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

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

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

J Gerontol: Medical Sciences 2001,

Vol. 56A, No3, M146-M156.

Scoring:

0: robust

1-2: pre-frail

3 or more: frail

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.

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

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

Essential

Frailty

Toolset

Domains:

-Physical

-Cognitive

-Anemia

-Nutrition

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

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

FRAILTY AND OUTCOMES POST DT-LVAD

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

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.

FRAILTY-AVR RESULTS J Am Coll Cardiol 2017;70:689–700

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

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THANK YOU!Natalie.sanders@hsc.utah.edu