frailty assessment: simplifying the complex · weight loss, weakness, slowness, dec activity, poor...
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Frailty Assessment:
Simplifying the ComplexNatalie Sanders, DO
Internal Medicine, Geriatrics
Rocky Mountain Geriatrics Conference 2017
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OBJECTIVES
• Define Frailty
• Review various tools used to assess for frailty
• Highlight the implications of frailty on the
health of older adults with cardiovascular
disease
• HTN
• Heart failure/Mechanical Support
• Aortic Stenosis/TAVR
• Next steps/Practice Tips
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DEFINING FRAILTY
• Originates from French frele (of little
resistance) and Latin fragilis (easily broken)
• Decline in physiologic reserve related to
multiple factors and involving many organ
systems
• Ultimately increases vulnerability
• Slowness, weakness, and physical inactivity
core features in most scales
JAMDA 2013;14(6):392-397.
Curr Cardiovasc Risk Rep (2011) 5:467–472
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Curr Cardiovasc Risk
Rep 2011; 5: 467-472
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TOOLS TO ASSESS FRAILTY
• Over 27 tools described
• Fried Phenotype
• Accumulated Deficits across multiple
domains
– Cognitive, disability, physical performance, nutrition
status, co-morbid illnesses)
• Clinical Judgement
Canadian Family Physician March 2015, 61 (3) 227-231
BMC Geriatrics 2013, 13:64
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Scale Criteria Measured Score
Fried Phenotype
(CHS)
Weight Loss, weakness, slowness, dec
activity, poor endurance
0-5
Fried + Above + Mood (SF-GDS) and
Cognition (MMSE)
0-7
FRAIL scale Fatigue, resistance, ambulation,
illnesses, wt loss
0-5
Clinical Frailty Scale
(CSHA)
Clinical judgement 0-7
Gronigen Frail Indicator Four domains: physical, cognitive,
social, psychological
0-15
Frailty Index (Deficit
Accumulation
Various domains; at least 30 variables
needed
Varies
Short Physical
Performance Battery
(SPPB)
Balance, Leg strength, Gait 0-12
Essential Frailty Toolset
(EFT)
Four domains: Physical, Cognition,
Anemia, Nutrition
0-5
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J Gerontol: Medical Sciences 2001,
Vol. 56A, No3, M146-M156.
Scoring:
0: robust
1-2: pre-frail
3 or more: frail
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KAPLAN MEIER CURVES CHS AND FRIED PHENOTYPE
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ROCKWOOD ACCUMULATION OF
DEFICITS APPROACH
• Used Canadian Health Study on Aging
• 70 Deficits Measured
– Presence/absence and/or severity of disease
– Activities of Daily living
– Physical exam findings
• FI = number of deficits/total deficits
measured (E.g. 7/70 yields FI= 0.7)
• May define adverse outcomes more
precisely J Gerontol A
Biol Sci Med Sci 2007;62:738-43.
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Score Score Description
Very Fit Robust, active,
energetic
Well No active disease
Well, with treated
comorbid disease
Disease symptoms
well controlled
CSHA Clinical Frailty Scale
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Score Score Description
Apparently
vulnerable
Not frankly
dependent, people c/o
being slowed up
Mildly frail Limited dependence
for IADLs
Moderately frail Need help with IADLs
and ADLs
Severely frail Completely
dependent for ADLs
CSHA Clinical Frailty Scale
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Essential
Frailty
Toolset
Domains:
-Physical
-Cognitive
-Anemia
-Nutrition
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J Aging Phys Act 2015; 23(2):314-322
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FRAILTY AND HYPERTENSION
Accessed 8.24.17 https://www.consumeraffairs.com/high-blood-pressure
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HTN AND FRAILTY (HYVET)
• Age 80+
• 1:1 indapamide +/- perindopril vs. placebo
• approx. 1300 participants in each group
• Frailty calculated by accumulation of deficits
approach
• Median FI 0.17 (treatment), 0.16 (placebo)
• Greater FI associated with increased
– Risk of death, CV events, Stroke (HR 1.23-1.26
• Treatment outcomes no different based on FI
Warwick et al. BMC Medicine (2015) 13:78
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HTN AND FRAILTY (SPRINT)
• Age 75+
• Intensive (SBP < 120 mmHg) vs Standard
• Stopped early due to lower CV outcomes
and mortality in intensive tx group
• Median FI 0.18
• Outcomes no different in frail vs non frail
• Greater FI associated with increased falls
and hospitalization (HR 1.03)
• Treatment outcomes no different based on FIJ Geronton A Biol Sci Med Sci. 2016 May;71(5):649-55
J Am Geriatr Soc 2017 65:16-21.
JAMA. 2016;315(24):2673-2682.
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FRAILTY IS COMMON IN HEART FAILURE
• 448 patients in MN with heart failure
• mean age 73 y/o
• Defined by phenotype
• Findings: 19% frail, 55% pre-frail
• 65% increased risk for hospitalization
• 92% increased risk for ER visit
J Am Coll Cardiol HF 2013;1:135–41
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FRAILTY AND ADVANCED HEART
FAILURE INTERVENTIONS-DT LVAD
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EXISTING MODELS TO PREDICT
DEATH
Circ Heart Fail. .
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FRAILTY AND DT-LVAD 2014
• 99 patients undergoing DT-LVAD Mayo Clinic
• Frailty defined by accumulation of deficits
approach
• 31 impairments, disabilities, co-morbidities
• FI > 0.32 = Frail
• FI 0.23-.32 Intermediate Frail
• FI < 0.23 Not frail
J Heart Lung Transplant. 2014 April ; 33(4): 359–365
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FRAILTY AND OUTCOMES POST DT-LVAD
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FRAILTY AND OUTCOMES POST DT-LVAD
Not Frail Intermediate Frail
Hazard Ratio
Frail
Hazard
Ratio
P for Trend
Mortality 1 (referent) 1.70 3.08 0.004
Re-hospitalization 1 1.7 1.42 0.024
*Adjusted for age, sex, and INTERMACS profile
Heart Lung Transplant. 2014 April ; 33(4): 359–365
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AORTIC STENOSIS AND FRAILTY BY
CLINICAL FRAILTY SCALE
Circulation. 2017;135:2025–2027.
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CONCLUSION OF EDITORIAL
• CFS may be less able to identify potentially
reversible causes of frailty
• Red Flags of Futility:
– Unable to complete gait speed or chair rise test
– Dependent in most ADLs
– Malnourished (low serum albumin or weight loss)
– Anemia
– Advanced dementia
– Advanced lung, kidney or liver disease
• Await FRAILTY-AVR Results
– Compared prognostic value of various frailty scales
– 1012 adults undergoing TAVR (646) or SAVR (374)
Circulation. 2017;135:2025–2027.
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FRAILTY-AVR RESULTS J Am Coll Cardiol 2017;70:689–700
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FRAILTY-AVR RESULTS: EFT
J Am Coll Cardiol 2017;70:689–700
EFT strongest predictor of
• Mortality 1 yr OR 3.72
• Disability at 1 yr OR 2.13
• 30 day mortality OR 3.29
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CONCLUSIONS
• Frailty is common among patients with CVD
• Many assessment tools available
• Consider setting, disease and purpose of
frailty score when choosing tool
• Deficit accumulation approach for research
• Patient Centered Tiered Approach
– Screening (gait speed or EFT)
– Comprehensive Geriatric Assessment
– Goals Assessment