Physical frailty and pulmonary rehabilitation in COPD: a prospective cohort study

Matthew Maddocks, Samantha S C Kon, Jane L Canavan, Sarah E Jones, Claire M Nolan, Alex Labey, Michael I Polkey, William D-C Man, Matthew Maddocks, Samantha S C Kon, Jane L Canavan, Sarah E Jones, Claire M Nolan, Alex Labey, Michael I Polkey, William D-C Man

Abstract

Background: Frailty is an important clinical syndrome that is consistently associated with adverse outcomes in older people. The relevance of frailty to chronic respiratory disease and its management is unknown.

Objectives: To determine the prevalence of frailty among patients with stable COPD and examine whether frailty affects completion and outcomes of pulmonary rehabilitation.

Methods: 816 outpatients with COPD (mean (SD) age 70 (10) years, FEV1% predicted 48.9 (21.0)) were recruited between November 2011 and January 2015. Frailty was assessed using the Fried criteria (weight loss, exhaustion, low physical activity, slowness and weakness) before and after pulmonary rehabilitation. Predictors of programme non-completion were identified using multivariate logistic regression, and outcomes were compared using analysis of covariance, adjusting for age and sex.

Results: 209/816 patients (25.6%, 95% CI 22.7 to 28.7) were frail. Prevalence of frailty increased with age, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, Medical Research Council (MRC) score and age-adjusted comorbidity burden (all p≤0.01). Patients who were frail had double the odds of programme non-completion (adjusted OR 2.20, 95% CI 1.39 to 3.46, p=0.001), often due to exacerbation and/or hospital admission. However, rehabilitation outcomes favoured frail completers, with consistently better responses in MRC score, exercise performance, physical activity level and health status (all p<0.001). After rehabilitation, 71/115 (61.3%) previously frail patients no longer met case criteria for frailty.

Conclusions: Frailty affects one in four patients with COPD referred for pulmonary rehabilitation and is an independent predictor of programme non-completion. However, patients who are frail respond favourably to rehabilitation and their frailty can be reversed in the short term.

Keywords: COPD epidemiology; Exercise; Pulmonary Rehabilitation.

Conflict of interest statement

MIP has received personal reimbursement for lecturing or consultancy regarding muscle function in COPD from Novartis and Philips Respironics. He discloses institutional reimbursement for consultancy from GSK, Novartis, Regneron, Lilly, Biomarin and BI and institutional agreements to conduct research with GSK, Novartis, AZ and Philips Respironics.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Figures

Figure 1
Figure 1
Profile showing recruitment, frailty status and flow of patients through the trial with reasons for non-uptake or non-completion of pulmonary rehabilitation.
Figure 2
Figure 2
Prevalence of frailty in COPD according to age (A), GOLD spirometric stage (B), Medical Research Council (MRC) Dyspnoea score (C) and co-morbidity burden (D) (n=816). Between-group differences (p

Figure 3

Patients with COPD grouped according…

Figure 3

Patients with COPD grouped according to Fried's frailty criteria before and after pulmonary…

Figure 3
Patients with COPD grouped according to Fried's frailty criteria before and after pulmonary rehabilitation (n=574). Overall, rehabilitation led to a shift away from physical frailty towards a more robust state.
Figure 3
Figure 3
Patients with COPD grouped according to Fried's frailty criteria before and after pulmonary rehabilitation (n=574). Overall, rehabilitation led to a shift away from physical frailty towards a more robust state.

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