Heart Failure Association of the European Society of Cardiology position paper on frailty in patients with heart failure

Heart failure (HF) and frailty are two distinct yet commonly associated conditions. The interplay between the two conditions is complex, due to overlaps in underlying mechanisms, symptoms and prognosis. The assessment of frailty in patients with HF is crucial, as it is associated with both unfavourable outcomes and reduced access and tolerance to treatments. However, to date a consensus definition of frailty in patients with HF remains lacking and the need for a validated assessment score, for identifying those HF patients with frailty, is high and timely. This position paper proposes a new definition of frailty for use by healthcare professionals in the setting of HF and creates a foundation for the design of a tailored and validated score for this common condition.     

老年心力衰竭患者合并衰弱的最新研究进展

衰弱作为一种常见的老年综合征,以多系统功能障碍,体内平衡受损,生理储备下降,以及死亡风险增加为特点。心力衰竭（HF）是由各种心脏结构或功能性疾病导致心室充盈和(或)射血能力受损而引起的一组综合征,常常合并衰弱,与身体机能下降、跌倒、失能及认知倒退等相关。衰弱在老年心力衰竭患者中很常见,二者具有共同的机制特征,与炎症、肌肉减少症和高负担合并症等密切相关。衰弱与老年心力衰竭患者较差的临床表现、功能和生活质量有关,因此开发简单、易操作并经过充分验证的评估工具识别衰弱至关重要。这些评估工具可以在常规临床环境中有效和快速地识别衰弱的心衰患者,以更好地改善临床预后。对于患有心力衰竭和衰弱的老年患者,应进一步研究新的治疗与管理策略,例如通过多学科评估和干预解决多系统疾病的模式。提高对心力衰竭合并衰弱的认识并加以管理,以期有助于改善患者不良预后和生活质量的提高。     

Frailty in Chinese older adults with hypertension: Prevalence,associated factors,and prediction for long‐term mortality

Hypertension and frailty are associated and often coexist in older adults. Few studies have examined the association between hypertension and frailty in Chinese population. We explored the prevalence of and the factors associated with frailty as well as whether frailty could identify patients at risk of adverse outcomes among older adults with hypertension. Data were from the Beijing Longitudinal Study of Aging. A total of 1111 hypertensive participants aged ≥60 years old who completed the comprehensive geriatrics assessment were included. All participants were followed up for 8 years. The total number of deaths was 604. Frailty was assessed by the 68‐item frailty index. Stepwise forward logistic regression was used to explore the association between the associated factors and frailty in hypertensive participants. The prediction for mortality was assessed using the adjusted Cox proportional hazards model. Two hundred and eighteen older adults were determined as frail (prevalence rate: 19.6%). Frail older adults with hypertension had worse physical performance, worse psychological, and social function, as well as worse lifestyle habits, compared to nonfrail older adults with hypertension. Chair stand test failure, balance test failure, fracture, disability, depression, and physical frailty measured with modified frailty phenotype were independently associated with frailty. Frailty was associated with a higher 8‐year mortality, hazard ratio (HR) = 3.40, adjusted for age and sex, HR = 2.61. Frailty is associated with poorer physical function and higher mortality in community‐dwelling hypertensive older adults in China. These findings emphasize the importance and need for frailty intervention and prevention in older adults with hypertension.     

Domain Management Approach to Heart Failure in the Geriatric Patient: Present and Future

Heart failure (HF) is a quintessential geriatric cardiovascular condition, with more than 50% of hospitalizations occurring in adults age 75 years or older. In older patients, HF is closely linked to processes inherent to aging, which include cellular and structural changes to the myocardium, vasculature, and skeletal muscle. In addition, HF cannot be considered in isolation of physical functioning, or without the social, psychological, and behavioral dimensions of illness. The role of frailty, depression, cognitive impairment, nutrition, and goals of care are each uniquely relevant to the implementation and success of medical therapy. In this paper, we discuss a model of caring for older adults with HF through a 4-domain framework that can address the unique multidimensional needs and vulnerabilities of this population. We believe that clinicians who embrace this approach can improve health outcomes for older adults with HF.     

Incident frailty and cognitive impairment by heart failure status in older patients with atrial fibrillation: the SAGE-AF study

BackgroundAtrial fibrillation (AF) and heart failure (HF) frequently co-occur in older individuals. Among patients with AF, HF increases risks for stroke and death, but the associations between HF and incident cognition and physical impairment remain unknown. We aimed to examine the cross-sectional and prospective associations between HF, cognition, and frailty among older patients with AF.MethodsThe SAGE-AF (Systematic Assessment of Geriatric Elements in AF) study enrolled 1244 patients with AF (mean age 76 years, 48% women) from five practices in Massachusetts and Georgia. HF at baseline was identified from electronic health records using ICD-9/10 codes. At baseline and 1-year, frailty was assessed by Cardiovascular Health Survey score and cognition was assessed by the Montreal Cognitive Assessment.ResultsPatients with prevalent HF (n = 463, 37.2%) were older, less likely to be non-Hispanic white, had less education, and had greater cardiovascular comorbidity burden and higher CHA₂DS₂VASC and HAS-BLED scores than patients without HF (all P''s < 0.01). In multivariable adjusted regression models, HF (present vs. absent) was associated with both prevalent frailty (adjusted odds ratio [aOR]: 2.38, 95% confidence interval [CI]: 1.64-3.46) and incident frailty at 1 year (aOR: 2.48, 95% CI: 1.37-4.51). HF was also independently associated with baseline cognitive impairment (aOR: 1.60, 95% CI: 1.22-2.11), but not with developing cognitive impairment at 1 year (aOR 1.04, 95%CI: 0.64-1.70).ConclusionsAmong ambulatory older patients with AF, the co-existence of HF identifies individuals with physical and cognitive impairments who are at higher short-term risk for becoming frail. Preventive strategies to this vulnerable subgroup merit consideration.     

Frailty and multiple comorbidities in the elderly patient with heart failure: implications for management

Heart failure (HF) in the elderly is a major public health problem, and its prevalence is rising. Outcomes of HF in the elderly have not changed in the past 2 decades despite the introduction of novel HF therapies. This may be due to the combined impact of multiple comorbidities and frailty. The majority of elderly patients with HF are frail with multiple comorbidities. These comorbidities, along with frailty, contribute to the poor outcome of HF in the elderly and pose independent management challenges. More research is needed to better understand the interaction between frailty and multiple comorbidities and the mechanisms by which they impact HF and its management; develop prognostic tools that incorporate frailty and multiple comorbidities and provide more accurate prediction of outcomes; test available treatments in typical elderly patients; and develop and test novel interventions that directly address the adverse impact of multiple comorbidities and frailty.     

Frailty in Heart Failure

Considering the increasing age of individuals affected with heart failure (HF), a specific approach to their treatment is required, with more attention paid to geriatric conditions such as poor mobility, multiple disabilities, and cognitive impairment. Frailty is a distinct biological syndrome reflecting decreased physiologic reserve and resistance to stressors. It was shown to occur frequently in patients with heart failure, with the prevalence ranging from 15 to 74 %, depending on the studied population and the method of assessment. We reviewed literature data on the influence of frailty, skeletal abnormalities, comorbidities and geriatric condition on diagnosis, treatment, and outcomes in elderly patients with HF. Identification of frailty in patients with HF is important from the clinical point of view, as this condition exerts unfavorable effects on the course of heart failure. Frailty contributes to a higher frequency of visits to emergency departments, hospitalizations, and mortality in patients with HF. Exercise may improve mobility, and nursing support can be implemented to help the patients adhere to medications. Therefore, frail patients should be diagnosed and treated according to available guidelines, and successfully educated about their condition.     

Progression from hypertension to heart failure. Mechanisms and management

Patients with hypertension are at increased risk of developing heart failure (HF), but the mechanisms by which hypertension leads to HF have not been clarified [although left ventricular hypertrophy (LVH) is clearly a predictor of an increased risk of HF]. Similarly, although antihypertensive therapy has been shown to reduce the risk of HF in hypertensive patients, it is not known how this benefit is produced and, currently, there is no clear evidence that any class of antihypertensive agent is more effective than any other in this respect. On theoretical grounds, beta-blockers would be expected to be ideal agents for the prevention of HF in hypertensive patients. In addition to control of blood pressure and regression of LVH, they have clear benefits on morbidity and mortality after myocardial infarction (MI), which probably plays a major role in the development of HF in hypertensive patients, and on the prognosis of HF itself. A reduction in long-term mortality after MI has been demonstrated only for non-selective beta-blockers. Carvedilol, a non-selective beta-blocker which also has other ancillary properties including alpha-1-receptor blockade and antioxidant effects and a favourable metabolic profile, may be an appropriate choice for the prevention of HF in hypertensive patients. This is reinforced by the salutary benefits of carvedilol for the reduction in the morbidity and mortality of HF itself.     

Frailty phenotype and associated nutritional factors in a sample of Portuguese outpatients with heart failure

Background and aimFrailty phenotype (FP) is very common in heart failure (HF) and both syndromes worsen one another. The aim of this study is to first describe FP in a sample of Portuguese patients with HF, and to analyse its association with nutritional and clinical statuses, namely, muscle mass, obesity and functional class.Methods and resultsIn this cross-sectional study, a sample of 136 outpatients with HF (24–81 years, 33.8% women) were randomly selected from the appointments' listings of a HF and Transplant clinic in a Portuguese University Hospital. FP was assessed according to Fried et al. muscle mass was estimated from the mid-upper arm muscle circumference; weight status was assessed using the body mass index; HF functional classes were registered. The association between participants' characteristics and FP categories was analysed using logistic ordinal regression. The frequency of pre-frailty and frailty is 57.4% and 15.4%, respectively. Within frail individuals, 52.4% were under the age of 65. In multivariable analysis, frailty was positively associated with age 70 or older (OR = 3.44) and obesity (OR = 2.66), and negatively associated with muscle mass (OR = 0.77) and HF functional classes I (OR = 0.14) or II (OR = 0.29).ConclusionMuscle mass seems to be an important predictor of frailty in patients with HF and should be taken into account when designing intervention plans that allow for reverting or modifying frailty and pre-frailty. Younger patients should be monitored for the presence and evolution of FP.     

The estimation of relative fitness and frailty in community-dwelling older adults using self-report data

BACKGROUND: While on average health declines with age, it also becomes more variable with age. As a consequence of this marked variability, it becomes more important as people age to have a means of summarizing health status, but how precisely to do so remains controversial. We developed one measure of health status, personal biological age, from a frailty index. The index itself is a count of deficits derived, in the first instance, from a clinical database. In our earlier investigations, personal biological age demonstrated a strong relationship with 6-year survival. Here we extend this approach to self-reported data. METHODS: This is a secondary analysis of community-dwelling people aged 65 years and older (n = 9008) in the Canadian Study of Health and Aging. The frailty index was calculated from 40 self-reported variables, representing symptoms, attitudes, illnesses, and function. Personal biological age was estimated for each individual as the age corresponding to the mean chronological age for the index value. Individual frailty (and the related construct of fitness) was calculated as the difference between chronological and personal biological age. RESULTS: The frailty index showed, on average, an exponential increase with age at an average rate of 3% per year. Although women, on average, demonstrate more frailty than men of the same chronological age, their survival chances are greater. The frailty index strongly correlated (Pearson r =.992 for women and.955 for men) with survival. CONCLUSIONS: A frailty index, based on self-report data, can be used as a tool for capturing heterogeneity in the health status of older adults.     

Heart failure in the oldest patients: the impact of comorbid conditions

Heart failure (HF) is the leading cause of hospitalization in older adults; it is also an important cause of death and chronic disability. HF in the elderly differs in many respects from HF occurring during middle age; in particular, the diagnosis and treatment of HF in the elderly are often complicated by the presence of multiple cardiac and noncardiac comorbid conditions, many of which have important implications for the care of the older HF patient. This article reviews the effects of common noncardiac comorbidities on the management of HF in older adults and discusses the impact of noncardiac comorbid conditions on clinical outcomes in the geriatric HF patient.     

FRAIL‐HF,a Study to Evaluate the Clinical Complexity of Heart Failure in Nondependent Older Patients: Rationale,Methods and Baseline Characteristics

The clinical scenario of heart failure (HF) in older hospitalized patients is complex and influenced by acute and chronic comorbidities, coexistent geriatric syndromes, the patient's ability for self‐care after discharge, and degree of social support. The impact of all these factors on clinical outcomes or disability evolution is not sufficiently known. FRAIL‐HF is a prospective observational cohort study designed to evaluate clinical outcomes (mortality and readmission), functional evolution, quality of life, and use of social resources at 1, 3, 6, and 12 months after admission in nondependent elderly patients hospitalized for HF. Clinical features, medical treatment, self‐care ability, and health literacy were prospectively evaluated and a comprehensive geriatric assessment with special focus on frailty was systematically performed in hospital to assess interactions and relationships with postdischarge outcomes. Between May 2009 and May 2011, 450 consecutive patients with a mean age of 80 ± 6 years were enrolled. Comorbidity was high (mean Charlson index, 3.4 ± 2.9). Despite being nondependent, 118 (26%) had minor disability for basic activities of daily living, only 76 (16.2%) had no difficulty in walking 400 meters, and 340 (75.5%) were living alone or with another elderly person. In addition, 316 patients (70.2%) fulfilled frailty criteria. Even nondependent older patients hospitalized for HF show a high prevalence of clinical and nonclinical factors that may influence prognosis and are usually not considered in routine clinical practice. The results of FRAIL‐HF will provide important information about the relationship between these factors and different postdischarge clinical, functional, and quality‐of‐life outcomes.     

老年高血压合并衰弱患者降压治疗的研究进展

高血压是影响老年人健康的重要因素,降压治疗可降低老年高血压患者脑卒中、心血管事件和死亡等风险。老年人群中衰弱常与高血压并存,但目前关于老年高血压与衰弱的研究相对较少,尤其是老年高血压合并衰弱的降压治疗研究结论不一。老年高血压合并衰弱患者降压治疗的起始值与目标值、衰弱老年人能否从降压治疗中获益以及降压治疗方案的选择等仍争议较大。因此,本文对老年高血压患者合并衰弱的降压治疗进行综述。     

Failing to Focus on Healthy Aging: A Frailty of Our Discipline?

The academic geriatrics community has provided outstanding leadership in addressing frailty and complexity in older adults, but a minority of older adults are frail. Although resources to treat older adults are limited, and it is appropriate to focus clinical efforts on those with frailty and multimorbidity, there is also important expertise that can be brought to bear on the health of ALL older adults. A review of the literature suggests that attention to healthy or successful aging has failed to keep pace with the focus on frailty. By providing leadership to promote successful aging, the quality of life of older adults across the spectrum can be improved and transitions to frailty reduced. The template that leaders have established in understanding frailty—defining and operationalizing it, understanding outcomes, identifying pathophysiology—can be used as an approach to successful aging. Several community‐based programs have been successful in promoting successful aging. These are potentially highly scalable and could have a substantial effect on the aging population, but their essential components need to be better understood. The geriatrics community is uniquely positioned to take on this role. This is a critical time to work together to make the lives of all older adults as healthy and fulfilling as possible.     

Women, men and heart failure: a review

Chronic heart failure (HF) is a major cause of morbidity and mortality, and is the reason for more than one in five of all hospital admissions in patients aged >65 years. Major advances in the diagnosis and treatment of HF over the last two decades have proven effective in reducing morbidity and mortality among both men and women, but with less improvement for women and elderly patients. Women and men with HF differ in several respects. Women tend to be older and more often hypertensive, but are less likely to demonstrate any clinical evidence of coronary heart disease (CHD) and more often have preserved ventricular function. Conversely, hypertension plays a greater role in the development of HF in women than in men. Sex differences in systolic and diastolic function in patients with hypertension have been demonstrated. Although men have higher incidence of HF at all ages, lifetime risk is similar in men and women because women live longer. Intervention studies have included far more men than women but in patients with reduced ventricular function there is no evidence to suggest that women benefit less than men from evidence-based treatments, and current guidelines do not differentiate between men and women. There is no consistent recent evidence that women receive poorer quality of care than men. Women with HF have better survival rates than men, which may be due to better systolic function or less CHD among women; however, mortality rates for HF are still very high regardless of sex. As most trials have been targeted towards patients with left ventricular systolic dysfunction, which is less typical for women than for men with HF, more research is needed to help define treatment aimed at improving prognosis for patients with HF and preserved systolic function. In light of these differences and ongoing uncertainties, future European guidelines should incorporate gender issues. Heart Fail Monit 2008;6(1):34-40.     

Pharmacotherapy of heart failure in the elderly: adverse events

Aging is associated with numerous alterations in body composition and organ function that result in substantial changes in the absorption, distribution, metabolism, and elimination of virtually all drugs. In addition, older patients with heart failure (HF) almost invariably have multiple coexisting medical conditions for which they are receiving medications. This article reviews common adverse drug effects and drug interactions associated with HF therapy in older patients and discusses strategies for reducing the risk of adverse drug events. In order to minimize these risks, it is essential that clinicians avoid prescribing unnecessary medications, adjust medication dosages to optimally balance benefits and side effects, and remain ever vigilant to the potential for medications to cause or contribute to clinically important adverse events and impaired quality of life. In treating older HF patients, the oft-cited dictum “start low, go slow” clearly applies. Despite the inherent challenges, with careful management and close follow-up, most older HF patients can be successfully treated through the judicious use of guideline-recommended HF therapies.     

Optimal management of older patients with chronic lymphocytic leukemia: some facts and principles guiding therapeutic choices

Chronic lymphocytic leukemia (CLL) is a disease of older patients and median age at diagnosis is 72 years. This older group is under-represented in clinical trials, (median age 58-62 years). Here we review background data on incidence, survival, definitions of older age, fitness criteria, frailty and co-morbidities. Issues influencing the choice of therapy in older patients are also addressed and different therapeutic options are highlighted based on recent available data. Fit older patients with less co-morbidities benefit most from the very effective chemoimmunotherapy (FC-R) given for younger patients today, but whether other novel drug combinations or new agents are more suitable for less fit patients is still unsettled. Based on careful evaluation of published data from larger clinical trials and major referral centers we present our concept of therapy as a guide to optimal management for subgroups of older patients with CLL.     

Musculoskeletal health,frailty and functional decline

Frailty in older people is associated with a vulnerability to adverse events. While ageing is associated with a loss of physiological reserves, identifying those with the syndrome of frailty has the potential to assist clinicians to tailor treatments to those at the risk of future decline into disability with an increased risk of complications, morbidity and mortality. Sarcopenia is a key component of the frailty syndrome and on its own puts older people at risk of fragility fractures; however, the clinical syndrome of frailty affects the musculoskeletal and non-musculoskeletal systems. Hip fractures are becoming a prototype condition in the study of frailty. Following a hip fracture, many of the interventions are focused on limiting mobility disability and restoring independence with activities of daily living, but there are multiple factors to be addressed including osteoporosis, sarcopenia, delirium and weight loss. Established techniques of geriatric evaluation and management allow systematic assessment and intervention on multiple components by multidisciplinary teams and deliver the best outcomes. Using the concept of frailty to identify older people with musculoskeletal problems as being at the risk of a poor outcome assists in treatment planning and is likely to become more important as effective pharmacological treatments for sarcopenia emerge.This review will focus on the concept of frailty and its relationship with functional decline, as well as describing its causes, prevalence, risk factors, potential clinical applications and treatment strategies.     

Prognostic impact of the coexistence of hepato-renal dysfunction and frailty in patients with heart failure

BackgroundComplex multi-organ interactions such as coexistence of hepato-renal dysfunction in heart failure (HF) adversely affects patient prognosis. However, the association between liver/kidney dysfunction and frailty and effects of their coexistence on HF prognosis remain unclear.MethodsThis retrospective cohort study included 922 patients with HF (median age, 72 years; interquartile range: 62–79 years). All patients underwent hepato-renal function testing using the model for end-stage liver disease, excluding international normalized ratio (MELD-XI) score and frailty score. Frailty was measured using a composite of four markers: handgrip strength, gait speed, serum albumin, and activities of daily living status, combined into a total frailty score (range 0–12). Patients were assigned to a frailty score <5 (without frailty) or ≥5 (frailty) group. The multivariable logistic regression model was used to analyze the association between MELD-XI score and frailty; the prognostic value of high MELD-XI score and frailty coexistence was investigated. The endpoint was all-cause mortality.ResultsAfter adjusting for covariates and dividing by the median MELD-XI score, the high MELD-XI score group [odds ratio: 1.663, 95 % confidence interval (CI): 1.200–2.304, p = 0.002] was significantly associated with frailty, compared with the low MELD-XI score group. One hundred and fifty deaths occurred during follow-up (median, 2.13 years; interquartile range, 0.93–4.09 years). Patients in the high MELD-XI score/frailty group had a significantly higher mortality risk, even after adjusting for HF severity (hazard ratio: 4.326, 95 % CI: 2.527–7.403, p < 0.001).ConclusionsHepato-renal dysfunction is associated with frailty in patients with HF, which affects patient prognosis.Brief summaryThis study showed that hepato-renal dysfunction in patients with HF, as assessed by the model for end-stage liver disease excluding international normalized ratio (MELD-XI) score, is associated with frailty, even after adjusting for factors involved in the frailty or severity of HF. Additionally, high MELD-XI score combined with frailty is associated with a poorer prognosis. These results suggest that hepato-renal dysfunction and frailty can be used for risk stratification in patients with HF.