Importance of frailty in patients with cardiovascular disease

Abstract

Cardiovascular diseases (CVDs) are the leading cause of morbidity and mortality. With the ageing population, the prognostic determinants among others include frailty, health status, disability, and cognition. These constructs are seldom measured and factored into clinical decision-making or evaluation of the prognosis of these at-risk older adults, especially as it relates to high-risk interventions. Addressing this need effectively requires increased awareness and their recognition by the treating cardiologists, their incorporation into risk prediction models when treating an elderly patient with underlying complex CVD, and timely referral for comprehensive geriatric management. Simple measures such as gait speed, the Fried score, or the Rockwood Clinical Frailty Scale can be used to assess frailty as part of routine care of elderly patients with CVD. This review examines the prevalence and outcomes associated with frailty with special emphasis in patients with CVD.

Keywords: Assessment; Cardiovascular disease; Frailty; Prognosis.

Figure 1

Trajectories of health and functioning with ageing. On the ‘Y’ axis is the global measure of performance which may be physical, cognitive, social, or quality of life. Performance is divided into the meaningful levels. Individuals with full performance and high functional reserve can face environmental perturbations with ease. In contrast frail, individuals have a high risk from homoeostasis disruption and negative health outcomes including disability and death, due to exhaustion of functional reserve. With disability assistance is needed to function. The trajectory of decline with ageing varies widely between individuals. In some it is much steeper, and crosses the threshold of disability years before death. It may be precipitous after stroke, myocardial infarction, or fracture. Effective treatments of the presenting condition, avoiding complications and interventions which reduce frailty (arrow) may decrease the rate of decline or improve performance (modified from source).

Figure 2

Relationship between frailty, age and the risk of death. This figure demonstrates a relationship between deficit accumulation as an estimate of biologic age and its correlation with the risk of death. Consider two people, A and B, of the same chronologic age. At 78 years, the mean value of the frailty index is 0.16. Person A has a frailty index value of 0.26 that is higher than the mean value by 0.1 corresponding to the mean value of the frailty index at age 93 years. In essence, person A has the life expectancy of 93 years old; thus, although chronologically 78 years old, person A can be considered to be biologically 93 years old. In contrast, person B has a frailty index value of 0.1 that is lower than the mean value by 0.06 corresponding to the mean value of the frailty index at age 63 years. In essence, person B has the life expectancy of 63 years old; thus, although chronologically 78 years old, person B can be considered to be biologically 63 years old.

Figure 3

Proposed algorithm for older adults with cardiovascular disease.