait speed can independently predict poor outcomes in patients with CVD.17 New guidance in this area may come from recently completed and ongoing studies evaluating frailty assessment measures in aortic valve replacement (AVR), other cardiac surgery patients, and in patients with acute myocardial infarction (CoreValve, Frailty-AVR, Partner II, and Silver AMI).33

Management of frailty in CVD also remains an under-researched area: exercise (often a combination of resistance and aerobic components) currently stands out as a key intervention in frailty, and may be more effective as part of a comprehensive geriatric assessment (CGA) programme.33 Many clinical guidelines now mention older patients, but many of these are of a general theme and tend to advocate caution rather than specific advice.34 The American College of Cardiology has recognised the relevance of frailty in the treatment of heart failure,35 and a recent survey by the European Heart Rhythm Association concluded that the complex clinical condition in frail patients presenting with arrhythmias warrants an integrated multi-disciplinary approach, both for the management of rhythm disturbances, and for the decision on using CIEDs (cardiac implantable electrical devices).36

The challenge

So the challenge has been set: cardiology specialists should recognise that frailty is a condition to accept responsibility for in their routine clinical practice, and its management not left to others. Focused assessment and intervention may be able to reverse the often ‘progressive dwindling’ seen in frailty, and this is surely something worth aiming for!37

Conflicts of interest

None declared.

Editor’s note

Whilst frailty scores are clearly very important, they can be difficult to understand for most clinicians in both primary and secondary care. They have been based on numbers, which work well for research purposes but not as a clinical tool. Many primary care centres, emergency care departments and outpatients departments therefore use the Rockford Score to make life easier.38 It is a pictorial design, which is more pragmatic. TMcC

References

1. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet 2013;381:752–62. https://doi.org/10.1016/S0140-6736(12)62167-9

2. Cesari M, Prince M, Thiyagarajan JA et al. Frailty: an emerging public health priority. J Am Medical Dir Assoc 2016;17:188–92. https://doi.org/10.1016/j.jamda.2015.12.016

3. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc 2012;60:1487–92. https://doi.org/10.1111/j.1532-5415.2012.04054.x

4. Flint K. Which came first, the frailty or the heart disease? Exploring the vicious cycle. J Am Coll Cardiol 2015;65:984–6. https://doi.org/10.1016/j.jacc.2014.12.042

5. Fried LP, Tangen CM, Walston J et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146–M156. https://doi.org/10.1093/gerona/56.3.M146

6. Joyce E. Frailty and cardiovascular disease: a two-way street? Cleve Clin J Med 2018;85:65–8. https://doi.org/10.3949/ccjm.85a.17075

7. Kleipool EE, Hoogendijk EO, Trappenburg MC et al. Frailty in older adults with cardiovascular disease: cause, effect or both? Aging Disease 2018;9:489–97. https://doi.org/10.14336/AD.2017.1125

8. Singh M, Stewart R, White H. Importance of frailty in patients with cardiovascular disease. Eur Heart J 2014;35:1726–31. https://doi.org/10.1093/eurheartj/ehu197

9. Purser JL, Kuchibhatla MN, Fillenbaum GG, Harding T, Peterson ED, Alexander KP. Identifying frailty in hospitalized older adults with significant coronary artery disease. J Am Geriatr Soc 2006;54:1674–81. https://doi.org/10.1111/j.1532-5415.2006.00914.x

10. Chin APMJ, Dekker JM, Feskens EJ, Schouten EG, Kromhout D. How to select a frail elderly population? A comparison of three working definitions. J Clin Epidemiol 1999;52:1015–21. https://doi.org/10.1016/S0895-4356(99)00077-3

11. Newman AB, Gottdiener JS, McBurnie MA et al. Associations of subclinical cardiovascular disease with frailty. J Gerontol A Biol Sci Med Sci 2001;56:M158–M166. https://doi.org/10.1093/gerona/56.3.M158

12. Ramsay SE, Arianayagam DS, Whincup PH et al. Cardiovascular risk profile and frailty in a population-based study of older British men. Heart 2015;101:616–22. https://doi.org/10.1136/heartjnl-2014-306472

13. Veronese N, Sigeirsdottir K, Eiriksdottir G et al. Frailty and risk of cardiovascular diseases in older persons: the age, gene/environment susceptibility-Reykjavik study. Rejuvenation Res 2017;20:517–24. https://doi.org/10.1089/rej.2016.1905

14. Zhang Y, Yuan M, Gong M, Tse G, Li G, Liu T. Frailty and clinical outcomes in heart failure: a systematic review and meta-analysis. J Am Med Dir Assoc 2018;9:1003.e1–1008.e1. https://doi.org/10.1016/j.jamda.2018.06.009

15. Afilalo J, Alexander KP, Mack MJ et al. Frailty assessment in the cardiovascular care of older adults. J Am Coll Cardiol 2014;63:747–62. https://doi.org/10.1016/j.jacc.2013.09.070

16. Crow RS, Lohman MC, Titus AJ et al. Mortality risk along the frailty spectrum: data from the National Health and Nutrition Examination Survey 1999 to 2004. J Am Geriatr Soc 2018;66:496–502. https://doi.org/10.1111/jgs.15220

17. Afilalo J, Kim S, O’Brien S et al. Gait speed and operative mortality in older adults following cardiac surgery. JAMA Cardiol 2016;1:314–21. https://doi.org/10.1001/jamacardio.2016.0316

18. Kim DH, Kim CA, Placide S, Lipsitz LA, Marcantonio ER. Preoperative frailty assessment and outcomes at 6 months or later in older adults undergoing cardiac surgical procedures: a systematic review. Ann Intern Med 2016;165:650–60. https://doi.org/10.7326/M16-0652

19. Kubala M, Guedon-Moreau L, Anselme F et al. Utility of frailty assessment for elderly patients undergoing cardiac resynchronization therapy. JACC Clin Electrophysiol 2017;3:1523–33. https://doi.org/10.1016/j.jacep.2017.06.012

20. Martin-Sanchez FJ, Rodriguez-Adrada E, Vidan MT et al. Impact of geriatric assessment variables on 30-day mortality among older patients with acute heart failure. Emergencias 2018;30:149–55.

21. Sündermann SH, Dademasch A, Seifert B et al. Frailty is a predictor of short- and mid-term mortality after elective cardiac surgery independently of age. Interact Cardiovasc Thorac Surg 2014;18:580–5. https://doi.org/10.1093/icvts/ivu006

22. Sepehri A, Beggs T, Hassan A et al. The impact of frailty on outcomes after cardiac surgery: a systematic review. J Thorac Cardiovasc Surg 2014;148:3110–17. https://doi.org/10.1016/j.jtcvs.2014.07.087

23. Dewey TM, Brown D, Ryan WH, Herbert MA, Prince SL, Mack MJ. Reliability of risk algorithms in predicting early and late operative outcomes in high-risk patients undergoing aortic valve replacement. J Thorac Cardiovasc Surg 2008;135:180–7. https://doi.org/10.1016/j.jtcvs.2007.09.011

24. Wendt D, Osswald BR, Kayser K et al. Society of Thoracic Surgeons score is superior to the EuroSCORE determining mortality in high risk patients undergoing isolated aortic valve replacement. Ann Thorac Surg 2009;88:468–74; discussion 74–5. https://doi.org/10.1016/j.athoracsur.2009.04.059

25. British Geriatrics Society. Fit for Frailty – consensus best practice guidance for the care of older people living in community and outpatient settings – a report from the British Geriatrics Society 2014. Available from: https://www.bgs.org.uk/sites/default/files/content/resources/files/2018-05-23/fff_full.pdf

26. Reeves D, Pye S, Ashcroft DM et al. The challenge of ageing populations and patient frailty: can primary care adapt? BMJ 2018;362:k3349. https://doi.org/10.1136/bmj.k3349

27. Strain WD, Hope SV, Green A, Kar P, Valabhji J, Sinclair AJ. Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative. Diabet Med 2018;35:838–45. https://doi.org/10.1111/dme.13644

28. Bagnall NM, Faiz O, Darzi A, Athanasiou T. What is the utility of preoperative frailty assessment for risk stratification in cardiac surgery? Interact Cardiovasc Thorac Surg 2013;17:398–402. https://doi.org/10.1093/icvts/ivt197

29. Opasich C, Patrignani A, Mazza A, Gualco A, Cobelli F, Pinna GD. An elderly-centered, personalized, physiotherapy program early after cardiac surgery. Eur J Cardiovasc Prev Rehabil 2010;17:582–7. https://doi.org/10.1097/HJR.0b013e3283394977

30. Peterson MJ, Giuliani C, Morey MC et al. Physical activity as a preventative factor for frailty: the health, aging, and body composition study. J Gerontol A Biol Sci Med Sci 2009;64:61–8. https://doi.org/10.1093/gerona/gln001

31. Heckman GA, McKelvie RS, Rockwood K. Individualizing the care of older heart failure patients. Curr Opin Cardiol 2018;33:208–16. https://doi.org/10.1097/HCO.0000000000000489

32. Frailty Screening and Assessment Tools Comparator. iHub: Healthcare Improvement Scotland 2017. Available at: https://ihub.scot/media/3023/frailty-screening-and-assessment-tools-comparator.pdf

33. Chen MA. Frailty and cardiovascular disease: potential role of gait speed in surgical risk stratification in older adults. J Geriatr Cardiol 2015;12:44–56. https://doi.org/10.11909/j.issn.1671-5411.2015.01.006

34. Jansen J, McKinn S, Bonner C et al. Systematic review of clinical practice guidelines recommendations about primary cardiovascular disease prevention for older adults. BMC Fam Pract 2015;16:104. https://doi.org/10.1186/s12875-015-0310-1

35. Goldwater D, Altman NL. Frailty and heart failure. American College of Cardiology, 5 August 2016. Available at: https://www.acc.org/latest-in-cardiology/articles/2016/08/05/08/40/frailty-and-heart-failure

36. Fumagalli S, Potpara TS, Bjerregaard Larsen T et al. Frailty syndrome: an emerging clinical problem in the everyday management of clinical arrhythmias. The results of the European Heart Rhythm Association survey. European Society of Cardiology. Europace 2017;19:1896–902. https://doi.org/10.1093/europace/eux288

37. Oliver D. “Progressive dwindling,” frailty, and realistic expectations. BMJ 2017;358:j3954. https://doi.org/10.1136/bmj.j3954

38. Subbe CP, Burford C, Le Jeune I, Masterton-Smith C, Ward D. Relationship between input and output in acute medicine secondary analysis of the Society for Acute Medicines benchmarking audit 2013 (SAMBA13). Clin Med 2015;15(1):15–19. https://doi.org/ 10.7861/clinmedicine.15-1-15

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