Measuring frailty in heart failure: a community perspective

Sheila M McNallan, Alanna M Chamberlain, Yariv Gerber, Mandeep Singh, Robert L Kane, Susan A Weston, Shannon M Dunlay, Ruoxiang Jiang, Véronique L Roger, Sheila M McNallan, Alanna M Chamberlain, Yariv Gerber, Mandeep Singh, Robert L Kane, Susan A Weston, Shannon M Dunlay, Ruoxiang Jiang, Véronique L Roger

Abstract

Background: Frailty, an important prognostic indicator in heart failure (HF), may be defined as a biological phenotype or an accumulation of deficits. Each method has strengths and limitations, but their utility has never been evaluated in the same community HF cohort.

Methods: Southeastern Minnesota residents with HF were recruited from 2007 to 2011. Frailty according to the biological phenotype was defined as 3 or more of: weak grip strength, physical exhaustion, slowness, low activity and unintentional weight loss >10 lb in 1 year. Intermediate frailty was defined as 1 to 2. The deficit index was defined as the proportion of deficits present out of 32 deficits.

Results: Among 223 patients (mean age 71 ± 14, 61% male), 21% were frail and 48% intermediate frail according to the biological phenotype. The deficit index ranged from 0.02-0.75, with a mean (SD) of 0.25 (0.13). Over a mean follow-up of 2.4 years, 63 patients died. After adjustment for age, sex and ejection fraction, patients categorized as frail by the biological phenotype had a 2-fold increased risk of death compared to those with no frailty, whereas a 0.1 unit increase in the deficit index was associated with a 44% increased risk of death. Both measures predicted death equally (C-statistics: 0.687 for biological phenotype and 0.700 for deficit index).

Conclusion: The deficit index and the biological phenotype equally predict mortality. As the biological phenotype is not routinely assessed clinically, the deficit index, which can be ascertained from medical records, is a feasible alternative to ascertain frailty.

© 2013.

Figures

Figure 1
Figure 1
Boxplot of the Deficit Index by the Biological Phenotype
Figure 2
Figure 2
Figure 2a. Survival after heart failure by biological frailty phenotype group Figure 2b. Survival after heart failure by deficit index tertile
Figure 2
Figure 2
Figure 2a. Survival after heart failure by biological frailty phenotype group Figure 2b. Survival after heart failure by deficit index tertile

References

    1. Cacciatore F, Abete P, Mazzella F, et al. Frailty predicts long-term mortality in elderly subjects with chronic heart failure. Eur J Clin Invest. 2005;35:723–30.
    1. Chaudhry SI, Wang Y, Gill TM, et al. Geriatric conditions and subsequent mortality in older patients with heart failure. J Am Coll Cardiol. 55:309–16.
    1. Lupon J, Gonzalez B, Santaeugenia S, et al. Prognostic implication of frailty and depressive symptoms in an outpatient population with heart failure. Rev Esp Cardiol. 2008;61:835–42.
    1. Newman AB, Gottdiener JS, McBurnie MA, et al. Associations of subclinical cardiovascular disease with frailty. J Gerontol A Biol Sci Med Sci. 2001;56:M158–66.
    1. Afilalo J, Karunananthan S, Eisenberg MJ, et al. Role of Frailty in Patients With Cardiovascular Disease. Am J Cardiol. 2009;103:1616–1621.
    1. Rodriguez-Manas L, Feart C, Mann G, et al. Searching for an Operational Definition of Frailty: A Delphi Method Based Consensus Statement. The Frailty Operative Definition-Consensus Conference Project. J Gerontol A Biol Sci Med Sci. 2012
    1. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146–56.
    1. Searle SD, Mitnitski A, Gahbauer EA, et al. A standard procedure for creating a frailty index. BMC Geriatrics. 2008;8:24.
    1. Strawbridge WJ, Shema SJ, Balfour JL, et al. Antecedents of frailty over three decades in an older cohort. J Gerontol B Psychol Sci Soc Sci. 1998;53:S9–16.
    1. Ensrud KE, Ewing SK, Taylor BC, et al. Comparison of 2 frailty indexes for prediction of falls, disability, fractures, and death in older women. Arch Intern Med. 2008;168:382–9.
    1. Hubbard RE, O’Mahony MS, Woodhouse KW. Characterising frailty in the clinical setting--a comparison of different approaches. Age Ageing. 2009;38:115–9.
    1. Sternberg SA, Wershof Schwartz A, Karunananthan S, et al. The identification of frailty: a systematic literature review. J Am Geriatr Soc. 2011;59:2129–38.
    1. de Vries NM, Staal JB, van Ravensberg CD, et al. Outcome instruments to measure frailty: a systematic review. Ageing Res Rev. 2011;10:104–14.
    1. Afilalo J. Frailty in Patients with Cardiovascular Disease: Why, When, and How to Measure. Curr Cardiovasc Risk Rep. 2011;5:467–472.
    1. Rockwood K, Andrew M, Mitnitski A. A comparison of two approaches to measuring frailty in elderly people. J Gerontol A Biol Sci Med Sci. 2007;62:738–43.
    1. Fried TR, Mor V. Frailty and hospitalization of long-term stay nursing home residents. J Am Geriatr Soc. 1997;45:265–9.
    1. Ensrud KE, Ewing SK, Taylor BC, et al. Frailty and risk of falls, fracture, and mortality in older women: the study of osteoporotic fractures. J Gerontol A Biol Sci Med Sci. 2007;62:744–51.
    1. Fugate Woods N, LaCroix AZ, Gray SL, et al. Frailty: Emergence and Consequences in Women Aged 65 and Older in the Women’s Health Initiative Observational Study. J Am Geriatr Soc. 2005;53:1321–1330.
    1. Rochat S, Cumming RG, Blyth F, et al. Frailty and use of health and community services by community-dwelling older men: the Concord Health and Ageing in Men Project. Age Ageing. 2010;39:228–33.
    1. Kulminski AM, Ukraintseva SV, Kulminskaya IV, et al. Cumulative deficits better characterize susceptibility to death in elderly people than phenotypic frailty: lessons from the Cardiovascular Health Study. J Am Geriatr Soc. 2008;56:898–903.
    1. Cigolle CT, Ofstedal MB, Tian Z, et al. Comparing models of frailty: the Health and Retirement Study. J Am Geriatr Soc. 2009;57:830–9.
    1. Woo J, Leung J, Morley JE. Comparison of frailty indicators based on clinical phenotype and the multiple deficit approach in predicting mortality and physical limitation. J Am Geriatr Soc. 2012;60:1478–86.
    1. Melton LJ., 3rd History of the Rochester Epidemiology Project. Mayo Clin Proc. 1996;71:266–74.
    1. Pakhomov SV, Buntrock J, Chute CG. Prospective recruitment of patients with congestive heart failure using an ad-hoc binary classifier. J Biomed Inform. 2005;38:145–53.
    1. Bursi F, Weston SA, Redfield MM, et al. Systolic and diastolic heart failure in the community. JAMA. 2006;296:2209–16.
    1. Dunlay SM, Eveleth JM, Shah ND, et al. Medication adherence among community-dwelling patients with heart failure. Mayo Clin Proc. 2011;86:273–81.
    1. Ho KK, Pinsky JL, Kannel WB, et al. The epidemiology of heart failure: the Framingham Study. J Am Coll Cardiol. 1993;22:6A–13A.
    1. McNallan SM, Singh M, Chamberlain AM, et al. Frailty and Healthcare Utilization Among Patients With Heart Failure in the Community. JACC:Heart Failure. 2013;1:135–141.
    1. Martin A, Rief W, Klaiberg A, et al. Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population. Gen Hosp Psychiatry. 2006;28:71–7.
    1. Ware J, Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220–33.
    1. Purser JL, Kuchibhatla MN, Fillenbaum GG, et al. Identifying frailty in hospitalized older adults with significant coronary artery disease. J Am Geriatr Soc. 2006;54:1674–81.
    1. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560–72.
    1. American Diabetes Association: clinical practice recommendations 1997. Diabetes Care. 1997;20 (Suppl 1):S1–70.
    1. Izaks GJ, Westendorp RG, Knook DL. The definition of anemia in older persons. JAMA. 1999;281:1714–7.
    1. Levey AS, Coresh J, Greene T, et al. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med. 2006;145:247–54.
    1. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.
    1. Owan TE, Hodge DO, Herges RM, et al. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med. 2006;355:251–9.
    1. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation. 2013;127:e6–e245.
    1. Kremers WK. Concordance for survival time data: Fixed and time-dependent covariates and possible ties in predictor and time. Mayo Foundation; 2007. (Technical Report Series #80).
    1. Chou CH, Hwang CL, Wu YT. Effect of exercise on physical function, daily living activities, and quality of life in the frail older adults: a meta-analysis. Arch Phys Med Rehabil. 2012;93:237–44.
    1. Theou O, Stathokostas L, Roland KP, et al. The effectiveness of exercise interventions for the management of frailty: a systematic review. J Aging Res. 2011;2011:569194.
    1. O’Connor CM, Whellan DJ, Lee KL, et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301:1439–50.

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