Interventions for Frailty Among Older Adults With Cardiovascular Disease: JACC State-of-the-Art Review

Abstract

With the aging of the world's population, a large proportion of patients seen in cardiovascular practice are older adults, but many patients also exhibit signs of physical frailty. Cardiovascular disease and frailty are interdependent and have the same physiological underpinning that predisposes to the progression of both disease processes. Frailty can be defined as a phenomenon of increased vulnerability to stressors due to decreased physiological reserves in older patients and thus leads to poor clinical outcomes after cardiovascular insults. There are various pathophysiologic mechanisms for the development of frailty: cognitive decline, physical inactivity, poor nutrition, and lack of social supports; these risk factors provide opportunity for various types of interventions that aim to prevent, improve, or reverse the development of frailty syndrome in the context of cardiovascular disease. There is no compelling study demonstrating a successful intervention to improve a global measure of frailty. Emerging data from patients admitted with heart failure indicate that interventions associated with positive outcomes on frailty and physical function are multidimensional and include tailored cardiac rehabilitation. Contemporary cardiovascular practice should actively identify patients with physical frailty who could benefit from frailty interventions and aim to deliver these therapies in a patient-centered model to optimize quality of life, particularly after cardiovascular interventions.

Keywords: aging; cardiovascular disease; frailty; interventions; older adult.

Figure 1.. Theoretical model of the drivers of frailty syndrome and CVD.

A combination of genetic and environmental factors cause dysfunction at a cellular/molecular scale (yellow) driving physiological responses in different organ systems (orange) resulting in clinical manifestations of CVD and/or the physical frailty syndrome (red). Both are intertwined in a bidirectional relationship as the presence of one entity drives the progression of the other. *Revised with author’s permission. Nat Aging 1, 36–46 (2021).

Figure 2.. Selected instruments for frailty screening in patients with CVD.

In the Physical Frailty Phenotype model, frailty is defined by meeting three or more of the five criteria of unintentional weight loss, exhaustion, low activity, slowness, and weakness. The Essential Frailty Toolset is scored from 0 (least frail) to 5 (most frail), based on the following components chair stands, cognitive impairment, hemoglobin, and serum albumin. The Deficit Accumulation Index is a deficit-accumulation approach based off the theory that vulnerability stems from the accumulation of health deficits.

Central Illustration.. Interventions aimed to prevent or reverse frailty in patients with CVD.

Physical, pharmacological, cognitive, nutritional, and psychosocial interventions or a combination thereof have the potential to prevent the onset of frailty (primary prevention), reverse frailty (secondary prevention), or improve the quality of life in older patients with preexisting frailty (tertiary prevention).