April 26th, 2012

Frailty Evaluation and High-Risk Interventions

When taking care of older patients, we often have an intuitive sense of which ones will do well after an intervention and which ones won’t. This has been termed the “foot of the bed” test, or alternately something which separates a “young 80-year old” from an “old 80-year old.”  Frailty is a syndrome defined as an increased physiologic vulnerability to stressors, and through its quantification we can help to standardize this clinical intuition. However, the routine measurement of frailty has largely remained outside both clinical trials and patient care.

A review published this past week (J Cardiovasc Nurs Mar/Apr 2012; 27: 120-131) calls for use of a consistent definition of frailty across studies of older adults with cardiovascular disease, in order to help determine its ability to predict outcomes.  The authors support using previously defined criteria (Fried et al. J Gerontol A Biol Sci Med Sci 2001; 56: M146-M157) which consist of three or more of the following five:  (1) unintentional weight loss, (2) self-reported exhaustion, (3) weakness (grip strength), (4) slow gait speed, and (5) low physical activity.  In the original study by Fried et al., frailty was independently predictive of worsening disability, hospitalization, and death.

As there are a growing number of high-risk interventions that can be applied to older adults, including transcatheter aortic valve replacement (TAVR), left ventricular assist devices, and cardiac surgery, can a standardized definition of frailty help to predict which patients will derive meaningful benefit?  For example, with TAVR, in the PARTNER trial (N Engl J Med 2010;363:1597-1607) where the mean age of patients was 83 years, 31% of patients undergoing TAVR still died at 1 year (despite a 20% absolute risk reduction with TAVR versus usual care).  While frailty was reported, its degree of standardization (and association with outcomes) was unclear.

Can frailty help to identify a particular subgroup of older patients who may not benefit from high-risk interventions?  Does it have the potential to become an important covariate in a similar manner to more traditional factors such as creatinine and ejection fraction?  What are some of the barriers to its routine measurement?

3 Responses to “Frailty Evaluation and High-Risk Interventions”

  1. Donald Hislop, MS MD says:

    Frailty is physical,mental or moral weakness.

    Octogenarians without cancer may die of heart problems.

    Therefore,mental and moral strength help decide heart surgery questions.

  2. Jonathan Newman, MD, MPH says:

    Excellent post and very important issue/questions raised.
    The definition of the frailty phenotype, outside of and more objective than the “eyeball test” is essential. I think the frailty phenotype can help to assess risk of not only invasive, interventional procedures but also for the burdens of aggressive medical therapy, many targets for which have never shown clear benefit in older individuals. I’d say the main barriers to the routine measurement of frailty would be a) the ease of measurement of “objective” factors, such as gait speed and b) the absence of clear financial incentive to assess frailty. What if reimbursement before intervention was withheld if patients a) did not have a frailty assessment or b) were found to be too frail to likely derive benefit?

  3. Stephen Evans, MD says:

    I agree and would go further, arguing that all elderly greater than 75 years in acute, all SNF and assisted living, and the very frail at home should all have some assessment for frailty. Makary’s article from late 2010 suggested that pre-op evaluations were enhanced with a frailty evaluation in the Fried Phenotype, and our group’s research (submitted) shows that frailty in the Rockwood correlates significantly with death within 30 and 60 days in the acute non-ICU setting. The data is headed to encourage routine frailty testing, based on its ability to contextualize risks/benefits for patients and their families.