Archives of Gerontology and Geriatrics 61 (2015) 1–7

Contents lists available at ScienceDirect

Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger

Frailty predictors and outcomes among older patients with cardiovascular disease: Data from Fragicor ˆ ngela T. Paes d, Esther Tinoco a, Alberto Frisoli Jr.a,b,*, Sheila Jean McNeill Ingham b,c, A a a a Andrea Greco , Norma Zanata , Vitor Pintarelli , Izo Elber a, Jairo Borges a, Antonio Carlos Camargo Carvalho b a

Cardiogeriatric Unit, Cardiology Division, Federal University of Sa˜o Paulo, Sa˜o Paulo, Brazil Cardiology Division, Federal University of Sa˜o Paulo, Sa˜o Paulo, Brazil c Physical Medicine and Rehabilitation, Federal University of Sa˜o Paulo, Sa˜o Paulo, Brazil d Statistics Department, Federal University of Sa˜o Paulo, Sa˜o Paulo, Brazil b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 7 June 2014 Received in revised form 6 March 2015 Accepted 6 March 2015 Available online 14 March 2015

The aim of this study was to evaluate predictive factors for frailty among older outpatient adults with cardiovascular disease (CVD) and to assess the predictive value of frailty in regard to mortality, disability and hospitalization at 1-year follow-up. A prospective cohort study was carried out with subjects over 65 years of age from an outpatient Cardiology clinic, with at least one CVD. At baseline, we classified frailty as proposed by Fried, i.e.; unintentional weight loss (10 lbs in the past year), self-reported exhaustion, weakness (measured by grip strength), slow walking speed, and low physical activity. A frail person was defined by the presence of three or more criteria, prefrail by one or two and robust by the absence of them. Disability, previous hospitalizations, falls, morphometric and socio-demographic variables were collected; as well as the presence of CVD and hemodynamic parameters (HP): systolic (SPB) and diastolic blood pressure (DBP), heart rate (HR) and ejection fraction (EF). At 1-year follow-up, the outcomes assessed were: disability, number of hospitalizations and death. 172 subjects were included in this study with a mean age of 77 years old. The prevalence of frail was 39.8%, prefrail 51.5% and robust was 8.7%. Among the CVD and HP evaluated, myocardial infarction (MI), presence of three or more CVDs, lower SPB and DBP were significant and independent factors associated with the frailty phenotype. At 1-year follow up, frailty was an independent predictor for disability (Odds Ratio (OR): 3.94 (1.59–9.75); p = 0.003) and it increased death probability by three times if compared to the robust group. In conclusion, older outpatients with CVD have a higher probability to be frail than older adults who do not have a CVD. Low SPB and DBP must always be taken into consideration due to their high association with frailty. It is also important to diagnose frailty in this population due to the high association with mortality and disability. ß 2015 Elsevier Ireland Ltd. All rights reserved.

Keywords: Fragility Cardiovascular disease Disability Mortality

1. Introduction Frailty is a very heterogeneous clinical syndrome characterized by a diversity of signs and symptoms; it is associated with a decreased reserve or disturbances in the systemic reactions to stress (Fried et al., 2001) and it promotes a greater susceptibility to

* Corresponding author at: Rua Pedro de Toledo, 1010, Sao Paulo, SP 04039-002, Brazil. Tel.: +55 11 5084 6041; fax: +55 11 5575 5710. E-mail address: [email protected] (A. Frisoli Jr.). http://dx.doi.org/10.1016/j.archger.2015.03.001 0167-4943/ß 2015 Elsevier Ireland Ltd. All rights reserved.

disability, falls, hip fractures, hospitalization and death (Bilotta et al., 2010; De Lepeleire, Iliffe, Mann, & Degryse, 2009; Fried et al., 2001; Gill, Gahbauer, Han, & Allore, 2010; Rockwood & Mitnitski, 2007). Prior studies have demonstrated that frailty status in older people increases the mortality rate by six (18%) when compared to robust (3%) older people after a 7-year follow up period (Fried, Ferrucci, Darer, Williamson, & Anderson, 2004; Fried et al., 2001). Prevalence of frailty among elderly adluts from the community varies significantly according to the continent, age and ethnic groups. In subjects aged 65 years or more it ranges from 7 to 12% in the U.S. (Fried et al., 2001), increasing to 21–48% in Latin American

2

A. Frisoli Jr. et al. / Archives of Gerontology and Geriatrics 61 (2015) 1–7

and Caribbean countries, while, intermediate numbers are seen in some European countries (Alvarado, Zunzunegui, Beland, & Bamvita, 2008; Santos-Eggimann, Cuenoud, Spagnoli, & Junod, 2009). CVDs, very prevalent in the older population, have emerged as a strong risk factor for frailty (Afilalo, Karunananthan, Eisenberg, Alexander, & Bergman, 2009). Recent cross sectional studies, evaluating older people from the community, have demonstrated an association between CVD and frailty (Bandeen-Roche et al., 2006; Chin, Dekker, Feskens, Schouten, & Kromhout, 1999; Di Napoli, Papa, & V, 2002; Klein, Klein, Knudtson, & Lee, 2005; Newman et al., 2001; Woods et al., 2005). Also, in prospective cohort studies CVDs were associated with incidental frailty (Bandeen-Roche et al., 2006; Chin et al., 1999; Klein et al., 2005; Newman et al., 2001; Woods et al., 2005). Specific CVDs (coronary artery disease, stroke and hypertension (HTN)) among older women who were not frail at baseline, were each predictive of incident frailty over a 3-year follow-up. In addition to this, subclinical cardiovascular alterations detected by noninvasive testing (echocardiographic left ventricular hypertrophy, regional wall motion abnormalities, electrocardiographic abnormalities, systolic HTN, carotid intima-media thickness, magnetic resonance imaging evidence of stroke, and ankle arm index 3 months), Angina pectoris (AP), HTN and CVD3+ that was defined as the presence of three or more CVDs. All diagnoses were made according to the American Heart Association (AHA) Guidelines of Diagnosis (American College of Cardiology et al., 2013; Jessup et al., 2009; Wenger, 2012) with exception of PAD that was diagnosed by duplex ultrasound of lower limbs or ABI results described in the medical charts. Hemodynamic parameters evaluated were: SBP and DBP, HR and EF categorized by quartiles. Cognitive status by mini mental state examination (Folstein et al., 1975); presence of comorbidities (chronic obstructive pulmonary disease (COPD), diabetes mellitus, dyslipidemia, non dialitic kidney failure, osteoarthritis and osteoporosis) and previous hospitalization were also assessed. Alcohol intake was classified as high (more than 2 drinks a day), moderate (1 or 2 drinks a day), low (less than 1 drink a day) and no intake. Smoking was considered positive if it was current or if stopped less than 4 years prior to the interview. Disability was assessed by the number of tasks performed in activities of daily living (ADL) and instrumental activities of daily living (IADL); the cut point for disability was 5 for ADL and 25 for IADL (Abou-Raya & Abou-Raya, 2009; Katz, Downs, Cash, & Grotz, 1970; Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963; Lawton & Brody, 1969). Weight, height and body mass index (BMI), arterial blood pressure (measured 3 times in the supine position) and HR (measured 3 times in the supine position) were also evaluated.

204 outpatients were invited to participate in the study

2. Methods Exclusion criteria (n = 32) Moderate or severe dementia Chronic infectious disease Parkinson’s disease Cancer in last 5 years

2.1. Design, setting and participants Fragicor (FRAgilidade em idosos com doenc¸as CardiOvasculaRes/Frailty in an older population with CVD) is a prospective cohort study that aimed at evaluating frailty status and its outcomes in an older population with cardiovascular disease. The Ethical Review Board at our Institution approved this study and informed written consent was obtained from all participants.

172 Included in the study

2.2. Inclusion and exclusion criteria Inclusion criteria were: adults from a Cardiology outpatient clinic with at least one CVD, age over 65 years old, both genders and all ethnic groups. We considered, as exclusion criteria, the majority of clinical conditions or diseases that could confound any frailty criteria or physical activity, as follows: unstable medical conditions, any form of cancer in the last five years, chronic renal failure in need of dialysis, chronic liver disease, Parkinson’s disease, severe infectious disease requiring hospitalization in the last month, moderate or severe dementia classified by the MMSE (mini-mental state examination) (Folstein, Folstein, & McHugh, 1975; Fried et al., 2001).

Lost to follow-up (n = 69) Did not want to continue Could not be contacted Was not able to answer the questions by phone

103 completed the one year follow-up or died Fig. 1. Study flowchart.

A. Frisoli Jr. et al. / Archives of Gerontology and Geriatrics 61 (2015) 1–7

Frailty phenotype was determined by Fried’s criteria (Fried et al., 2001). Frailty was diagnosed by the presence of 3 or more, of the following criteria: Unintentional weight loss of 10 pounds in the prior year or, at follow-up, loss of 5% of body weight in the prior year (by direct weight measurement); Weakness: If the strongest of the three measures of grip strength of the dominant hand was lower than the cut off; Exhaustion: Identified by two questions from the CES–D scale ‘‘ (a) I felt that everything I did was an effort; (b) I could not get going. The question is asked ‘‘How often in the last week did you feel this way?’’ 0 = rarely or none of the time (1 day), 1 = some or a little of the time (1–2 days), 2 = a moderate amount of the time (3– 4 days), or 3 = most of the time. Subjects answering ‘‘2’’ or ‘‘3’’ to either of these questions are categorized as frail by the exhaustion criterion." (Orme, Reis, & Herz, 1986); Low walking speed: if the walking velocity, based on the time to walk 15 feet, was lower than the cut off; Low physical activity: If physical activities, based on the short version of the Minnesota Leisure Time Activity questionnaire (Lustosa et al., 2011; Taylor et al., 1978) were lower than the cut off. Prefrail was diagnosed when 1 or 2 criteria were present and robust when no criterion was present. We considered the same cut off values for all frailty criteria described by Fried (Fried et al., 2001). 2.4. One-year follow-up At one-year follow-up, subjects, caregivers or relatives were contacted for a structured interview, by phone, by an investigator blinded to the baseline data. If the subject or his/her caregiver was not reached by the first phone call, a maximum of four calls, with a one-week interval, was allowed. Adverse outcomes evaluated after one year were: incidental disability, hospitalization and death. Mortality was evaluated by phone call and confirmed by fax or e-mail of the death certificates. Two certificates were not received. Incidental disability was diagnosed in patients that: (i) were not disabled at baseline but at the one year follow-up presented with a score of ADL

Frailty predictors and outcomes among older patients with cardiovascular disease: Data from Fragicor.

The aim of this study was to evaluate predictive factors for frailty among older outpatient adults with cardiovascular disease (CVD) and to assess the...
425KB Sizes 1 Downloads 6 Views