Frailty Assessment: Simplifying the Complex Natalie Sanders, DO Internal Medicine, Geriatrics Rocky Mountain Geriatrics Conference 2017 U N I V E R S I T Y O F U T A H H E A L T H, 2 0 1 7
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 U N I V E R S I T Y O F U T A H H E A L T H, 2 0 1 7
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 U N I V E R S I T Y O F U T A H H E A L T H, 2 0 1 7
Curr Cardiovasc Risk Rep 2011; 5: 467-472
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 U N I V E R S I T Y O F U T A H H E A L T H, 2 0 1 7
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 Clinical Frailty Scale (CSHA) Gronigen Frail Indicator Fatigue, resistance, ambulation, illnesses, wt loss 0-5 Clinical judgement 0-7 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) Essential Frailty Toolset (EFT) Balance, Leg strength, Gait 0-12 Four domains: Physical, Cognition, Anemia, Nutrition 0-5
Scoring: 0: robust 1-2: pre-frail 3 or more: frail J Gerontol: Medical Sciences 2001, Vol. 56A, No3, M146-M156.
KAPLAN MEIER CURVES CHS AND FRIED PHENOTYPE
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. U N I V E R S I T Y O F U T A H H E A L T H, 2 0 1 7
CSHA Clinical Frailty Scale 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 Mildly frail Not frankly dependent, people c/o being slowed up Limited dependence for IADLs Moderately frail Need help with IADLs and ADLs Severely frail Completely dependent for ADLs
Essential Frailty Toolset Domains: -Physical -Cognitive -Anemia -Nutrition
J Aging Phys Act 2015; 23(2):314-322
FRAILTY AND HYPERTENSION U N I V E R S I T Y O F U T A H H E A L T H, 2 0 1 7 Accessed 8.24.17 https://www.consumeraffairs.com/high-blood-pressure
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 U N I V E R S I T Y O F U T A H H E A L T H, 2 0 1 7
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 FI J 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. U N I V E R S I T Y O F U T A H H E A L T H, 2 0 1 7
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 U N I V E R S I T Y O F U T A H H E A L T H, 2 0 1 7
FRAILTY AND ADVANCED HEART FAILURE INTERVENTIONS-DT LVAD U N I V E R S I T Y O F U T A H H E A L T H, 2 0 1 7
EXISTING MODELS TO PREDICT DEATH Circ Heart Fail..
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 U N I V E R S I T Y O F U T A H H E A L T H, 2 0 1 7
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.
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. U N I V E R S I T Y O F U T A H H E A L T H, 2 0 1 7
FRAILTY-AVR RESULTS J Am Coll Cardiol 2017;70:689 700
FRAILTY-AVR RESULTS: EFT EFT strongest predictor of Mortality 1 yr OR 3.72 Disability at 1 yr OR 2.13 30 day mortality OR 3.29 J Am Coll Cardiol 2017;70:689 700
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 U N I V E R S I T Y O F U T A H H E A L T H, 2 0 1 7
THANK YOU! Natalie.sanders@hsc.utah.edu U N I V E R S I T Y O F U T A H H E A L T H, 2 0 1 7