www.revportcardiol.org
Revista
Portuguesa
de
Cardiologia
Portuguese
Journal
of
Cardiology
REVIEW
ARTICLE
Frailty
in
cardiovascular
disease:
Screening
tools
Ana
Zão
a,∗,
Sandra
Magalhães
a,
Mário
Santos
b,caServic¸odeMedicinaFísicaedeReabilitac¸ão,CentroHospitalardoPorto,Porto,Portugal bServic¸odeCardiologia,CentroHospitalardoPorto,Porto,Portugal
cDepartamentodeFisiologiaeCirurgiaCardiotorácica,FaculdadedeMedicinadaUniversidadedoPorto,Porto,Portugal
Received24September2017;accepted19May2018
KEYWORDS Frailty; Cardiovascular disease; Assessment; Screening
Abstract Cardiovasculardisease(CVD)istheleadingcauseofdeathindevelopedcountries anddisproportionatelyaffectsolderadults.Frailtyisacomplexclinicalsyndromewithmultiple causes andcontributingfactorsinwhich thereisincreasedvulnerabilitywhenexposed toa minorstressorandincreasedriskforadverseoutcomes,suchasdisability,hospitalizationand mortality.FrailtyisanimportantprognosticfactorinpatientswithCVD,andsoidentifyingthis featurewhenassessingthesepatientsmayhelptoindividuallytailorcardiovasculartreatment. Thefirststepistoidentifyfrailty.Severaltoolshavebeenvalidatedasscreeningmethodsfor frailty.However,theydivergewithregardtocomplexity,nature,feasibilityandtheoutcome theycanpredict.Theaimofthisreviewistodescribetheavailablescreeningtoolsforfrailty andtoexaminetheirusefulnessinpatientswithCVD.
©2019SociedadePortuguesadeCardiologia.PublishedbyElsevier Espa˜na,S.L.U.
PALAVRAS-CHAVE Fragilidade; Doenc¸as cardiovasculares; Avaliac¸ão; Rastreio
Fragilidadenasdoenc¸ascardiovasculares:instrumentosderastreio
Resumo Asdoenc¸ascardiovasculares(DCV)constituemaprincipalcausademortenospaíses desenvolvidos eafetamdesproporcionalmente osindivíduos idosos.A fragilidade é definida comoumasíndromeclínicacomplexacommúltiplosfatorespredisponentesecaraterizadapor um aumentodavulnerabilidade emaiorriscodedesfechosadversos,nomeadamente, inca-pacidade,institucionalizac¸ãoe/oumortalidade.Pareceserumfatorprognósticoimportante emdoentescomDCV,peloqueoreconhecimentodosdoentescomfragilidadepodepermitir identificarosdoentescommaiorriscoeassimorientaraestratégiaterapêuticacardiovascular mais segura e eficaz.Assim, primeiramenteé fundamental identificar a fragilidade. Vários
∗Correspondingauthor.
E-mailaddress:[email protected](A.Zão).
https://doi.org/10.1016/j.repc.2018.05.019
0870-2551/©2019SociedadePortuguesadeCardiologia.PublishedbyElsevierEspa˜na,S.L.U.
This is an open access article under CC BY-NC-ND license.
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
instrumentos foram validados como métodos de rastreio de fragilidade. No entanto, eles divergemquantoàcomplexidade,natureza,viabilidadeeresultadosquepodemprever.O obje-tivodestarevisãoédescreverasferramentasdisponíveispararastreiodefragilidadeeavaliar assuasdiferenc¸aseutilidadenosdoentescomDCV.
©2019SociedadePortuguesadeCardiologia.PublicadoporElsevierEspa˜na,S.L.U.Esteéum artigoOpenAccesssobalicençadeCCBY-NC-SA( http://creativecommons.org/licenses/by-nc-sa/4.0/).
Listofabbreviations
ACS acutecoronarysyndrome BADL basicactivitiesofdailyliving CABG coronaryarterybypassgrafting CAF ComprehensiveAssessmentofFrailty CFS ClinicalFrailtyScale
CHS CardiovascularHealthStudy CSHA CanadianStudyofHealthandAging CVD cardiovasculardisease
EFS EdmontonFrailScale EFT EssentialFrailtyToolset
EuroSCORE European System for Cardiac Operative RiskEvaluation
GFI GroningenFrailtyIndicator GFST GérontopôleFrailtyScreeningTool LVAD leftventricularassistdevice
MACCE majoradversecardiovascularand cerebrovas-cularevents
MMSE Mini-MentalStateExam MNA MiniNutritionalAssessment
MPI MultidimensionalPrognosticInstrument MSSA MacArthurStudyofSuccessfulAging STS SocietyofThoracicSurgeons
TAVI transcatheteraorticvalveimplantation TFI TilburgFrailtyIndicator
TUG TimedUpandGo
Introduction
Cardiovasculardisease(CVD)istheleadingcauseofdeath indevelopedcountriesanddisproportionatelyaffectsolder adults.1 Age by itself is a strong predictor of adverse
events in acute coronary syndrome(ACS) and other CVD. Mostprognosticmodelsconsiderage,butdonottake into accountotherrelatedfactors,suchasfrailty,healthstatus, disabilityandcognition.2 Patientswhohave lower
physio-logical reserve and functional capacity are at higher risk forhomeostaticdisruptionwhenfacingastressfulevent.3
Identificationof patientsat increasedriskof frailtyanda betterunderstandingoftheimpactofthisvariableonCVD outcomesmayimprovethequalityofhealthcare.
Theaimofthisreviewistodefinefrailtyandtodescribe theavailablescreeningtoolsthatcanhelptoidentifyfrailty
amongpatients withCVD. We discussthe advantages and limitationsofeachtool,aswellasthepotentialimpactof theiruseinclinicalpractice.
Frailty
Definitionandepidemiology
Frailtyisacomplexclinicalsyndromewithmultiplecauses and contributing factors in which there is increased vul-nerabilitywhenexposedtoaminorstressorandincreased riskforadverseoutcomes,suchasdisability,hospitalization and/ormortality.4,5Thisisoftenmanifestedbymaladaptive
responsetostressors,leadingtoaviciouscycletoward func-tionaldeclineandother seriousadverse healthoutcomes. It ischaracterized bydiminished strength,endurance and physiological reserve across theneuromuscular, metabolic andimmunesystems.6Itisimportanttonotethatoldage
itselfdoesnotdefinefrailty,becausesomepatientsremain vigorousdespiteadvancedage,whileotherscanhave func-tional decline in the absent of apparent stress factors or failuretoreboundfollowinghospitalizationorillness.5Thus,
itisimportanttonotethedifferencebetweenbiologicalage andchronologicalage.7
Theprevalenceoffrailtyrangesfrom4%to17%,andis higheramongwomen(almostdoublethatinmen), increas-ing significantly in patients older than 80 yearsof age.8,9
Pre-frailty(whichdescribes patientsatriskforfrailtywho fulfill some,but notall,criteriafor frailty)hasbeen also beenthesubjectofvariousstudies,whichshowaprevalence around28-44%.9 Severalfactors arethoughttocontribute
to the development of frailty, including poor nutrition, reduced exercise tolerance, aging, chronic inflammation and immunological decline.7 Thus, it can potentially be
preventedortreatedwithspecificmodalities,suchas exer-cise, protein-calorie and vitamin D supplementation, and reductionofpolypharmacy.6However,acommonfeatureof
frailpersonsis mildcognitiveimpairment,which hampers theapplicationoftherapeuticregimens,especiallyexercise programs.
Pathophysiology
Frailty is a multifactorial condition. The literature shows that certain changes in physiological systems are asso-ciated with an increased risk for frailty, including a
proinflammatory state and elevated markers of blood clotting,10 sarcopenia,7 anemia,11 anabolic hormone
deficiencies,12,13 insulin resistance,14 significant immune
systemalterations,15 andoxidativestress.16
Theimportanceofdiagnosingfrailtyinpatients withcardiovasculardisease
The agingof populationsis increasingthe numberof frail patients withCVD. Thus,identifyingfrailty has important implications for clinical care. Frailtyworsens prognosisin patientswithCVD(Table1)andofpatientsundergoing car-diac surgery and other cardiovascular interventions, and canreduce thenetbenefitsof somecardiacinterventions because of competing risks.17,18 Frailty also increases the
riskofcardiovascularandnon-cardiovascularmortalityand the need for rehabilitation andinstitutional care.2,19,20 In
thelargeTRILOGYACS trial,whichincluded4671patients olderthan65yearswithACS,25%wereconsideredpre-frail and5%frail(accordingtotheFriedscore).21 Frailpatients
were morelikely tosuffer stroke or cardiovascular death after adjusting for the Global Registry of Acute Coronary Events(GRACE)score.Frailtyis alsoa strongindependent predictorofmortalityin heartfailurepatients.Onestudy foundapopulation-attributableriskassociatedwithfrailty for emergency department visits of 35% and for hospital-izations of 19% among patients withheart failure.22 Kang
etal.foundthatfrailtywasstronglyandindependently asso-ciatedwithshort-termoutcomesforelderly patientswith ACS.23 InastudybyEkerstadetal.frailtywasstronglyand
independently associated with in-hospital mortality, one-monthmortality,prolongedhospitalcare,andtheprimary compositeoutcomeinpatientswithnon-ST-segment eleva-tionmyocardialinfarction.24Riccietal.alsofoundthatfrail
andpre-frail older individualsaccounted for a substantial proportionof thosewithmore cardiovascularrisk factors, especially diabetes, highlighting the need for preventive strategiesin ordertoavoid theco-occurrenceofCVD and frailty.25
Similarly, frailtyis associatedwithhighermortalityand morbidityandgreaterneedforhealthcareinpatientswith valvulardiseaseundergoingcardiacsurgery.20,26
The number of elderly patients undergoing cardiac surgery is increasing. Frailty screening may be useful to identifypatientswithincreasedriskofadverse outcomes. Sundermannetal.foundthatpatientswhodiedwithinone year had a median Comprehensive Assessment of Frailty (CAF)scoreof16[5;33]comparedto11[3;33]inone-year survivors(p=0.001),proving theprognosticvalueof frailty in cardiac surgery.20 Afilalo et al. also demonstrated the
association between frailty and mortality or major mor-bidityaftercoronaryarterybypassgrafting(CABG)and/or valvesurgery(oddsratio[OR]2.63; 95%confidence inter-val[CI]1.17-5.90).28 Inastudy byJungetal.,frailtywas
associatedwitha3-to8-foldincreasein riskof postoper-ativedelirium.Accordingtotheseauthors,‘frail’and‘fit’ maybeconsidered twoendsof acontinuum,andtherisk of postoperative delirium grows as one becomes increas-inglyfrail.29 Therehasalsobeeninterestinunderstanding
whetherpreoperativefrailty isassociatedwithworse out-comesafterimplantationofaleftventricularassistdevice
(LVAD)asdestinationtherapy.AstudybyDunlayetal.using adeficitindextoassessfrailtyfoundthatpatientswhowere intermediatefrail(adjustedHR1.70,95%CI0.71-4.31)and frail(HR3.08,95%CI1.40-7.48)wereatincreasedriskfor death(p=0.004fortrend).Themeannumberofdaysalive outof hospital thefirst year after LVADimplantation was higher for patients who were not frail.30 Schoenenberger
et al. studied elderly patients undergoing transcatheter aortic valve implantation (TAVI) and showed that all the componentsoftheirgeriatricbaselineexaminationhelped predictfunctionaldeclineafterintervention(OR:3.31;95% CI1.21-9.03).26Storteckyetal.foundthatfrailtywas
asso-ciatedwithincreasedall-causemortality(OR:3.68;95%CI 1.21-11.19),and withincreased majoradverse cardiovas-cular andcerebrovascular events (MACCE) (OR:4.89; 95% CI1.64-14.60) oneyearafterTAVI (OR:3.68;95%CI 1.21-11.19).31
Pre-frailty,which is a potentially reversiblestate, also appearstohavesomeprognosticvalue.ThefindingsofSergi etal. suggest that pre-frailtyis independently associated withahigher risk of older adultsdeveloping CVD. Among thephysicaldomainsofpre-frailty,lowgaitspeedseemsto bethebestpredictoroffutureCVD.32
Assessmentoffrailtymayleadtopatientsbeing reclas-sified to different clinical risk categories, suggesting it signalsrisknotcapturedbycurrentlyusedriskassessment scores.2,32
Howtoscreenforfrailty
Anidealfrailty screeningtool should(1)beable to accu-rately identify frailty; (2) predict the response of frail patientstopotentialtherapies;and(3)besimpleandeasy to apply and have low cost.33 Simple and rapid
screen-ingtestshavebeendevelopedandvalidatedtoenablethe objectiverecognition of frail persons. They differ mainly inthenatureandnumberofdeficitstheymeasure,inline withtwo contrasting conceptual models:the frailty phe-notype,or physical frailty, andthefrailty indexor deficit accumulation.34Thephenotypeconceptconsidersfrailtyas
a syndrome, consisting of a small number of highly spe-cificdeficits in health, such asunintentional weightloss, exhaustion,slowness,lowphysicalactivityandimpairedgrip strength.Furtherspecifichealthdeficits,suchascognitive deficits,havebeenproposedaspartofafrailtyphenotype scale.Bycontrast,frailtyindicesarebasedontheconceptof cumulativedeficit,assessingfrailtythroughalargernumber ofunspecifiedage-associatedhealthdeficits(usuallyatleast 30).ThemostcommonlyusedaretheFRAILQuestionnaire screeningtool,35---38theCardiovascularHealthStudyFrailty
ScreeningScale (Friedcriteria),9 theClinicalFrailty Scale
(CFS),39 frailtyindices,40,41 andtheEdmontonFrail Scale42
(Table2).
TheFRAILQuestionnairescreeningtool
The FRAIL Questionnaire screening tool considers deficits accumulatedinfivedomains,formingitsacronym:Fatigue
(self-reported), Resistance, Ambulation (slow walking speed),Illnesses,andLossofweight(5%ormoreinthepast year). The five domains areweighted equally. Individuals
Table1 Studiesoffrailtyincardiovasculardisease. Study CVDand
population
Screeningtoolsfor frailty
Othertools Results Kangetal.23 ACS
352patients, age>65years
CFS CGA
CAD-specificindex
CFSwasusefulinevaluationofelderly patientswithACS.Frailtywasstronglyand independentlyassociatedwithshort-term outcomesforelderlypatientswithACS. Uchmanowicz
etal.50
ACS TFI CGA Significantcorrelationsweredemonstrated
betweenthevaluesoftheTFIandother scales.
Ekerstadetal.24 ACS
307patients, age>75years
CFS CAD-specificindex Frailtywasstronglyandindependently associatedwithin-hospitalmortality, 1-monthmortality,prolongedhospitalcare andtheprimarycompositeoutcome.The combineduseoffrailtyandcomorbidity mayconstituteanovelriskprediction conceptinregardtocardiovascular patientswithcomplexneeds.
Boxeretal.17 Heartfailure CHS 6MW Bothtoolswereassociatedwithmortality
(p=0.005)andhighlycorrelated.The6MW maybeusefulasameasureoffrailty. Invasivecardiacinterventions
Afilaloetal.51 TAVIandvalve
surgery 1020patients, medianage82 years EFT CHS Fried+a CFS PPB BernScale ColumbiaScale
Frailtyisariskfactorfordeathand disabilityfollowingTAVIandvalvesurgery. TheEFToutperformedotherfrailtyscales andisrecommendedforuseinthissetting. Jungetal.29 Elective
cardiacsurgery, 133patients MFC 35-itemFrailty Index SPPB SPBB EuroSCOREII
Frailtyresultsina3-to8-foldincreasein riskofpostoperativedelirium,independent oftheEuroSCOREII.Theadditionoffrailty improvestheabilityoftheEuroSCOREIIto predictpostoperativedelirium,pointingto opportunitiesforimprovedpreventionand management.
Dunlayetal.30 LVAD 31-itemFrailty
Index
- FrailtybeforedestinationLVAD
implantationisassociatedwithincreased riskofdeathandmayrepresenta significantpatientselectionconsideration. Schoenenberger
etal.26
TAVI Geriatricbaseline examination
EuroSCORE STS
Thegeriatricbaselineexamination,butnot establishedriskscores,waspredictive offunctionaldecline.
Greenetal.53 TAVI MFC Frailtywasassociatedwithincreased
1-yearmortalityafterTAVI.
Storteckyetal.31 TAVI MGA EuroSCORE
STS MACCE
Riskpredictioncanbeimprovedbyadding multidimensionalgeriatric
assessment-basedinformationtoglobalrisk scores.
Afilaloetal.28 CABGand/or
valvesurgery SimplifiedFried criteria(5-item) Friedcriteria (7-item) MSSA Five-metergait speedtest Disabilityscalesb
Surgicalriskscoresc
Cliniciansshoulduseanintegrative approachcombiningfrailty,disability,and riskscorestobettercharacterizeelderly patientsreferredforcardiacsurgeryand identifythosethatareatincreasedrisk.
Table1(Continued)
Study CVDand population
Screeningtoolsfor frailty
Othertools Results Sundermann etal.20 CABG(25%)vs. valvesurgery (35%)vs. combined procedures (26%) CAF EuroSCORE STS
CAFisanadditionaltooltoassessprognosis ofelderlypatientsbeforecardiacsurgical interventions.TheCAFscorefacilitates predictionof30-dayoutcomeofhigh-risk elderlypatients.
6MW:six-minutewalktest;ACS:acutecoronarysyndrome;CABG:coronaryarterybypassgrafting;CAD:coronaryarterydisease;CAF: ComprehensiveAssessmentofFrailtyscore;CFS:ClinicalFrailtyScale;CGA:ComprehensiveGeriatricAssessment;CHS:Cardiovascular HealthStudyscale; CVD:cardiovasculardisease; EFT:EssentialFrailtyToolset;EuroSCORE:EuropeanSystemfor CardiacOperative RiskEvaluation;LVAD:leftventricularassistdevice;MACCE:majoradversecardiovascularandcerebralevents;MFC:ModifiedFried Criteria;MSSA:4-itemMacArthurStudyofSuccessfulAgingfrailtyscale; MGA:MultidimensionalGeriatricAssessment;PPB: Physical PerformanceBattery;SPPB:ShortPhysicalPerformanceBattery;STS:SocietyofThoracicSurgeonsriskscore;TAVI:Transcatheteraortic valveimplantation;TFI:TilburgFrailtyIndicator.
a Fried+:Friedcriteria+cognitionandmoodassessment.
b Disabilityscales:6-itemKatzActivitiesofDailyLivingscale;7-itemOlderAmericansResearchandServicesInstrumentalActivitiesof DailyLivingscale;7-itemNagiscale.
c Surgicalriskscores:theSocietyofThoracicSurgeonsPredictedRiskofMortality,theSocietyofThoracicSurgeonsPredictedRiskof MortalityorMajorMorbidity;EuroSCORE;revisedParsonnetscore;Age-Creatinine-EjectionFractionscore.
withtwodeficits areconsidered pre-frail,and thosewith threeormoredeficitsareclassifiedasfrail.
Friedcriteriaforfrailty
TheFriedcriteriaforfrailty(alsoknownasthe Cardiovascu-larHealthStudyFrailtyScreeningScale,thePhysicalFrailty Phenotype and the Hopkins Frailty Phenotype) was first developed intheCardiovascular HealthStudy.9It assesses
physical characteristics or phenotype, which include five domains: unintentionalweightloss(4.5 kgor morein the lastyear),exhaustion(self-reported),lowphysicalactivity, weakness (low grip strength), and walking speed.9,43 Low
physicalactivityisassessedthroughthefrequencyof mod-erate intensity activities, such asgardening or household chores.Similarlytothepreviousscale,individualswithtwo deficits are considered pre-frail, and those with threeor moredeficitsareclassifiedasfrail.29
ClinicalFrailtyScale
The CFSisaglobal clinical assessmentof frailtybasedon physicalfunctionandlevelofindependencewithactivities ofdailylivingproposedbyRockwoodetal.39Eachpointonits
scalehasavisualchartandawrittendescriptionoffrailtyto assisttheclassificationprocess.Scoringisbasedonclinical judgmentandrangesfrom1(veryfit)to9(terminallyill).39 Frailtyindices
Frailty indices are based on the deficit accumulation approachtomeasuringfrailty,andarecommonlyusedtools to assess frailty in order to estimate the related risk for adversehealthoutcomes,suchasmortality.44Afrailtyindex
is based on the concept that frailty is a consequence of interacting physical, psychological, and social factors. As deficitsaccumulate,peoplebecomeincreasinglyvulnerable
toadverseoutcomes.Thesubjectanswers20ormore ques-tionsrelatedtomedicalandfunctionalissues.Thetoolcan beadaptedtoinformationavailable inthemedicalrecord anddoesnotrequireapatientintervieworexamtoassess frailty.The 70 items of theoriginal version arenottobe considered a fixed set of variables (Table 3). It has been reportedthatestimates of riskare strongerwhena mini-mumof 50items areconsidered, but shorter versions (as few as 20 items) have also been studied.39---41 Rockwood
andMitnitski44proposedadeficitaccumulation-basedfrailty
indexusingacomprehensivegeriatricassessment(FI-CGA). Thisinvolvestheaccumulationof30ormorecomorbidities, symptoms, diseases, disabilities and other health deficits and is expressed as a ratio calculated as the number of deficits in an individual divided by the number of total deficitsmeasured; thegreaterthenumberofdeficits,the higherthescore.The comprehensive geriatric assessment (CGA)includesmedical,nutritional,functionaland psycho-logicalassessmentsbyamultidimensionalteam.TheFI-CGA wasinitiallydevelopedasaten-domainindexwith14CGA components and was later expanded to include 52 CGA components.33
EdmontonFrailScale
TheEdmontonFrailScale(EFS)wasdevelopedtobe practi-calandusableinthecommunitysettingoratthebedside. It is scored out of 17 and contains the following com-ponents: cognition, general health status, self-reported health,functionalindependence,socialsupport,nutrition, mood,continence,and functionalperformance.The com-ponentscores are summedand the following cut-offs are usedtoclassifyfrailtyseverity:notfrail(0-5),apparently vulnerable(6-7),mildlyfrail(8-9),moderatelyfrail(10-11) andseverelyfrail(12-17).
Table2 Characteristicsofthemostcommonlyusedfrailtyscales.
Screeningtool Measurementmethod Criteriaforfrailty
SimpleFRAIL Questionnaire
1.Fatigue:areyoufatigued? Frail:≥3
Pre-frail:1or2 2.Resistance:cannotwalkup1flightofstairs?
3.Aerobic:cannotwalk1block?
4.Illnesses:doyouhavemorethan5illnesses?
5.Lossofweight:Haveyoulostmorethan5%ofyourweightinthepast 6months?
Cardiovascular HealthStudy FrailtyScreening Scale
1.Weightloss---lossof10poundsunintentionallyinpastyearorweightatage 60-weightatexam≥10%ofage60weight.
Frail:≥3 Pre-frail:1or2 2.Exhaustion--- self-reportoffatigueorfeltunusuallytiredorweakinthe
pastmonth.
3.Lowactivity--- frequencyanddurationofphysicalactivities(walking,doing strenuoushouseholdchores,doingstrenuousoutdoorchores,dancing, bowling,exercise).
-Men:<383kcal/week=1 -Women:<270kcal/week=1 4.Slowness:
-Men:walking4m≥7sifheight≤173cmor≥6sifheight≥173cm=1 -Women:walking4m≥7sifheight≤159cmor≥6sifheight≥159cm=1 5.Weakness---gripstrength(kg)forbodymassindex(kg/m2)a
ClinicalFrailty Scale
1.Veryfit---peoplewhoarerobust,active,energeticandmotivated.These peoplecommonlyexerciseregularly.Theyareamongthefittestfortheirage. 2.Well---peoplewhohavenoactivediseasesymptomsbutarelessfitthan category1.Often,theyexerciseorareveryactiveoccasionally,e.g. seasonally.
3.Managingwell---peoplewhosemedicalproblemsarewellcontrolled,but arenotregularlyactivebeyondroutinewalking.
4.Vulnerable--- whilenotdependentonothersfordailyhelp,oftensymptoms limitactivities.Acommoncomplaintisbeing‘‘slowedup’’,and/orbeing tiredduringtheday.
5.Mildlyfrail---thesepeopleoftenhavemoreevidentslowing,andneedhelp inhighorderIADLs(finances,transportation,heavyhousework,medications). Typically,mildfrailtyprogressivelyimpairsshoppingandwalkingoutside alone,mealpreparationandhousework.
6.Moderatelyfrail---peopleneedhelpwithalloutsideactivitiesandwith keepinghouse.Inside,theyoftenhaveproblemswithstairsandneedhelp withbathingandmightneedminimalassistance(cuing,standby)with dressing.
7.Severelyfrail---completelydependentforpersonalcare,fromwhatever cause(physicalorcognitive).Evenso,theyseemstableandnotathighrisk ofdying(within∼6months).
8.Veryseverelyfrail---completelydependent,approachingtheendoflife. Typically,theycouldnotrecoverevenfromaminorillness.
9.Terminallyill-approachingtheendoflife.Thiscategoryappliestopeople withalifeexpectancy<6months,whoarenototherwiseevidentlyfrail. Scoringfrailtyinpeoplewithdementia:
-Thedegreeoffrailtycorrespondstothedegreeofdementia.
-Commonsymptomsinmilddementiaincludeforgettingthedetailsofa recentevent,thoughstillrememberingtheeventitself,repeatingthesame question/storyandsocialwithdrawal.
-Inmoderatedementia,recentmemoryisveryimpaired,eventhoughthey seeminglycanremembertheirpastlifeeventswell.Theycandopersonal carewithprompting.
-Inseveredementia,theycannotdopersonalcarewithouthelp. EdmontonFrail
Scale
Cognition
Pleaseimaginethatthispre-drawncircleisaclock.Iwouldlikeyoutoplace thenumbersinthecorrectpositionsthenplacethehandstoindicateatime of‘tenaftereleven’
Noerrors=0;Minorspacingerrors=1;Othererrors=2
0-5=Notfrail 6-7=Vulnerable 8-9=Mildfrailty 10-11=Moderatefrailty 12-17=Severefrailty
Table2(Continued)
Screeningtool Measurementmethod Criteriaforfrailty
Generalhealthstatus
-Inthepastyear,howmanytimeshaveyoubeenadmittedtoahospital? -0times=0;1-2times=1;>2times=2-Ingeneral,howwouldyoudescribeyour health?Excellent,verygood,good=0;Fair=1;Poor=2
Functionalindependence
Withhowmanyofthefollowingactivitiesdoyourequirehelp?(meal preparation,shopping,transportation,telephone,housekeeping,laundry, managingmoney,takingmedications)
0-1activities=0;2-4activities=1;5-8activities=2 Socialsupport
Whenyouneedhelp,canyoucountonsomeonewhoiswillingandable tomeetyourneeds?
Always=0;Sometimes=1;Never=2 Medicationuse
-Doyouusefiveormoredifferentprescriptionsonaregularbasis? No=0;Yes=1
-Attimesdoyouforgettotakeyourprescription medication?
No=0;Yes=1 Nutrition
Haveyourecentlylostweightsuchthatyourclothinghasbecomelooser? No=0;Yes=1
Mood
Doyouoftenfeelsadordepressed? No=0;Yes=1
Continence
Doyouhaveaproblemwithlosingcontrolofurinewhenyoudon’twantto? No=0;Yes=1
Functionalperformance
Iwouldlikeyoutositinthischairwithyourbackandarmsresting.Then,when Isay‘GO,’pleasestandupandwalkatasafeandcomfortablepacetothe markonthefloor(approximately3maway),returntothechairandsitdown 0-10s=0;11-20s=1;>20sorpatientunwilling,orrequiresassistance=2 IADLs:instrumentalactivitiesofdailyliving.
a Men:Bodymassindex(BMI)≤24andgripstrength≤29kg=1;BMI24.1-26andgripstrength≤30kg=1;BMI26.1-28kgandgripstrength ≤30kg=1;BMI>28andstrength≤32kg=1;women:BMI≤23andgripstrength≤17kg=1;BMI23.1-26andgripstrength≤17.3kg=1;BMI 26.1-29andgripstrength≤18kg=1;BMI>29andgripstrength≤21kg=1.
Otherscreeningtools
Thescalesdescribedabovearethosemostcommonlyused toassessfrailty.However,otherfrailtyscalesareavailable, aslistedbelow.
The Groningen Frailty Indicator (GFI) considers 15 dichotomous self-reported deficitsin fourdomains: physi-cal,cognitive,social,andpsychological.45
The Tilburg Frailty Indicator contains 15 self-reported itemsinphysical,psychological,andsocialdomains.46
TheGérontopôleFrailtyScreeningTool(GFST)comprises twosteps: an initial questionnaire (containingsix compo-nents: living alone, involuntary weight loss, fatigability, mobility,memorycomplaintsandslowgaitspeed)followed bytheclinician’sjudgmentoffrailtystatus.47
PRISMA-7containssevenself-reportedcomponents:older than 85 years; male; health problems which limit activi-ties;healthproblemsrequiringstayingathome;supportof anotherperson needed;social support; anduseof acane
orwalkerorwheelchair.Frailtyisdefinedbyascoreof3or more.48
The Multidimensional Prognostic Instrument (MPI) is a multidimensionalprognostictoolusedforhospitalizedolder patients. It includes eight CGA components: ADL, instru-mentalADL,riskofdevelopingpressuresores,comorbidity, medicationnumber,nutritionalstatus,cognitivestatus,and livingstatus.49
Frailtyassessmenttoolsusedincardiovascular disease
Somefrailtyassessmenttoolshavebeendesignedtobeused specificallyinthesettingofCVD(Table4).Someofthetools describedabovearealsousedforthispurpose.23,24,50
Kang et al. used the CFS, which was useful in assess-ment of elderly patients with ACS, predicting all-cause
Table3 ListofvariablesusedbytheCanadianStudyofHealthandAging(CSHA)toconstructthe70-itemCSHAFrailtyIndex.39
Changesineverydayactivities Problemsgoingoutalone Poorlimbcoordination Headandneckproblems Impairedmobility Poorcoordination,trunk Facialbradykinesia Musculoskeletalproblems Poorstandingposture Poormuscletoneinneck Bradykinesiaofthelimbs Irregulargaitpattern Problemsgettingdressed Poormuscletoneinlimbs Falls
Problemswithbathing Impairedvibration Moodproblems
Problemscarryingoutpersonalgrooming Tremoratrest Feelingsad,blue,depressed
Urinaryincontinence Posturaltremor Historyofdepressedmood
Toiletingproblems Intentiontremor Tirednessallthetime
Bulkdifficulties HistoryofParkinson’sdisease Depression(clinicalimpression) Rectalproblems Familyhistoryofdegenerativedisease Sleepchanges
Gastrointestinalproblems Seizures,partialcomplex Restlessness
Problemscooking Seizures,generalized Memorychanges
Suckingproblems Syncopeorblackouts Short-termmemoryimpairment
Skinproblems Peripheralpulses Long-termmemoryimpairment
Malignantdisease Cardiacproblems Changesingeneralmentalfunctioning
Breastproblems Myocardialinfarction Onsetofcognitivesymptoms
Abdominalproblems Arrhythmia Cloudingordelirium
Presenceofsnoutreflex Congestiveheartfailure Paranoidfeatures
Presenceofthepalmomentalreflex Lungproblems Historyrelevanttocognitiveimpairmentorloss Historyofthyroiddisease Respiratoryproblems Familyhistoryrelevanttocognitiveimpairmentorloss
Thyroidproblems Historyofdiabetes Headache
Historyofstroke Arterialhypertension Cerebrovascularproblems
Othermedicalhistory
mortality, unscheduled return visit, and in-hospital and recurrentmajoradversecardiovascularevents.23
Ekerstadet al.usedfrailty asmeasured by the CFSto assessshort-termoutcomesforelderlypatientswith non-ST-segmentelevationmyocardial infarction,andshowedthat thecombineduseoffrailtyandothercomorbiditytools(such asthecoronaryarterydisease-specificindex)mayconstitute anovel riskpredictionconceptinregardtocardiovascular patientswithcomplexneeds.24
Uchmanowicz et al. investigated the correlation of a scaleforassessingfrailty---theTilburgFrailtyIndicatorand itsmentalandphysicaldomains---withotherscreeningtools commonlyusedforCGAinpatientswithACS.Significant cor-relationsweredemonstratedbetweenthevaluesoftheTFI andotherscales.50
Boxeretal.alsofoundthatthesix-minutewalkandthe five-itemCardiovascular HealthStudy wereindependently predictive of mortalityin older adults withheart failure, withhazardratio(HR)0.82(95%CI0.72-0.94)and1.64(95% CI1.19-2.26), respectively, andboth could beuseful asa measureoffrailty.17
In a prospective observational study by Jung et al. in electivecardiacsurgerypatients,frailtywasdefinedusing theseven-itemCardiovascularHealthStudyscore,theShort PhysicalPerformance Battery(SPPB)and a35-itemfrailty index.Theyfoundthattheadditionoffrailtyimprovedthe abilityof theEuroSCOREII topredict postoperative delir-ium,pointingtoopportunitiesforimprovedpreventionand management.29
TheCAFisatoolcreatedbySundermannetal.20toassess
the prognosis of elderly patients before cardiac surgical interventionsandaccuratelypredictsmortality.Itcomprises grip strength,walking speed,balance, andability topick upapen fromthefloor,risefroma chairthreetimesand putonandremoveajacket,thuscombiningcharacteristics
oftheCHScriteria9 ofpatientphenotype,physical
perfor-mance, and laboratory results. According to the authors, a combination of theCAF and traditional scoring systems may facilitate more accurate risk scoring in elderly high-riskpatientsscheduledforconventionalcardiacsurgeryor transcatheteraorticvalvereplacement.27TheCAFwas
pre-operativelyappliedto400patientsaged≥74yearsadmitted toacardiacsurgicaldepartmentbetweenSeptember2008 andJanuary2010.For213ofthesepatientsone-year follow-up was assessed by telephone interview until April 2010. Onehundred andten maleand103 femalepatients were included.Twenty-fivepercentunderwentisolatedcoronary revascularization, 35% isolated valve procedures and 26% underwent combined procedures.One-year mortality was 12.2%. Patients who died within one year had a median frailty score of 16 [5;33] compared to 11 [3;33] in one-yearsurvivors(p=0.001).20 Sundermannetal.showedthat
theCAFscorefacilitatespredictionofmid-termoutcomeof high-riskelderlypatientsandthemodifiedCAFscoreshowed apromisingabilitytopredictone-yearmortalityinpatients undergoingcardiacsurgery.20,27
The study by Dunlay et al. assessed the association between preoperative frailty and worse outcomes after implantationofanLVAD.PatientsundergoingLVAD implan-tationasdestinationtherapyattheMayoClinic,Rochester, MN between February 2007 and June 2012 wereincluded in this study. Frailty was assessed using a deficit index (including 31 impairments, disabilities and comorbidities) anddefinedastheproportionof deficitspresent.Patients were then divided based on tertiles of the deficit index (>0.32=frail, 0.23 to 0.32=intermediate frail, <0.23=not frail). The authors concludedthat frailty before destina-tionLVADimplantation,asassessedbytheirdeficitindex,is associatedwithincreasedriskofdeathandmayrepresenta significantpatientselectionconsideration.30
Some tools have also been applied to patients under-goingTAVI. Storteckyetal. assessedthe Multidimensional Geriatric Assessment (MGA) as a predictor of mortality and MACCE after TAVI. This prospective cohort com-prised100consecutivepatientsaged≥70yearsundergoing TAVI. Global risk scores (Society of Thoracic Surgeons [STS] score, EuroSCORE) and MGA-based scores (cogni-tion, nutrition, mobility, activities of daily living [ADL], andfrailtyindex)wereassessedaspredictorsof all-cause mortality and MACCE 30 days and one year after TAVI. This study provides evidence that risk prediction can be
improved by adding MGA-based informationto global risk scores.31
Schoenenberger et al. used the EuroSCORE, the STS score, and a geriatric baseline examination (based on assessment of cognition, mobility, nutrition, instrumental and basic activities of daily living) to predict functional decline in elderly patients undergoing TAVI. Overall pre-dictive performance was best for the geriatric baseline examinationandlow forthe EuroSCOREandSTSscore.In univariate analysis,all components of the geriatric base-line examination helped predict functional decline. The
Table4 Toolsusedtoassessfrailtyincardiovasculardisease.
Study Tool Measurementmethod Criteriaforfrailty Sundermann
etal.20
CAF •Patientisaskedtogetupanddownfroma chair3timesandtimeismeasured
•Self-reportedweakness
•Patientisaskedtoclimbasmanystairsas theyareable
•Twophysicians(oneacardiacsurgeon) conducttheCFSfromtheCSHA
Serumcreatininelevel
ResultsfromtheCAFscoresare tabulatedintoascalefrom1 to35pointsasoutlinedbythe supplementaryCAFTestSheet.Scores between1and10aredeemednot frail,between11and25aredeemed moderatelyfrail,andbetween26 and36aredeemedseverelyfrail Greenetal.53 ModifiedFried
frailtycriteria
•Slow15-mgaitspeed
•Weakdominanthandgripstrength •AssistancerequiredinanyofKatzIndex ofIndependenceinActivitiesofDailyLiving criteria
•Serumalbuminasameasurement ofmalnutrition
Frailtydefinedasascore>5ona scalefrom0-12whereahigherscore equatestomorefrail
Forgaitspeed,gripstrength,and serumalbumin,basedonwhich quartileapatientwasin,avalueof 0-3wasgivenforeachquartilein descendingorder.Foractivitiesof dailyliving,0pointsweregivenfor independentand3
fordependent Afilaloetal.28 4scalesused:
•5-itemModified FriedCriteria •7-itemexpanded ModifiedFried Criteria •4-itemMSSA •Five-MeterGait SpeedTest
•5-itemModifiedFriedCriteria:gaitspeed, handgripstrength,inactivity,exhaustion, andweightloss
•7-itemModifiedFriedCriteria:theaboveas wellascognitiveimpairmentanddepressed mood
•4-itemMSSAusedgaitspeed,handgrip strength,inactivity,andcognitiveimpairment •prolongedtimeforgaitspeedtest(>6s towalk5m)
Definedasfrailifanyofthe4scales deemedpatientasfrail
Storteckyetal.31 Multidimensional
Geriatric Assessment
•MMSEshowingcognitiveimpairment MNAshowsmalnutrition
•TUGshowinglimitationofmobility •BADLandinstrumentalactivitiesofdaily livingshowedanactivitywithlimitation •Preclinicalmobilitydisabilitydefinedas decreasedfrequencyofwalking200m and/orclimbingstairsinpreceding6months
Definedfrailtyas≥3points,2points ifMMSE<21,1pointifMMSE≥21and <27,MNA<12,TUG≥20s,BADLwith atleast1limitedactivity,
instrumentalactivitiesofdailyliving withatleast1limitedactivity, preclinicalmobilitydisability Schoenenberger
etal.26
Geriatricbaseline examination
•MMSEshowingcognitiveimpairment •MNAshowsmalnutrition
•TUGshowinglimitationofmobility •BADLandinstrumentalactivitiesofdaily livingshowedanactivitywithlimitation •Preclinicalmobilitydisabilitydefinedas decreasedfrequencyofwalking200m and/orclimbingstairsinpreceding6months
Definedfrailtyas≥3points,2points ifMMSE<21,1pointifMMSE≥21, and<27,MNA<12,TUG≥20s,BADL withatleast1limitedactivity, instrumentalactivitiesofdailyliving withatleast1limitedactivity, preclinicalmobilitydisability
Table4(Continued)
Study Tool Measurementmethod Criteriaforfrailty
Jungetal.29 ModifiedFried
FrailtyCriteria definitionoffrailty
Slowness
---Aftertwotrialsofa5mwalk,averagetime>6s Weakness
---Afterthreegripstrengthmeasurementswitheach hand,maximumvalue≤30kgifmaleor≤20kgiffemale Weightloss
--- Self-reportedweightloss>4.5kg(10lbs)or>5%body weightinpast12months
Exhaustion
---Two-itemCES-Dscale≥1outof2 Depression
---5-GDS≥2outof5 Lowphysicalactivity
---PaffenbargerPhysicalActivityIndex<383kcal perweekifmaleor<270kcalperweekiffemale Cognitiveimpairment
---MoCAscore<26outof30
Patientwasdeemedfrailifat least3ofthe7criteriawere present 35-itemFrailty Index (i)Comorbidities ---Angina ---Arthritis ---Asthma ---Cerebrovasculardisease ---Cognitiveimpairment ---COPD ---Dyslipidemia ---Gastrointestinaldisease ---Hearingimpairment ---Hypertension ---Myocardialinfarction --- Pacemaker
--- Peripheralvasculardisease
--- Pre-operativeatrialflutterorfibrillation --- Priorangioplastyorstent
--- Pulmonaryhypertension --- Solidtumor
--- Visualimpairment
(ii)Physicalandemotionalmeasures ---Declineinfoodintake
---Depressionbasedonthe5-GDS
---Exhaustionbasedonthetwo-itemCES-D ---Fallsinpastyear
---Inabilitytocompleterepeatedchairstandtest ---LowphysicalactivitybasedonPaffenbargerPhysical ActivityIndex
---Poorbalance ---Self-ratingofhealth ---TUG
---Unintentionalweightlossinpast3months ---Unintentionalweightloss>4.5kg(10lbs) ---Weakgrip
(iii)Functionalmeasures ---Banking,inabilitytoperform ---Cleaning,inabilitytoperform ---Cooking,inabilitytoperform ---Driving,inabilitytoperform ---Shopping,inabilitytoperform
FrailtyIndexscore=individual’s totalnumberofdeficits/35 Deficits:eachcountedas presentorabsent
Table4(Continued)
Study Tool Measurementmethod Criteriaforfrailty SPPB (i)5-mgaitspeedmeasurement
---Aftertwotrials,averagetime: ≤6.5s:4points;6.6-8.3s: 3points;8.4-11.6s:2points; ≥11.7s:1point;unable:0points (ii)Balancetests
--- Side-by-sidestandtime ≥10s:1point;<10s:0points; ---Semi-tandemstand ≥10s:1point;<10s:0points ---Tandemstand ≥10s:2points;3-9.99s:1point; <3s:0points
(iii)Repeatedchairstandtest ---Timetostandupfromchair 5times
≤11.19s:4points;11.20-13.69s: 3points;13.70-16.69s:2points; 16.70-59.99s:1point;≥60s orunable:0points
Patientwasdeemedfrailif compositescore≥9points
Uchmanowicz etal.50
TFI Firstpart:
Sociodemographiccharacteristics ofaparticipant:
gender,age,maritalstatus, countryoforigin,educational level,andmonthlyincome Potentialdeterminantsoffrailty. Secondpart:
Componentsoffrailty(15 self-reportedquestions,divided intothreedomains):
-Physicaldomain(0-8points): eightquestionsrelatedtophysical health,unexplainedweightloss, difficultyinwalking,balance problems,hearingproblems, visionproblems,strengthin hands,andphysicaltiredness. -Psychologicaldomain(0-4 points):fouritemsrelatedto cognition,depressivesymptoms, anxiety,andcoping.
-Socialdomain(0-3points):three questionsrelatedtolivingalone, socialrelations,andsocial support.
ElevenitemsfromparttwooftheTFI havetworesponsecategories(‘‘yes’’ and‘‘no’’),whiletheotheritems havethree(‘‘yes’’,‘‘no,’’ and‘‘sometimes’’).
‘‘Yes’’or‘‘sometimes’’responses arescored1pointeach,while‘‘no’’ responsesarescored0.
Theinstrument’stotalscoremay rangefrom0to15:thehigherthe score,thehigherone’sfrailty. Frailtyisdiagnosedwhenthetotal TFIscoreis>5.
Table4(Continued)
Study Tool Measurementmethod Criteriaforfrailty Dunlayetal.30 31-itemdeficit
index
Needhelppreparingmeals Needhelpfeedingyourself Needhelpdressingyourself Needhelpusingthetoilet Needhelpwithhousekeeping Needhelpclimbingstairs Needhelpbathing Needhelpwalking
Needhelpusingtransportation Needhelpgettinginandoutofbed Needhelpmanagingmedications
Dependonassistivedevices(walker,cane, etc.)orotherpeopletoperformactivities ofdailylife
Dependentonadevicefornormalbreathing Climb2flightsofstairswithoutrest Myocardialinfarction
Diabetes
Peripheralvasculardisease Cerebrovasculardisease COPD
Ulcer Hemiplegia
Moderate/severerenalinsufficiency Historyofliverdisease
Rheumatologicdisease Historyofmalignancy Historyofdementia Hypertension Hyperlipidemia Bodymassindex Depression Anemia Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0
No,cannotdoatall=1;Yes,with difficulty=0.5;Yeswithnodifficulty=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Underweightorobese=1; overweight=0.5;normal=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0 Yes=1,No=0
Patientsweredividedintotertiles ofthedeficitindex:
Lowesttertile=notfrail;middle tertile=intermediatefrail;highest tertile=frail
Afilaloetal.51 EssentialFrailty
Toolset
(i)Timetostand5timesfromaseated positionwithoutusingarms:<15s=0points; ≥15s=1point;unabletocomplete=2points (ii)Cognition:MMSE≥24:0points;MMSE<24: 1point
(iii)Hemoglobin:≥13g/dl(inmen)
or≥12g/dl(inwomen):0points;<13g/dl(in men)
or<12g/dl(inwomen):1point (iv)Serumalbumin:
≥3.5g/dl:0points;<3.5g/dl:1point
Compositescore:0-5
5-GDS:five-itemGeriatricDepressionScale;BADL:basicactivitiesofdailyliving;CAF:ComprehensiveAssessmentofFrailtyscore; CES-D:CenterforEpidemiologicStudiesDepressionscale;CFS:ClinicalFrailtyScale;COPD:chronicobstructivepulmonarydisease; CSHA:CanadianStudyofHealthandAging;MMSE:MiniMentalStateExam;MNA:MiniNutritionalAssessment;MoCA:MontrealCognitive Assessmentscore;MSSA:4-itemMacArthurStudyofSuccessfulAgingfrailtyscale;SPPB:ShortPhysicalPerformanceBattery;TFI:Tilburg FrailtyIndicator;TUG:TimedUpandGotest.
authorsconcludedthatthegeriatricbaselineexamination, butnotestablishedriskscores,waspredictiveoffunctional decline.26
Inthe2012studybyAfilaloetal.,atotalof152patients wereenrolledinaprospective,multicentercohortstudyof elderlypatients(>70years)undergoingCABGand/orvalve surgeryintheUSandCanada.Fourdifferentfrailtyscales, threedisabilityscales,andfivecardiacsurgeryriskscores weremeasuredinallpatients.Theprimaryoutcomewasthe STScompositeendpointofin-hospitalpostoperative mortal-ityormajormorbidity.Thefourfrailtyscalesexaminedin thisstudyaredescribedinTable4.Theauthorsconcluded thatcliniciansshouldusean integrativeapproach combin-ingfrailty,disability,andriskscorestobettercharacterize elderly patients referred for cardiac surgery and identify thosethatareatincreasedrisk.28
The sameauthor,ina recentstudy (2017),51 compared
theincrementalpredictivevalueof sevendifferentfrailty scales topredict poor outcomes following TAVI and valve surgery: the Fried criteria (described above),9 Fried+(the
Fried criteria plus cognition assessed by the Mini Mental StateExam [MMSE] and mood assessed by theShort-form GeriatricDepressionScale),theRockwoodCFS,39 theSPPB
(threephysicaltests,witheachscored0to4foracomposite scoreof0to12:gaitspeed,timetostandfivetimesfroma seatedpositionwithoutusingarmsandtheabilitytostand 10 s with the feetin tandem or side-by-side positions),52
theBernScale (sixitems fora compositescoreof0 to7: gait speed, mobility, cognition, nutrition and disabilityin activitiesofdailylivingandinstrumentalactivities),26,31the
ColumbiaScale (fouritems,witheach scored0 to3for a compositescoreof0to12:gaitspeed,gripstrength,serum albuminand disability),53 andtheEssential FrailtyToolset
(EFT) (four items for a composite score of 0 to 5: time to stand five times from a seated position without using arms (1 point if ≥15 s, 2 points if unable to complete), cognition(1pointifMMSE<24),hemoglobin(1pointif<13 g/dlinmenor <12g/dlinwomen),andserumalbumin (1 pointif<3.5g/dl).51FrailtyasmeasuredbytheEFTwasthe
strongest predictorof deathatone year(p<0.001)andof worseningdisabilityat1year(adjustedOR:2.13;95%CI:1.57 to2.87)anddeathat 30days(adjustedOR:3.29; 95%CI: 1.73to6.26).
Some authors, instead of validating existing frailty screening tools, used certain parameters to derive their ownfrailtyscore.Green etal.useda modificationof the Friedfrailtycriteriathatincludedgaitspeed,gripstrength, serumalbumin,andactivitiesofdailylivingstatustoderive afrailtyscoreamongolderadultswithsevereaorticstenosis whounderwentTAVI.Inthisstudyfrailtywasnotassociated with increased periprocedural complications in patients selectedascandidatestoundergoTAVR,butwasassociated withincreasedone-yearmortalityafterTAVR.53
Screeningtools:criticalanalysis
Wehavedescribedindividualmultiplefrailtymeasurement scales.Therehavebeenvariousstudiescomparingthemost commonlyusedscreeningtools,butagreementonwhichhas thebestabilitytopredictprognosisandall-causemortality is lacking. While some studies found similar prognostic
Table5 Comparisonofthefrailty phenotypeandfrailty indices.57
Frailtyphenotype Frailtyindices Performanceon
fivevariables
Deficitcountorproportionof potentialdeficitsthatapersonhas accumulated
Signs,symptoms Diseases,activitiesofdailyliving, resultsofaclinicalevaluation Possiblebeforea
clinical assessment
Doableonlyafteracomprehensive clinicalassessment Categorical variable Continuousvariable Predefinedset ofcriteria
Unspecifiedsetofcriteria Frailtyasa
pre-disability syndrome
Frailtyasanaccumulationofdeficits
Meaningfulresults potentially restrictedto non-disabledolder persons
Meaningfulresultsinevery individual,independently offunctionalstatusorage
Advantages: - performance-based -easytoapply Advantages: -simpleapproach
-robustindicatoroffrailty Disadvantages:
-flooreffectfor somevariables (immobile patients)
Disadvantages:
-cumbersomeinclinicalsetting
performanceinsomeofthesetools,54,55otherstudiesfound
significant differences.56 In 2013, a consensus conference
identified some of these tools as allowing physicians to objectively recognize frail persons.6 However, theyrange
fromshort,fastandcrudescreeningtoolstosophisticated andtime-consumingscales.Asourceofconcernisthefact thatmanyfrailtyscaleshavebeenmodifiedsomewhatfrom theiroriginal and validated version, leadingto significant differencesinfrailtyclassification.33
Sincethefrailtyphenotypeandfrailtyindicesarebased ondifferentconcepts,itisinappropriatetoconsiderthem asalternativesand/orinterchangeable.57 Table5describes
themaincharacteristicsofthesetwodifferentinstruments. The FRAILscreeningtoolis clinicallyadvantageousdue toitssimple natureand ability tobeobtained fromdata alreadyincluded in a CGA.2 It has been found to be
pre-dictiveofmortalityinspecificpopulations,suchaspatients withCVD.43
The CHS scale (Fried criteria) is a widely used scale appliedin multiple epidemiological studies,and hasgood predictive value for adverse clinical outcomes, including mortality. However, a major factor precluding its clinical applicationistheinclusionofmeasurementsnotroutinely usedforpatientassessment(suchasgripstrengthmeasured by a dynamometer). Anotherimportant limitation of this
scale is that itdoes notinclude psychosocial components offrailty.9
The CFS has been validated as a predictor of adverse outcomesin hospitalized older people, such as all-cause, in-hospital mortality, one-month mortality and prolonged hospitalcare.23,24,33
Deficitaccumulation-basedfrailtyindicesarewell vali-datedand arebetter atpredicting adverseclinical events than other frailty measurements in both hospital and community settings. They have been applied to multiple datasets,butcanbetime-consumingtocalculate.The FI-CGAisusedasaclinicalstandardforfrailtyassessmentand hasbeenfoundtopredictpatientresponseinmultiplefields, includingcardiology.2
TheEFSisavalidandreliablemeasurementtoolinthe hospitalsetting and,sinceit hasonly ninecomponents,it is muchsimpler toextract from CGAsthan the FI-CGA.42
Inacommunity-basedsample,evenwhenadministeredby non-specialists with no formal training in geriatric care, theEFScomparedfavorablywiththeclinicalassessmentof geriatricspecialistswhocompletedamorecomprehensive evaluation.42
Compared withother frailtyassessment tools, theMPI appearstohavegreaterabilitytopredictadverseoutcomes. Nevertheless,additionalresearchisneededtoconfirmthese results.33,49
TheGFIhasmoderateinternalconsistencyandadequate discriminativeability,andshowsgoodfeasibilityand relia-bilityasafrailtymeasurement.Someauthorshaveproposed thatitshouldbeusedtogetherwithafrailtyindexaspart ofatwo-stepscreeningprocess.58
The TFI shows good reliability for identifying frailty in community-dwelling older people. However, although its physical components show good ability to predict adverse events, itssocial components appeartobe weak predictors.59,60
The GFST, designed for early recognition of frailty in community-dwelling older people, appears to be a good frailtyscreeningtool;however,itgivesnospecificguidance forclinicians onhowtoidentifyfrailty andtheclinician’s judgmentoffrailtystatusisquitesubjective.33
Although PRISMA-7 shows good accuracy in identifying frailtyincommunity-dwelling olderpeople,itsabilityasa screening toolis limited sinceit has a tendency to over-screenforfrailty.59
Someofthesetoolshavealsobeenusedincardiovascular patients, such asthe Fried frailty criteria,17,23,24,29 frailty
indices,29,30andtheTFI.50
Thegeriatricbaselineexaminationdevelopedby Schoe-nenberger et al.,26 the multidimensional geriatric
assess-mentusedbyStorteckyetal.,31andtheCAF,20,27developed
bySundermannetal.,arethreerecentfrailtytoolswhich havebeen shown tobe useful inpredicting mortalityand assessingprognosisof elderlypatients withCVD or before cardiacsurgicalinterventions.
Someauthors,suchasAfilaloetal.,prefertousean inte-grativeapproachcombiningfrailty,disability,andriskscores tobettercharacterizeelderlypatientsreferredforcardiac surgery,whichhasprovedtobeusefulforidentifyingthose atincreasedrisk.28
Thesameauthorrecentlyshowedthesuperiorityofthe EFTcomparedtoother frailtyscaleswhenpredictingpoor
outcomesfollowingTAVIandvalvesurgery,sinceitisa rel-ativelysimpletoolthatisneitherparticularlyburdensome nortime-consumingandatthesametimecapturesmultiple domainsoffrailty.Theauthorssuggestedithadthehighest predictivevalue for deathandworseningdisabilityat one yearandrecommendeditsuseinthissetting.51
Assessmentoffrailtyasapreoperativesurgicalriskfactor hasbeenshowntobeusefulandmayincreasethenumber ofelderlypatientsconsideredeligibleforsurgical interven-tions,sinceitenablespriorscreeningforriskandprediction ofsurgicalsuccessandsafety.
When selecting a screening tool, it is also important to take into accountthe ecology of itsapplication, since some frailty measurements are more suitable for use in populationhealthstudiesasscreening,whereasothersare appropriateintheclinicalsettingforscreeningordiagnosis offrailty.42,55,57
Conclusion
Frailty is an important prognostic factor in patients with CVD. It increases the risk of adverse events associated with cardiovascular therapeutic interventions, and there-fore needs to be taken into account when considering whether to intervene. Frail patients may have more complicationsandfewerbenefitsbecauseofthecompeting adverseeventrisk.Theclinicalrelevanceoffrailty assess-mentwillbeevengreaterinthefuturebecausethenumber of frail patients with CVD is set to grow as populations age.Bothsuccessfultreatmentapproachesforfrailpatients andtheinclusionoffrailtywhenassessingpatientsforCVD interventionrequirethesystematicandroutine identifica-tionoffrailty.Simple andrapidscreeningtestshavebeen developedandvalidatedtoenabletheobjectiverecognition offrailpersons. Therearesignificant differencesbetween thesescalesintheirnature,validityandfeasibility.Further studiesareneededtoestablishtheirsignificanceregarding overall andcardiovascularmortality. IntheCVD field,the twomostcommonlyusedandmostrobustfrailtyassessment toolsforusebycliniciansandresearchersaretheFried crite-riaandfrailtyindices.Othernewtoolsspecificallydesigned for CVDhave provedextremely usefulfor thispropose. In linewithpreviousstudies,wesuggesttheuseofonesimple toolforfrailtyscreeningandasecondoneforafull assess-ment,andforthesepurposeswerecommendtheuseofthe Friedcriteriaandafrailtyindex,respectively.Theimpactof therapeuticstrategiestargetingfrailtyitselfisstillunclear. Nevertheless,routinescreeningandobjectivediagnosis of frailtyisboundtoimprovethetherapeuticdecision-making processandprognosticassessmentofpatientswithCVD.
Conflicts
of
interest
Theauthorshavenoconflictsofinteresttodeclare.
References
1.Heart disease and stroke: the nation’s leading killers; 2005 http://www.cdc.gov
2.SinghM,StewartR,WhiteH.Importanceoffrailtyinpatients withcardiovasculardisease.EurHeartJ.2014;35:1726-31.
3.Strandberg T, Pitkala K. Frailty in elderly people. Lancet. 2007;369:1328---9.
4.Rodríguez-Ma˜nas L, Féart C, Mann G, et al. Searching for an operational definition of frailty: a delphi method based consensus statement. Frailty Oper Def Cons Conf Project. 2013;68:62---7.
5.CleggA,YoungJ,IliffeS,etal.Frailtyinolderpeople.Lancet. 2014;381:752---62.
6.MorleyJ,VellasB,VanKanA,etal.FrailtyConsensus:acallto action.2014;14:392---7.
7.FerrucciL,CavazziniC,CorsiA,etal.Biomarkersoffrailtyin olderpersons.JEndocrinolInvest.2002;25Suppl.:10---5. 8.CollardR,BoterH,SchoeversR,etal.Prevalenceoffrailtyin
community-dwellingolderpersons:asystematicreview.JAm GeriatrSoc.2012;60:1487---92.
9.FriedL,TangenC,WalstonJ,CardiovascularHealthStudy Col-laborativeResearchGroup.Frailtyinolderadults:evidencefor aphenotype.JGerontolABiolSciMedSci.2001;56:M146---56. 10.WalstonJ,McBurnieM,NewmanA,etal.Frailtyandactivation
oftheinflammationandcoagulationsystemswithandwithout clinicalcomorbidities:resultsfromtheCardiovascularHealth Study.ArchInternMed.2002;162:2333---41.
11.ChavesP,SembaR,LengaS,etal.Impactofanemiaand cardio-vasculardiseaseonfrailtystatusofcommunity-dwellingolder women:thewomen’shealthandagingstudiesIandII.J Geron-tolABiolSciMedSci.2005;60:729---35.
12.Cappola A, Xue Q, Fried L. Multiple hormonal deficiencies in anabolic hormones are found in frail older women: the Women’sHealthandAgingstudies.JGerontolABiolSciMed Sci.2009;64:243---8.
13.Varadhan R, Chaves P,Lipsitz L, et al. Frailty and impaired cardiacautonomiccontrol:newinsightsfromprincipal compo-nentsaggregationoftraditionalheartratevariabilityindices. JGerontolABiolSciMedSci.2009;64:682---7.
14.BarzilayJ,BlaumC,MooreT,etal.Insulinresistanceand inflam-mationasprecursorsoffrailty:theCardiovascularHealthStudy. ArchInternMed.2007;167:635---41.
15.YaoX,LiH,LengS.Inflammationandimmunesystemalterations infrailty.ClinGeriatrMed.2011;27:79---87.
16.Semba R, Ferrucci L, Sun K, et al. Oxidative stress and severe walking disability among older women. Am J Med. 2007;120:1084---9.
17.BoxerR,KleppingerA,AhmadA,etal.The6-minutewalkis associatedwithfrailty andpredicts mortalityinolderadults withheartfailure.2011;16:208---13.
18.SanchezE,VidanM,SerraJ,etal.Prevalenceofgeriatric syn-dromesandimpactonclinicalandfunctionaloutcomesinolder patientswithacutecardiacdiseases.Heart.2011;97:1602---6. 19.LeeD,ButhK,MartinB,etal.Frailpatientsareatincreased
riskformortalityandprolongedinstitutionalcareaftercardiac surgery.Circulation.2010;121:973---8.
20.SundermannS,DademaschA,RastanA,etal.One-year follow-upofpatientsundergoingelectivecardiacsurgeryassessedwith theComprehensiveAssessmentofFrailtytestanditssimplified form.InteractCardiovascThoracSurg.2011;13:119---23. 21.RoeM,ArmstrongP,FoxK,etal.Prasugrelversusclopidogrel
foracutecoronarysyndromeswithoutrevascularization.NEngl JMed.2012;367:1297---309.
22.VolpatoS,CavalieriM,SioulisF,etal.Predictivevalueofthe ShortPhysicalPerformanceBatteryfollowinghospitalizationin olderpatients.JGerontolABiolSciMedSci.2011;66:89---96. 23.KangL, ZhangS-Y, ZhuW-L,et al. Isfrailty associatedwith
short-termoutcomesforelderlypatientswithacutecoronary syndrome?JGeriatrCardiol.2015;12:662---7.
24.EkerstadN,SwahnE,JanzonM,etal.Frailtyisindependently associatedwithshort-termoutcomesforelderlypatientswith
non-ST-segment elevation myocardial infarction.Circulation. 2011;124:2397---404.
25.RicciNA,PessoaGS,FerriolliE,etal.Frailtyandcardiovascular riskincommunity-dwellingelderly:apopulation-based study. ClinIntervAging.2014;9:1677---85.
26.SchoenenbergerA,StorteckyS,NeumannS,etal.Predictors of functional decline in elderly patients undergoing tran-scatheteraorticvalveimplantation(TAVI).EurHearJ.2013;34: 684---92.
27.Sündermann S, Dademasch A, Praetorius J, et al. Compre-hensive assessment of frailty for elderly high-risk patients undergoingcardiacsurgery.EurJCardiothoracSurg.2011;39: 33---7.
28.Afilalo J,Mottillo S, Eisenberg MJ,et al. Addition offrailty and disabilityto cardiacsurgeryriskscoresidentifieselderly patientsathighriskofmortalityormajormorbidity.Circ Car-diovascQualOutcomes.2012;5:222---8.
29.JungP,PereiraMA,HiebertB,etal.Theimpactoffrailtyon postoperativedelirium in cardiacsurgery patients. JThorac CardiovascSurg.2015;149:869---75.e2.
30.DunlaySM,ParkSJ,JoyceLD,etal.Frailtyandoutcomesafter implantation of left ventricular assist device as destination therapy.JHearLungTransplant.2014;33:359---65.
31.Stortecky S, Schoenenberger AW, Moser A, et al. Evalua-tion of multidimensional geriatricassessment asa predictor of mortality and cardiovascular events after transcatheter aortic valve implantation. JACC Cardiovasc Interv. 2012;5: 489---96.
32.FurukawaH,TanemotoK.Frailtyincardiothoracicsurgery: sys-tematicreviewoftheliterature.GenThoracCardiovascSurg. 2015;63:425---33.
33.DentE,HoogendijkPKE.Frailtymeasurementinresearchand clinicalpractice:areview.EurJInternMed.2016:S0953. 34.WalstonJD,Bandeen-rocheK.Frailty:ataleoftwoconcepts.
BMCMed.2015;13:185.
35.Lopez D, Flicker L, Dobson A. Validation of the frail scale in a cohort of older Australian women. JAmGeriatrSoc.2012;60:171---3.
36.MorleyJ,MalmstromT,MillerD.Asimplefrailtyquestionnaire (FRAIL)predictsoutcomesinmiddleagedAfricanAmericans.J NutrHealAging.2012;16:601---8.
37.Woo J, Leung J, Morley J. Comparison of frailty indica-tors based on clinical phenotype and the multiple deficit approach in predicting mortality and physical limitation. JAmGeriatrSoc.2012;60:1478---86.
38.WooJ,YuR,WongM,etal.Frailtyscreeninginthecommunity usingtheFRAILscale.JAmMedDirAssoc.2015;16:412. 39.Rockwood K, Song X, Macknight C, et al. A global
clini-cal measure of fitness and frailty in elderly people. CMAJ. 2005;173:489---95.
40.RockwoodK,MitnitskiA.Frailtydefinedbydeficit accumula-tionandgeriatricmedicinedefinedbyfrailty.ClinGeriatrMed. 2011;27:17---26.
41.MitnitskiA, MogilnerA, Rockwood K, etal. Accumulationof deficits asa proxymeasure ofaging.ScientificWorldJournal. 2001;1:323---36.
42.RolfsonD,MajumdarS,TsuyukiR,etal.Validityandreliability oftheEdmontonFrailScale.AgeAgeing.2006;35:526---9. 43.Bandeen-RocheK,XueQ,FerrucciL,etal.Phenotypeoffrailty:
characterization in the women’s health and aging studies. JGerontolABiolSciMedSci.2006;61:262---6.
44.RockwoodK,MitnitskiA.Frailtyinrelationtotheaccumulation ofdeficits.JGerontolABiolSciMedSci.2007;62:722. 45.Schuurmans H, Steverink N, Lindenberg S, et al. Old or
frail: what tells us more? J Gerontol A Biol Sci Med Sci. 2004;59A:M962---5.
46.GobbensR, vanAssenM, LuijkxK, et al.The Tilburgfrailty indicator: psychometric properties. J Am Med Dir Assoc. 2010;11:344---55.
47.SubraJ,Gillette-GuyonnetS,CesariM.Theintegrationoffrailty intoclinicalpractice:preliminaryresultsfromtheGérontopôle. JNutrHealAging.2012;16:714---20.
48.RaicheM,HebertR,DuboisM.PRISMA-7:acase-findingtoolto identifyolderadultswithmoderatetoseveredisabilities.Arch GerontolGeriatr.2008;47:9---18.
49.Pilotto A, Ferrucci L, FranceschiM, et al. Developmentand validationofamultidimensionalprognosticindexforone-year mortalityfromcomprehensivegeriatricassessmentin hospital-izedolderpatients.2009;11:151---61.
50.UchmanowiczI,LisiakM,WontorR, etal.Frailtyinpatients withacutecoronarysyndrome:comparisonbetweentoolsfor comprehensivegeriatricassessmentandtheTilburgFrailty Indi-cator.ClinIntervAging.2015;10:521---9.
51.AfilaloJ,LauckS,KimD,etal.Frailtyinolderadultsundergoing aortic valvereplacement--- theFRAILTY-AVRstudy.JAmColl Cardiol.2017;70:689---700.
52.Guralnik J, Simonsick E, Ferrucci L. Al. E. A short physical performancebatteryassessinglowerextremityfunction: asso-ciationwithself-reporteddisabilityandpredictionofmortality andnursinghomeadmission.JGerontol.1994;49:M85---94. 53.GreenP,WoglomAE,GenereuxP,etal.Theimpactoffrailty
statusonsurvivalaftertranscatheteraorticvalvereplacement
inolderadultswithsevereaorticstenosis:asingle-center expe-rience.JACCCardiovascInterv.2012;5:974---81.
54.KielyD,CupplesL,LipsitzL,etal.Validationandcomparison oftwofrailtyindexes:theMOBILIZEBostonStudy.JAmGeriatr Soc.2009;57:1532---9.
55.EnsrudK, Ewing S, Taylor B, et al. Comparison of 2 frailty indexesforpredictionoffalls,disability,fractures,anddeath inolderwomen.ArchInternMed.2008;168:382.
56.TheouO,BrothersTD,MitnitskiA,etal.Operationalizationof frailtyusingeightcommonlyusedscalesandcomparisonoftheir abilitytopredictall-causemortality.2013;61:1537---51. 57.CesariM, Gambassi G, vanKan G, et al. Thefrailty
pheno-typeandthefrailtyindex:differentinstrumentsfordifferent purposes.AgeAgeing.2014;43:10---2.
58.Drubbel I, Bleijenberg N, Kranenburg G, et al. Identifying frailty: do the Frailty Index and Groningen Frailty Indicator coverdifferent clinicalperspectives?A cross-sectionalstudy. BMCFamPr.2013;14:64---9.
59.CleggA, RogersL, YoungJ. Diagnostictestaccuracy of sim-pleinstruments foridentifyingfrailty incommunity-dwelling olderpeople:asystematicreview.2015,http://dx.doi.org/10. 1093/ageing/afu157.
60.KarapolatH,EyigorS, ZoghiM, etal. Areswimming or aer-obicexercisebetterthanconventionalexercise inankylosing spondylitispatients?Arandomizedcontrolledstudy.EurJPhys RehabilMed.2009;45:449---57.
