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Frailty Assessment:
Simplifying the ComplexNatalie 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
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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
