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 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
The British Geriatrics Society Cardiovascular Section has partnered with the BJC. Find out more here.
References
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