Heart failure and frailty often co-exist and patients with both are likely to have worse outcomes. Part three of this three-part series looks at the management of frailty in the context of heart failure. This article comes with a handout for a journal club discussion
Frailty is a state of reduced physiological reserve leading to heightened vulnerability. It is highly prevalent in heart failure and patients with both conditions will have worse outcomes and prognosis. The interplay between these two conditions is complex due to an overlap in underlying mechanisms and symptoms. Assessing frailty should be part of routine care, as it helps stratify patients and supports decision-making. This article, the third in a three-part series, covers the management of frailty in patients with heart failure. Part one describes its pathophysiology, aetiology, clinical presentation and diagnostic features, while part two covers management, treatment options and the crucial role of nurses in supporting and educating patients.
Citation: Jarvis S, Saman S (2017) Heart failure 3: managing frailty in heart failure patients. Nursing Times [online]; 113: 10, 28-32.
Authors: Selina Jarvis is research nurse and former Mary Seacole development scholar, King’s Health Partners and Kingston and St George’s University of London; Selva Saman is consultant, Port Shepstone Regional Hospital, Port Shepstone, South Africa.
Frailty is a common syndrome often found in older people, many of whom also have heart failure (HF). The conditions are linked in terms of epidemiology and pathophysiology. Distinguishing between the two may be difficult, as their clinical features overlap. It is crucial to identify frailty in HF patients because it is associated with a worse prognosis. Identifying frailty can help health professionals plan their patients’ care and determine in whom invasive cardiac interventions may be an appropriate option.
What is frailty?
Frailty is characterised by reduced physiological reserve and a “loss of functionality leading to an increased vulnerability to adverse stress and health events” (Fried et al, 2001). There is considerable variation in the degree of frailty experienced by patients. It is due to biological ageing rather than chronological age and its prevalence increases with age but it is not synonymous with normal ageing, nor is it inevitable.
The British Geriatric Society (BGS) advises that people should not be labelled as ‘frail’ but as ‘having frailty’ (BGS, 2014). Recognising frailty is crucial because patients with frailty are at higher risk of hospitalisation, functional decline, dependency, institutionalisation, falls, fractures, disability and death (Fried et al, 2001).
There are two common models of frailty:
- The ‘frailty phenotype’ model, which defines frailty as the presence of three or more of five frailty criteria (Table 1);
- The ‘cumulative deficit’ model, which describes frailty as an accumulation of deficits, impairments, disabilities and diseases – for example, loss of hearing or tremor – which are used to calculate a ‘frailty index’ (Rockwood and Mitnitski, 2007).
Frailty occurs more often in older patients with HF than in the general older population (Uchmanowicz and Gobbens, 2014) and many assessments show a relationship with adverse cardiovascular outcomes. The decline in physiological reserve occurs across the body, but the cardiovascular system is particularly vulnerable, so frailty is highly prevalent in patients with cardiac dysfunction (Nadruz et al, 2017).
It is estimated that, by 2040, 24.2% of the UK population will be over the age of 65 (Age UK, 2017). It is estimated that the prevalence of frailty in older people ranges from 4% up to 59%. It is thought that 10% of people over the age of 65 who live independently, and 25-50% of people over the age of 85, have frailty. The syndrome is more prevalent in women than in men (Collard et al, 2012). In the UK, the prevalence rates are 8.5% in females and 4.1% in males, and it is more often seen in patients of lower socioeconomic status (Syddall et al, 2010).
The Cardiovascular Health Study identified that HF was strongly associated with frailty (Newman et al, 2001) and Boxer et al (2008) suggested that frailty was present in 25% of older people with HF.
More recently, the FRAIL-HF study showed that up to 70% of patients with HF aged over 80 years also had frailty (Vidán et al, 2014). Patients with both conditions are more likely to have other comorbidities, such as chronic obstructive pulmonary disease, chronic kidney disease, arthritis or anaemia.
The pathophysiology of frailty (Fig 1), which is poorly understood, revolves around a low-grade chronic inflammatory response, with the production of inflammatory cytokines (C-reactive protein, interleukin-6 [IL-6] tumour necrosis factor alpha [TNFα]) as well as endocrine and neurohormonal involvement (Fedarko, 2011). Alongside this chronic inflammatory state, other biological ageing processes take place: these include DNA damage, changes in chromosomes, impaired cellular function and increased oxidative stress (Butts and Gary, 2015). This culminates in muscle inflammation and loss of muscle mass and strength (sarcopenia).
Some mechanisms in HF are similar to mechanisms described in frailty (Wohlgemuth et al, 2014). HF is associated with accelerated biological ageing and the same cytokines (for example, IL-6, TNFα) are implicated. Reduced tissue perfusion from poor cardiac output can affect muscle mass and lead to inflammation. The changes in muscle mass may put patients at further risk of cardiovascular remodelling and dysfunction, with subsequent complications.
The overlap between the HF and frailty also occurs in clinical symptoms (Fig 2). In both, reduced physical strength and exercise tolerance can compound sarcopenia, which further reduces activity levels (Fried et al, 2001), triggering a downward spiral of increasing frailty. Overlapping symptoms include fatigue, weakness, mood disturbances and reduced activity; they also include cachexia, a generalised wasting process affecting skeletal muscles, fat tissues and bone, which is seen in up to 15% of patients with HF. Due to this overlap, differentiating between the two conditions, and identifying frailty in HF patients, can be challenging.
Implications of frailty
The clinical course of HF means patients are at risk of repeated periods of stress and vulnerability. Frailty co-existing with HF has been shown to be predictive of hospitalisation, disability and mortality (Sze et al, 2017; Cacciatore et al, 2005). The FRAIL-HF study looked at 450 acutely admitted HF patients and showed that the majority had a ‘frailty phenotype’ associated with reduced one-year survival independent of age and comorbidities (Vidán et al, 2016). Denfeld et al (2017a) showed that frailty affects half of HF patients regardless of age or New York Heart Association class (see part one for more information).
Frailty can compound other problems; for example, HF patients with frailty are more likely to have reduced cognitive function (Denfeld et al, 2017b), depression and anxiety (Denfeld et al, 2017a; Uchmanowicz and Gobbens, 2015), with consequences on quality of life scores (Buck and Riegel, 2011).
From a physiological standpoint, HF patients with frailty have worse cardiovascular indices, lower oxygen saturations in venous blood, reduced cardiac output, higher resting heart rates and lower sodium levels than those without co-existent frailty (Denfeld et al, 2017b).
There are over 25 tools for assessing frailty, which have varying levels of reliability and validity. None is considered to be the ‘gold standard’ (Bouillon et al, 2013). Frailty assessment tools are based on different conceptual models of frailty and take into account functional, nutritional and cognitive status.
Fried’s frailty criteria are based on the frailty phenotype model (Table 1). Objective tests are used, including a gait speed test to assess slowness – a measure itself associated with survival (Studenski et al, 2011). A handgrip strength test to assess weakness and questionnaires on exhaustion, physical activity and unintentional weight loss are also used (Goldwater and Altman, 2016; Ling et al, 2010).
The Frailty Index is based on the cumulative deficit model (Rockwood and Mitnitski, 2007) but it is lengthy, so possibly too cumbersome for routine clinical practice.
The Edmonton Frail Scale (EFS) attributes 0-2 points in nine domains: cognition, general health status, functional independence, social support, medication use, nutrition, mood, continence and functional performance (Bit.ly/EdmontonScale). The EFS, which has good construct validity, reliability and internal consistency (Hilmer et al, 2009; Rolfson et al, 2006), has been recommended to assess frailty in primary and community care (NHS England, 2014). It correlates with the mini mental state examination (MMSE) and the Geriatric Depression Scale (GDS) (Kim et al, 2014; Chan et al, 2010). In the inpatient setting, it has been shown to correlate with other measures of frailty (MMSE, GDS, mini-nutritional assessment, activities of daily living, handgrip and Barthel Index) (Perna et al, 2017).
There is no specific tool to assess frailty in HF patients, and a recent systematic review shows that there is no consensus on which existing tool to use (McDonagh et al, 2017). A robust and relevant frailty index for HF could act as a prognostic indicator and help guide management: this is a crucial area for future research.
Many professional societies and guidelines advocate the routine assessment of frailty (BGS, 2014; NHS England, 2014) and nurses play an important role in this screening process (Yates, 2017). The results of frailty assessments can be used to stratify HF patients according to their risk of adverse outcomes and determine the best care for those with advanced disease. Frailty assessments are now part of the process of determining which patients should have a heart transplant (Mehra et al, 2016; Ponikowski et al, 2016) or interventions such as implantable defibrillators and left ventricular assist devices. They help identify patients in whom the risks of adverse outcomes outweigh the potential benefits of such invasive treatments (Ponikowski et al, 2016).
In general, the management of frailty is aimed at preventing, delaying or reversing it, or at reducing its severity. When frailty is not reversible, interventions aim to prevent or reduce the severity of associated adverse health outcomes (Chen et al, 2014). In advanced HF, the reversibility of frailty is unproven, but better HF control and increased activity tolerance can have positive effects on mood and self-care, potentially triggering a virtuous circle of decreasing frailty.
Older patients with HF, particularly those who also have frailty, may have poor adherence to medications, poor diet, comorbidities and cognitive impairment (Samala et al, 2011), and will benefit from an interdisciplinary approach to their management (Pulignano et al, 2010).
Once frailty has been identified, patients should enter a process of care that involves a comprehensive geriatric assessment (Table 2) undertaken by the multidisciplinary team. This focuses on determining the patient’s medical, psychological and functional capability to develop a coordinated and holistic treatment and follow-up plan (BGS, 2014; NHS England, 2014). The European Society of Cardiology recommends support from the multidisciplinary HF team alongside older age care teams and dementia support teams. Tailored self-care advice, aids such as dosette boxes and the involvement of relatives and carers are crucial (Ponikowski et al, 2016).
HF patients have a 50-70% reduction in aerobic capacity, which may limit the amount of activity they can do and accelerate their physical decline (Butts and Gary, 2015). The disuse of skeletal muscles can lead to sarcopenia and further exacerbate symptoms.
For many years, rest was thought to be beneficial in HF, but it is now clear that this is not the case and that rest can lead to physical deconditioning, symptom progression and worse outcomes. Conversely, aerobic and strength exercise training can increase patients’ capacity to exercise and reduce levels of inflammatory mediators (Addison et al, 2012; O’Connor et al, 2009). Patients doing routine exercise have been shown to have lower rates of hospitalisation (De Meirelles et al, 2014). Exercise is therefore recommended in HF even when frailty is present (Chou et al, 2012; Theou et al, 2011).
Additionally, exercise can have positive effects on cognitive function: patients exercising more than three times per week have been observed to have a delay in the onset of dementia (Larson et al, 2006). These beneficial effects on cognition are thought to be due to improved cerebral perfusion from improved cardiac function (Colcombe and Kramer, 2003).
Pharmacological and nutritional support
There are no proven pharmacological treatments to prevent muscle wasting or reverse frailty in HF. From a nutritional standpoint, although the routine prescription of supplements may increase the weight of older patients with frailty, there is no evidence of improved physical functioning or reduced mortality. Vitamin D supplementation is advised in patients who are vitamin D-deficient, as it is associated with a reduced risk of falls and fractures (Bischoff-Ferrari et al, 2012; Murad et al, 2011).
In men, normal ageing is associated with declining levels of testosterone, which is important, for a range of factors incuding bone strength, muscle mass, mood and libido; testosterone deficiency is also implicated in the development of sarcopenia. Some researchers have recommended testosterone replacement therapy, highlighting benefits such as a reduction in cardiovascular risk (Rosano et al, 2015).
A recent randomised trial has shown that testosterone in conjunction with a high-calorie nutritional supplement had no effect on the level of frailty in undernourished older men (Theou et al, 2016). The benefits of testosterone therapy remain unclear, both in frailty and in frailty in the context of HF.
Frailty is highly prevalent in HF and there is strong evidence that patients with coexisting HF and frailty have a worse prognosis. Assessing frailty is an important aspect of routine care for patients with HF, and it helps to stratify risk and reach clinical decisions. The fact that many HF patients also have frailty stresses the need for other specialties to get involved, alongside the multidisciplinary HF team.
- Frailty, characterised by reduced physiological reserve, loss of functionality and increased vulnerability, is common in people with heart failure
- Symptoms common to both conditions include fatigue, weakness, mood disturbances, reduced activity, cachexia and sarcopenia
- Assessing frailty is an important aspect of routine care for patients with heart failure
- Exercise is recommended, even when frailty is present, as it improves physical strength and cognitive function
- Managing frailty requires multidisciplinary input from the heart failure and other teams
Age UK (2017) Later Life in the United Kingdom, June 2017. London: Age UK.
Addison O et al (2012) Inflammation, aging, and adiposity: implications for physical therapists. Journal of Geriatric Physical Therapy; 35, 2, 86-94.
Bischoff-Ferrari HA et al (2012) A pooled analysis of vitamin D dose requirements for fracture prevention. New England Journal of Medicine; 367: 1, 40-49.
Bouillon K et al (2013) Measures of frailty in population-based studies: an overview. BMC Geriatrics 13: 64.
Boxer RS et al (2008) The association between vitamin D and inflammation with the 6-minute walk and frailty in patients with heart failure. Journal of the American Geriatrics Society; 56: 3, 454-461.
British Geriatric Society (2014) Fit for Frailty: Consensus Best Practice Guidance for the Care of Older People Living in Community and Outpatient Settings. London: BGS.
Buck HG, Riegel B (2011) The impact of frailty on health related quality of life in heart failure. European Journal of Cardiovascular Nursing; 10: 3, 159-166.
Butts B, Gary R (2105) Coexisting frailty, cognitive impairment, and heart failure: implications for clinical care. Journal of Clinical Outcomes Management; 22: 1, 38-46.
Cacciatore F et al (2005) Frailty predicts long-term mortality in elderly subjects with chronic heart failure. European Journal of Clinical Investigation; 35: 12, 723-730.
Chan DC et al (2010) Validation of the Chinese-Canadian study of health and aging clinical frailty scale (CSHA-CFS) telephone version. Archives of Gerontology and Geriatrics; 50: 3, e74-80.
Chen X et al (2014) Frailty syndrome: an overview. Clinical Interventions in Aging; 9: 433-441.
Chou CH et al (2012) Effect of exercise on physical function, daily living activities, and quality of life in the frail older adults: a meta-analysis. Archives of Physical Medicine and Rehabilitation; 93: 2, 237-244.
Colcombe S, Kramer AF (2003) Fitness effects on the cognitive function of older adults: a meta-analytic study. Psychological Science; 14: 2, 125-130.
Collard RM et al (2012) Prevalence of frailty in community-dwelling older persons: a systematic review. Journal of the American Geriatrics Society; 60: 8, 1487-1492.
De Meirelles LR et al (2014) Chronic exercise leads to antiaggregant, antioxidant and anti-inflammatory effects in heart failure patients. European Journal of Preventive Cardiology; 21: 10, 1225-1232.
Denfeld QE et al (2017a) The prevalence of frailty in heart failure: A systematic review and meta-analysis. International Journal of Cardiology; 236: 1, 283-289.
Denfeld QE et al (2017b) Frequency of and significance of physical frailty in patients with heart failure. American Journal of Cardiology; 119: 8, 1243-1249.
Fedarko NS (2011) The biology of aging and frailty. Clinics in Geriatric Medicine; 27: 1, 27-37.
Fried LP et al (2001) Frailty in older adults: evidence for a phenotype. Journals of Gerontolology. Series A, Biological Sciences and Medical Sciences; 56: 3, M146-M156.
Goldwater D, Altman NL (2016) Frailty and heart failure. Expert analysis, American College of Cardiology.
Hilmer SN et al (2009) The assessment of frailty in older people in acute care. Australasian Journal on Ageing; 28: 4, 182-188.
Kim S et al (2014) Correlation between frailty and cognitive function in non-demented community dwelling older Koreans. Korean Journal of Family Medicine; 35: 6, 309-320.
Larson EB et al (2006) Exercise is associated with reduced risk for incident dementia among persons 65 years of age and older. Annals of Internal Medicine; 144: 3, 73-81.
Ling CH et al (2010) Handgrip strength and mortality in the oldest old population: the Leiden 85-plus study. Canadian Medical Association Journal; 182: 5, 429-435.
McDonagh J et al (2017) Frailty assessment instruments in heart failure: A systematic review. European Journal of Cardiovascular Nursing; 1: 1474515117708888.
Mehra MR et al (2016) The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: a 10-year update. Journal of Heart and Lung Transplantation; 35: 1, 1-23.
Murad MH et al (2011) Clinical review: The effect of vitamin D on falls: a systematic review and meta-analysis. Journal of Clinical Endocrinology and Metabolism; 96: 10, 2997-3006.
Nadruz W Jr et al (2017) Cardiovascular dysfunction and frailty among older adults in the community: the ARIC study. Journals of Gerontolology. Series A, Biological Sciences and Medical Sciences; 72: 7, 958-964.
Newman AB et al (2001) Associations of subclinical cardiovascular disease with frailty. Journals of Gerontolology. Series A, Biological Sciences and Medical Sciences; 56: 3, M158-166.
NHS England (2014) Safe, Compassionate Care for Frail Older People Using an Integrated Care Pathway: Practical Guidance for Commissioners, Providers and Nursing, Medical and Allied Health Professional Leaders. London: NHS England.
O’Connor CM et al (2009) Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. Journal of the American Medical Association; 301: 14, 1439-1450.
Perna S et al (2017) Performance of Edmonton Frail Scale on frailty assessment: its association with multi-dimensional geriatric conditions assessed with specific screening tools. BMC Geriatrics; 17: 1, 2.
Ponikowski P et al (2016) 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal; 37: 27, 2129-2200.
Pulignano G et al (2010) Usefulness of frailty profile for targeting older heart failure patients in disease management programs: a cost-effectiveness, pilot study. Journal of Cardiovascular Medicine; 11: 10, 739-747.
Rockwood K, Mitnitski A (2007) Frailty in relation to the accumulation of deficits. Journals of Gerontolology. Series A, Biological Sciences and Medical Sciences; 62: 7, 722-727.
Rolfson DB et al (2006) Validity and reliability of the Edmonton Frail Scale. Age and Ageing; 35: 5, 526-529.
Rosano GM et al (2015) Testosterone in men with hypogonadism and high cardiovascular risk, Pros. Endocrine; 50: 2, 320-325.
Samala RV et al (2011) Heart failure in frail, older patients: we can do ‘MORE’. Cleveland Clinic Journal of Medicine; 78: 12, 837-845.
Studenski S et al (2011) Gait speed and survival in older adults. Journal of the American Medical Association; 305: 1, 50-58.
Syddall H et al (2010) Prevalence and correlates of frailty among community-dwelling older men and women: findings from the Hertfordshire Cohort Study. Age and Ageing; 39: 2, 197-203.
Sze S et al (2017) Prognostic value of simple frailty and malnutrition screening tools in patients with acute heart failure due to left ventricular systolic dysfunction. Clinical Research in Cardiology; 106: 7, 533-541.
Theou O et al (2016) Can an intervention with testosterone and nutritional supplement improve the frailty level of under-nourished older people? Journal of Frailty and Aging; 5: 4, 247-252.
Theou O et al (2011) The effectiveness of exercise interventions for the management of frailty: a systematic review. Journal of Aging Research; 569194. doi: 10.4061/2011/569194.
Uchmanowicz I, Gobbens RJ (2015) The relationship between frailty, anxiety and depression, and health-related quality of life in elderly patients with heart failure. Clinical Interventions in Aging; 10: 1595-1600.
Vidán MT et al (2014) FRAIL-HF, a study to evaluate the clinical complexity of heart failure in nondependent older patients: rationale, methods and baseline characteristics. Clinical Cardiology; 37: 12, 725-732.
Vidán MT et al (2016), Prevalence and prognostic impact of frailty and its components in non-dependent elderly patients with heart failure. European Journal of Heart Failure; 18: 869–875.
Wohlgemuth SE et al (2014) The interplay between autophagy and mitochondrial dysfunction in oxidative stress-induced cardiac aging and pathology. Journal of Molecular and Cellular Cardiology; 71: 62-70.
Yates L (2017) Use of proactive case management to address frailty in older people. Nursing Times; 113: 6, 22-26.