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Review article
DOI: 10.1016/j.repc.2018.05.019
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Disponível online o 15 Março 2019
Frailty in cardiovascular disease: Screening tools
Fragilidade nas doenças cardiovasculares: instrumentos de rastreio
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Ana Zãoa,
Autor para correspondência
anazaomfr@gmail.com

Corresponding author.
, Sandra Magalhãesa, Mário Santosb,c
a Serviço de Medicina Física e de Reabilitação, Centro Hospitalar do Porto, Porto, Portugal
b Serviço de Cardiologia, Centro Hospitalar do Porto, Porto, Portugal
c Departamento de Fisiologia e Cirurgia Cardiotorácica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Recebido 24 Setembro 2017, Aceitado 19 Maio 2018
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Tabelas (5)
Table 1. Studies of frailty in cardiovascular disease.
Table 2. Characteristics of the most commonly used frailty scales.
Table 3. List of variables used by the Canadian Study of Health and Aging (CSHA) to construct the 70-item CSHA Frailty Index.39
Table 4. Tools used to assess frailty in cardiovascular disease.
Table 5. Comparison of the frailty phenotype and frailty indices.57
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Abstract

Cardiovascular disease (CVD) is the leading cause of death in developed countries and disproportionately affects older adults. Frailty is a complex clinical syndrome with multiple causes and contributing factors in which there is increased vulnerability when exposed to a minor stressor and increased risk for adverse outcomes, such as disability, hospitalization and mortality. Frailty is an important prognostic factor in patients with CVD, and so identifying this feature when assessing these patients may help to individually tailor cardiovascular treatment. The first step is to identify frailty. Several tools have been validated as screening methods for frailty. However, they diverge with regard to complexity, nature, feasibility and the outcome they can predict. The aim of this review is to describe the available screening tools for frailty and to examine their usefulness in patients with CVD.

Keywords:
Frailty
Cardiovascular disease
Assessment
Screening
Resumo

As doenças cardiovasculares (DCV) constituem a principal causa de morte nos países desenvolvidos e afetam desproporcionalmente os indivíduos idosos. A fragilidade é definida como uma síndrome clínica complexa com múltiplos fatores predisponentes e caraterizada por um aumento da vulnerabilidade e maior risco de desfechos adversos, nomeadamente, incapacidade, institucionalização e/ou mortalidade. Parece ser um fator prognóstico importante em doentes com DCV, pelo que o reconhecimento dos doentes com fragilidade pode permitir identificar os doentes com maior risco e assim orientar a estratégia terapêutica cardiovascular mais segura e eficaz. Assim, primeiramente é fundamental identificar a fragilidade. Vários instrumentos foram validados como métodos de rastreio de fragilidade. No entanto, eles divergem quanto à complexidade, natureza, viabilidade e resultados que podem prever. O objetivo desta revisão é descrever as ferramentas disponíveis para rastreio de fragilidade e avaliar as suas diferenças e utilidade nos doentes com DCV.

Palavras-chave:
Fragilidade
Doenças cardiovasculares
Avaliação
Rastreio
List of abbreviations
ACS

acute coronary syndrome

BADL

basic activities of daily living

CABG

coronary artery bypass grafting

CAF

Comprehensive Assessment of Frailty

CFS

Clinical Frailty Scale

CHS

Cardiovascular Health Study

CSHA

Canadian Study of Health and Aging

CVD

cardiovascular disease

EFS

Edmonton Frail Scale

EFT

Essential Frailty Toolset

EuroSCORE

European System for Cardiac Operative Risk Evaluation

GFI

Groningen Frailty Indicator

GFST

Gérontopôle Frailty Screening Tool

LVAD

left ventricular assist device

MACCE

major adverse cardiovascular and cerebrovascular events

MMSE

Mini-Mental State Exam

MNA

Mini Nutritional Assessment

MPI

Multidimensional Prognostic Instrument

MSSA

MacArthur Study of Successful Aging

STS

Society of Thoracic Surgeons

TAVI

transcatheter aortic valve implantation

TFI

Tilburg Frailty Indicator

TUG

Timed Up and Go

Texto Completo
Introduction

Cardiovascular disease (CVD) is the leading cause of death in developed countries and disproportionately affects older adults.1 Age by itself is a strong predictor of adverse events in acute coronary syndrome (ACS) and other CVD. Most prognostic models consider age, but do not take into account other related factors, such as frailty, health status, disability and cognition.2 Patients who have lower physiological reserve and functional capacity are at higher risk for homeostatic disruption when facing a stressful event.3 Identification of patients at increased risk of frailty and a better understanding of the impact of this variable on CVD outcomes may improve the quality of healthcare.

The aim of this review is to define frailty and to describe the available screening tools that can help to identify frailty among patients with CVD. We discuss the advantages and limitations of each tool, as well as the potential impact of their use in clinical practice.

FrailtyDefinition and epidemiology

Frailty is a complex clinical syndrome with multiple causes and contributing factors in which there is increased vulnerability when exposed to a minor stressor and increased risk for adverse outcomes, such as disability, hospitalization and/or mortality.4,5 This is often manifested by maladaptive response to stressors, leading to a vicious cycle toward functional decline and other serious adverse health outcomes. It is characterized by diminished strength, endurance and physiological reserve across the neuromuscular, metabolic and immune systems.6 It is important to note that old age itself does not define frailty, because some patients remain vigorous despite advanced age, while others can have functional decline in the absent of apparent stress factors or failure to rebound following hospitalization or illness.5 Thus, it is important to note the difference between biological age and chronological age.7

The prevalence of frailty ranges from 4% to 17%, and is higher among women (almost double that in men), increasing significantly in patients older than 80 years of age.8,9 Pre-frailty (which describes patients at risk for frailty who fulfill some, but not all, criteria for frailty) has been also been the subject of various studies, which show a prevalence around 28-44%.9 Several factors are thought to contribute to the development of frailty, including poor nutrition, reduced exercise tolerance, aging, chronic inflammation and immunological decline.7 Thus, it can potentially be prevented or treated with specific modalities, such as exercise, protein-calorie and vitamin D supplementation, and reduction of polypharmacy.6 However, a common feature of frail persons is mild cognitive impairment, which hampers the application of therapeutic regimens, especially exercise programs.

Pathophysiology

Frailty is a multifactorial condition. The literature shows that certain changes in physiological systems are associated with an increased risk for frailty, including a proinflammatory state and elevated markers of blood clotting,10 sarcopenia,7 anemia,11 anabolic hormone deficiencies,12,13 insulin resistance,14 significant immune system alterations,15 and oxidative stress.16

The importance of diagnosing frailty in patients with cardiovascular disease

The aging of populations is increasing the number of frail patients with CVD. Thus, identifying frailty has important implications for clinical care. Frailty worsens prognosis in patients with CVD (Table 1) and of patients undergoing cardiac surgery and other cardiovascular interventions, and can reduce the net benefits of some cardiac interventions because of competing risks.17,18 Frailty also increases the risk of cardiovascular and non-cardiovascular mortality and the need for rehabilitation and institutional care.2,19,20 In the large TRILOGY ACS trial, which included 4671 patients older than 65 years with ACS, 25% were considered pre-frail and 5% frail (according to the Fried score).21 Frail patients were more likely to suffer stroke or cardiovascular death after adjusting for the Global Registry of Acute Coronary Events (GRACE) score. Frailty is also a strong independent predictor of mortality in heart failure patients. One study found a population-attributable risk associated with frailty for emergency department visits of 35% and for hospitalizations of 19% among patients with heart failure.22 Kang et al. found that frailty was strongly and independently associated with short-term outcomes for elderly patients with ACS.23 In a study by Ekerstad et al. frailty was strongly and independently associated with in-hospital mortality, one-month mortality, prolonged hospital care, and the primary composite outcome in patients with non-ST-segment elevation myocardial infarction.24 Ricci et al. also found that frail and pre-frail older individuals accounted for a substantial proportion of those with more cardiovascular risk factors, especially diabetes, highlighting the need for preventive strategies in order to avoid the co-occurrence of CVD and frailty.25

Table 1.

Studies of frailty in cardiovascular disease.

Study  CVD and population  Screening tools for frailty  Other tools  Results 
Kang et al.23  ACS
352 patients, age >65 years 
CFS  CGA
CAD-specific index 
CFS was useful in evaluation of elderly patients with ACS. Frailty was strongly and independently associated with short-term outcomes for elderly patients with ACS. 
Uchmanowicz et al.50  ACS  TFI  CGA  Significant correlations were demonstrated between the values of the TFI and other scales. 
Ekerstad et al.24  ACS
307 patients, age >75 years 
CFS  CAD-specific index  Frailty was strongly and independently associated with in-hospital mortality, 1-month mortality, prolonged hospital care and the primary composite outcome. The combined use of frailty and comorbidity may constitute a novel risk prediction concept in regard to cardiovascular patients with complex needs. 
Boxer et al.17  Heart failure  CHS  6 MW  Both tools were associated with mortality (p=0.005) and highly correlated. The 6 MW may be useful as a measure of frailty. 
Invasive cardiac interventions
Afilalo et al.51  TAVI and valve surgery
1020 patients, median age 82 years 
EFT
CHS
Fried+a 
CFS
PPB
Bern Scale
Columbia Scale 
Frailty is a risk factor for death and disability following TAVI and valve surgery. The EFT outperformed other frailty scales and is recommended for use in this setting. 
Jung et al.29  Elective cardiac surgery, 133 patients  MFC
35-item Frailty Index
SPPB 
SPBB
EuroSCORE II 
Frailty results in a 3- to 8-fold increase in risk of postoperative delirium, independent of the EuroSCORE II. The addition of frailty improves the ability of the EuroSCORE II to predict postoperative delirium, pointing to opportunities for improved prevention and management. 
Dunlay et al.30  LVAD  31-item Frailty Index  Frailty before destination LVAD implantation is associated with increased risk of death and may represent a significant patient selection consideration. 
Schoenenberger et al.26  TAVI  Geriatric baseline examination  EuroSCORE
STS 
The geriatric baseline examination, but not established risk scores, was predictive of functional decline. 
Green et al.53  TAVI  MFC    Frailty was associated with increased 1-year mortality after TAVI. 
Stortecky et al.31  TAVI  MGA  EuroSCORE
STS
MACCE 
Risk prediction can be improved by adding multidimensional geriatric assessment-based information to global risk scores. 
Afilalo et al.28  CABG and/or valve surgery  Simplified Fried criteria (5-item)
Fried criteria (7-item)
MSSA
Five-meter gait speed test 
Disability scalesb
Surgical risk scoresc 
Clinicians should use an integrative approach combining frailty, disability, and risk scores to better characterize elderly patients referred for cardiac surgery and identify those that are at increased risk. 
Sundermann et al.20  CABG (25%) vs. valve surgery (35%) vs. combined procedures (26%)  CAF  EuroSCORE
STS 
CAF is an additional tool to assess prognosis of elderly patients before cardiac surgical interventions. The CAF score facilitates prediction of 30-day outcome of high-risk elderly patients. 

6 MW: six-minute walk test; ACS: acute coronary syndrome; CABG: coronary artery bypass grafting; CAD: coronary artery disease; CAF: Comprehensive Assessment of Frailty score; CFS: Clinical Frailty Scale; CGA: Comprehensive Geriatric Assessment; CHS: Cardiovascular Health Study scale; CVD: cardiovascular disease; EFT: Essential Frailty Toolset; EuroSCORE: European System for Cardiac Operative Risk Evaluation; LVAD: left ventricular assist device; MACCE: major adverse cardiovascular and cerebral events; MFC: Modified Fried Criteria; MSSA: 4-item MacArthur Study of Successful Aging frailty scale; MGA: Multidimensional Geriatric Assessment; PPB: Physical Performance Battery; SPPB: Short Physical Performance Battery; STS: Society of Thoracic Surgeons risk score; TAVI: Transcatheter aortic valve implantation; TFI: Tilburg Frailty Indicator.

a

Fried+: Fried criteria+cognition and mood assessment.

b

Disability scales: 6-item Katz Activities of Daily Living scale; 7-item Older Americans Research and Services Instrumental Activities of Daily Living scale; 7-item Nagi scale.

c Surgical risk scores: the Society of Thoracic Surgeons Predicted Risk of Mortality, the Society of Thoracic Surgeons Predicted Risk of Mortality or Major Morbidity; EuroSCORE; revised Parsonnet score; Age-Creatinine-Ejection Fraction score.

Similarly, frailty is associated with higher mortality and morbidity and greater need for health care in patients with valvular disease undergoing cardiac surgery.20,26

The number of elderly patients undergoing cardiac surgery is increasing. Frailty screening may be useful to identify patients with increased risk of adverse outcomes. Sundermann et al. found that patients who died within one year had a median Comprehensive Assessment of Frailty (CAF) score of 16 [5;33] compared to 11 [3;33] in one-year survivors (p=0.001), proving the prognostic value of frailty in cardiac surgery.20 Afilalo et al. also demonstrated the association between frailty and mortality or major morbidity after coronary artery bypass grafting (CABG) and/or valve surgery (odds ratio [OR] 2.63; 95% confidence interval [CI] 1.17-5.90).28 In a study by Jung et al., frailty was associated with a 3- to 8-fold increase in risk of postoperative delirium. According to these authors, ‘frail’ and ‘fit’ may be considered two ends of a continuum, and the risk of postoperative delirium grows as one becomes increasingly frail.29 There has also been interest in understanding whether preoperative frailty is associated with worse outcomes after implantation of a left ventricular assist device (LVAD) as destination therapy. A study by Dunlay et al. using a deficit index to assess frailty found that patients who were intermediate frail (adjusted HR 1.70, 95% CI 0.71-4.31) and frail (HR 3.08, 95% CI 1.40-7.48) were at increased risk for death (p=0.004 for trend). The mean number of days alive out of hospital the first year after LVAD implantation was higher for patients who were not frail.30 Schoenenberger et al. studied elderly patients undergoing transcatheter aortic valve implantation (TAVI) and showed that all the components of their geriatric baseline examination helped predict functional decline after intervention (OR: 3.31; 95% CI 1.21-9.03).26 Stortecky et al. found that frailty was associated with increased all-cause mortality (OR: 3.68; 95% CI 1.21-11.19), and with increased major adverse cardiovascular and cerebrovascular events (MACCE) (OR: 4.89; 95% CI 1.64-14.60) one year after TAVI (OR: 3.68; 95% CI 1.21-11.19).31

Pre-frailty, which is a potentially reversible state, also appears to have some prognostic value. The findings of Sergi et al. suggest that pre-frailty is independently associated with a higher risk of older adults developing CVD. Among the physical domains of pre-frailty, low gait speed seems to be the best predictor of future CVD.32

Assessment of frailty may lead to patients being reclassified to different clinical risk categories, suggesting it signals risk not captured by currently used risk assessment scores.2,32

How to screen for frailty

An ideal frailty screening tool should (1) be able to accurately identify frailty; (2) predict the response of frail patients to potential therapies; and (3) be simple and easy to apply and have low cost.33 Simple and rapid screening tests have been developed and validated to enable the objective recognition of frail persons. They differ mainly in the nature and number of deficits they measure, in line with two contrasting conceptual models: the frailty phenotype, or physical frailty, and the frailty index or deficit accumulation.34 The phenotype concept considers frailty as a syndrome, consisting of a small number of highly specific deficits in health, such as unintentional weight loss, exhaustion, slowness, low physical activity and impaired grip strength. Further specific health deficits, such as cognitive deficits, have been proposed as part of a frailty phenotype scale. By contrast, frailty indices are based on the concept of cumulative deficit, assessing frailty through a larger number of unspecified age-associated health deficits (usually at least 30). The most commonly used are the FRAIL Questionnaire screening tool,35–38 the Cardiovascular Health Study Frailty Screening Scale (Fried criteria),9 the Clinical Frailty Scale (CFS),39 frailty indices,40,41 and the Edmonton Frail Scale42 (Table 2).

Table 2.

Characteristics of the most commonly used frailty scales.

Screening tool  Measurement method  Criteria for frailty 
Simple FRAIL Questionnaire1. Fatigue: are you fatigued?  Frail: ≥3
Pre-frail: 1 or 2
2. Resistance: cannot walk up 1 flight of stairs? 
3. Aerobic: cannot walk 1 block? 
4. Illnesses: do you have more than 5 illnesses? 
5. Loss of weight: Have you lost more than 5% of your weight in the past 6 months? 
Cardiovascular Health Study Frailty Screening Scale1. Weight loss – loss of 10 pounds unintentionally in past year or weight at age 60-weight at exam ≥10% of age 60 weight.  Frail: ≥3
Pre-frail: 1 or 2
2. Exhaustion – self-report of fatigue or felt unusually tired or weak in the past month. 
3. Low activity – frequency and duration of physical activities (walking, doing strenuous household chores, doing strenuous outdoor chores, dancing, bowling, exercise).
- Men: <383 kcal/week=1
- Women: <270 kcal/week=1 
4. Slowness:
- Men: walking 4 m ≥7 s if height ≤173 cm or ≥6 s if height ≥173 cm=1
- Women: walking 4 m ≥7 s if height ≤159 cm or ≥6 s if height ≥159 cm=1 
5. Weakness – grip strength (kg) for body mass index (kg/m2)a 
Clinical Frailty Scale1. Very fit – people who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age.   
2. Well – people who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally.   
3. Managing well – people whose medical problems are well controlled, but are not regularly active beyond routine walking.   
4. Vulnerable – while not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up”, and/or being tired during the day.   
5. Mildly frail – these people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.   
6. Moderately frail – people need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.   
7. Severely frail – completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ∼6 months).   
8. Very severely frail – completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.   
9. Terminally ill - approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise evidently frail.   
Scoring frailty in people with dementia:
- The degree of frailty corresponds to the degree of dementia.
- Common symptoms in mild dementia include forgetting the details of a recent event, though still remembering the event itself, repeating the same question/story and social withdrawal.
- In moderate dementia, recent memory is very impaired, even though they seemingly can remember their past life events well. They can do personal care with prompting.
- In severe dementia, they cannot do personal care without help. 
 
Edmonton Frail ScaleCognition
Please imagine that this pre-drawn circle is a clock. I would like you to place the numbers in the correct positions then place the hands to indicate a time of ‘ten after eleven’
No errors=0; Minor spacing errors=1; Other errors=2 
0-5=Not frail
6-7=Vulnerable
8-9=Mild frailty
10-11=Moderate frailty
12-17=Severe frailty
General health status
- In the past year, how many times have you been admitted to a hospital?
- 0 times=0; 1-2 times=1; >2 times=2- In general, how would you describe your health? Excellent, very good, good=0; Fair=1; Poor=2 
Functional independence
With how many of the following activities do you require help? (meal preparation, shopping, transportation, telephone, housekeeping, laundry, managing money, taking medications)
0-1 activities=0; 2-4 activities=1; 5-8 activities=2 
Social support
When you need help, can you count on someone who is willing and able to meet your needs?
Always=0; Sometimes=1; Never=2 
Medication use
- Do you use five or more different prescriptions on a regular basis?
No=0; Yes=1
- At times do you forget to take your prescription
medication?
No=0; Yes=1 
Nutrition
Have you recently lost weight such that your clothing has become looser?
No=0; Yes=1 
Mood
Do you often feel sad or depressed?
No=0; Yes=1 
Continence
Do you have a problem with losing control of urine when you don’t want to?
No=0; Yes=1 
Functional performance
I would like you to sit in this chair with your back and arms resting. Then, when I say ‘GO,’ please stand up and walk at a safe and comfortable pace to the mark on the floor (approximately 3 m away), return to the chair and sit down
0-10 s=0; 11-20 s=1; >20 s or patient unwilling, or requires assistance=2 

IADLs: instrumental activities of daily living.

a

Men: Body mass index (BMI) ≤24 and grip strength ≤29 kg=1; BMI 24.1-26 and grip strength ≤30 kg=1; BMI 26.1-28 kg and grip strength ≤30 kg=1; BMI >28 and strength ≤32 kg=1; women: BMI ≤23 and grip strength ≤17 kg=1; BMI 23.1-26 and grip strength ≤17.3 kg=1; BMI 26.1-29 and grip strength ≤18 kg=1; BMI >29 and grip strength ≤21 kg=1.

The FRAIL Questionnaire screening tool

The FRAIL Questionnaire screening tool considers deficits accumulated in five domains, forming its acronym: Fatigue (self-reported), Resistance, Ambulation (slow walking speed), Illnesses, and Loss of weight (5% or more in the past year). The five domains are weighted equally. Individuals with two deficits are considered pre-frail, and those with three or more deficits are classified as frail.

Fried criteria for frailty

The Fried criteria for frailty (also known as the Cardiovascular Health Study Frailty Screening Scale, the Physical Frailty Phenotype and the Hopkins Frailty Phenotype) was first developed in the Cardiovascular Health Study.9 It assesses physical characteristics or phenotype, which include five domains: unintentional weight loss (4.5 kg or more in the last year), exhaustion (self-reported), low physical activity, weakness (low grip strength), and walking speed.9,43 Low physical activity is assessed through the frequency of moderate intensity activities, such as gardening or household chores. Similarly to the previous scale, individuals with two deficits are considered pre-frail, and those with three or more deficits are classified as frail.29

Clinical Frailty Scale

The CFS is a global clinical assessment of frailty based on physical function and level of independence with activities of daily living proposed by Rockwood et al.39 Each point on its scale has a visual chart and a written description of frailty to assist the classification process. Scoring is based on clinical judgment and ranges from 1 (very fit) to 9 (terminally ill).39

Frailty indices

Frailty indices are based on the deficit accumulation approach to measuring frailty, and are commonly used tools to assess frailty in order to estimate the related risk for adverse health outcomes, such as mortality.44 A frailty index is based on the concept that frailty is a consequence of interacting physical, psychological, and social factors. As deficits accumulate, people become increasingly vulnerable to adverse outcomes. The subject answers 20 or more questions related to medical and functional issues. The tool can be adapted to information available in the medical record and does not require a patient interview or exam to assess frailty. The 70 items of the original version are not to be considered a fixed set of variables (Table 3). It has been reported that estimates of risk are stronger when a minimum of 50 items are considered, but shorter versions (as few as 20 items) have also been studied.39–41 Rockwood and Mitnitski44 proposed a deficit accumulation-based frailty index using a comprehensive geriatric assessment (FI-CGA). This involves the accumulation of 30 or more comorbidities, symptoms, diseases, disabilities and other health deficits and is expressed as a ratio calculated as the number of deficits in an individual divided by the number of total deficits measured; the greater the number of deficits, the higher the score. The comprehensive geriatric assessment (CGA) includes medical, nutritional, functional and psychological assessments by a multidimensional team. The FI-CGA was initially developed as a ten-domain index with 14 CGA components and was later expanded to include 52 CGA components.33

Table 3.

List of variables used by the Canadian Study of Health and Aging (CSHA) to construct the 70-item CSHA Frailty Index.39

Changes in everyday activities  Problems going out alone  Poor limb coordination 
Head and neck problems  Impaired mobility  Poor coordination, trunk 
Facial bradykinesia  Musculoskeletal problems  Poor standing posture 
Poor muscle tone in neck  Bradykinesia of the limbs  Irregular gait pattern 
Problems getting dressed  Poor muscle tone in limbs  Falls 
Problems with bathing  Impaired vibration  Mood problems 
Problems carrying out personal grooming  Tremor at rest  Feeling sad, blue, depressed 
Urinary incontinence  Postural tremor  History of depressed mood 
Toileting problems  Intention tremor  Tiredness all the time 
Bulk difficulties  History of Parkinson's disease  Depression (clinical impression) 
Rectal problems  Family history of degenerative disease  Sleep changes 
Gastrointestinal problems  Seizures, partial complex  Restlessness 
Problems cooking  Seizures, generalized  Memory changes 
Sucking problems  Syncope or blackouts  Short-term memory impairment 
Skin problems  Peripheral pulses  Long-term memory impairment 
Malignant disease  Cardiac problems  Changes in general mental functioning 
Breast problems  Myocardial infarction  Onset of cognitive symptoms 
Abdominal problems  Arrhythmia  Clouding or delirium 
Presence of snout reflex  Congestive heart failure  Paranoid features 
Presence of the palmomental reflex  Lung problems  History relevant to cognitive impairment or loss 
History of thyroid disease  Respiratory problems  Family history relevant to cognitive impairment or loss 
Thyroid problems  History of diabetes  Headache 
History of stroke  Arterial hypertension  Cerebrovascular problems 
Other medical history     
Edmonton Frail Scale

The Edmonton Frail Scale (EFS) was developed to be practical and usable in the community setting or at the bedside. It is scored out of 17 and contains the following components: cognition, general health status, self-reported health, functional independence, social support, nutrition, mood, continence, and functional performance. The component scores are summed and the following cut-offs are used to classify frailty severity: not frail (0-5), apparently vulnerable (6-7), mildly frail (8-9), moderately frail (10-11) and severely frail (12-17).

Other screening tools

The scales described above are those most commonly used to assess frailty. However, other frailty scales are available, as listed below.

The Groningen Frailty Indicator (GFI) considers 15 dichotomous self-reported deficits in four domains: physical, cognitive, social, and psychological.45

The Tilburg Frailty Indicator contains 15 self-reported items in physical, psychological, and social domains.46

The Gérontopôle Frailty Screening Tool (GFST) comprises two steps: an initial questionnaire (containing six components: living alone, involuntary weight loss, fatigability, mobility, memory complaints and slow gait speed) followed by the clinician's judgment of frailty status.47

PRISMA-7 contains seven self-reported components: older than 85 years; male; health problems which limit activities; health problems requiring staying at home; support of another person needed; social support; and use of a cane or walker or wheelchair. Frailty is defined by a score of 3 or more.48

The Multidimensional Prognostic Instrument (MPI) is a multidimensional prognostic tool used for hospitalized older patients. It includes eight CGA components: ADL, instrumental ADL, risk of developing pressure sores, comorbidity, medication number, nutritional status, cognitive status, and living status.49

Frailty assessment tools used in cardiovascular disease

Some frailty assessment tools have been designed to be used specifically in the setting of CVD (Table 4). Some of the tools described above are also used for this purpose.23,24,50

Table 4.

Tools used to assess frailty in cardiovascular disease.

Study  Tool  Measurement method  Criteria for frailty 
Sundermann et al.20  CAF  • Patient is asked to get up and down from a chair 3 times and time is measured
• Self-reported weakness
• Patient is asked to climb as many stairs as they are able
• Two physicians (one a cardiac surgeon) conduct the CFS from the CSHA
Serum creatinine level 
Results from the CAF scores are tabulated into a scale from 1 to 35 points as outlined by the supplementary CAF Test Sheet. Scores between 1 and 10 are deemed not frail, between 11 and 25 are deemed moderately frail, and between 26 and 36 are deemed severely frail 
Green et al.53  Modified Fried frailty criteria  • Slow 15-m gait speed
• Weak dominant handgrip strength
• Assistance required in any of Katz Index of Independence in Activities of Daily Living criteria
• Serum albumin as a measurement of malnutrition 
Frailty defined as a score >5 on a scale from 0-12 where a higher score equates to more frail
For gait speed, grip strength, and serum albumin, based on which quartile a patient was in, a value of 0-3 was given for each quartile in descending order. For activities of daily living, 0 points were given for independent and 3 for dependent 
Afilalo et al.28  4 scales used:
• 5-item Modified Fried Criteria
• 7-item expanded Modified Fried Criteria
• 4-item MSSA
• Five-Meter Gait Speed Test 
• 5-item Modified Fried Criteria: gait speed, handgrip strength, inactivity, exhaustion, and weight loss
• 7-item Modified Fried Criteria: the above as well as cognitive impairment and depressed mood
• 4-item MSSA used gait speed, handgrip strength, inactivity, and cognitive impairment
• prolonged time for gait speed test (>6 s to walk 5 m) 
Defined as frail if any of the 4 scales deemed patient as frail 
Stortecky et al.31  Multidimensional
Geriatric Assessment 
• MMSE showing cognitive impairment
MNA shows malnutrition
• TUG showing limitation of mobility
• BADL and instrumental activities of daily living showed an activity with limitation
• Preclinical mobility disability defined as decreased frequency of walking 200 m and/or climbing stairs in preceding 6 months 
Defined frailty as ≥3 points, 2 points if MMSE <21, 1 point if MMSE ≥21 and <27, MNA <12, TUG ≥20 s, BADL with at least 1 limited activity, instrumental activities of daily living with at least 1 limited activity, preclinical mobility disability 
Schoenenberger et al.26  Geriatric baseline examination
 
• MMSE showing cognitive impairment
• MNA shows malnutrition
• TUG showing limitation of mobility
• BADL and instrumental activities of daily living showed an activity with limitation
• Preclinical mobility disability defined as decreased frequency of walking 200 m and/or climbing stairs in preceding 6 months 
Defined frailty as ≥3 points, 2 points if MMSE <21, 1 point if MMSE ≥21, and <27, MNA <12, TUG ≥20 s, BADL with at least 1 limited activity, instrumental activities of daily living with at least 1 limited activity, preclinical mobility disability 
Jung et al.29  Modified Fried Frailty Criteria definition of frailty  Slowness
– After two trials of a 5 m walk, average time >6 s
Weakness
– After three grip strength measurements with each hand, maximum value ≤30 kg if male or ≤20 kg if female
Weight loss
– Self-reported weight loss >4.5 kg (10 lbs) or >5% body weight in past 12 months
Exhaustion
– Two-item CES-D scale ≥1 out of 2
Depression
– 5-GDS ≥2 out of 5
Low physical activity
– Paffenbarger Physical Activity Index <383 kcal per week if male or <270 kcal per week if female
Cognitive impairment
– MoCA score <26 out of 30 
Patient was deemed frail if at least 3 of the 7 criteria were present 
  35-item Frailty Index  (i) Comorbidities
– Angina
– Arthritis
– Asthma
– Cerebrovascular disease
– Cognitive impairment
– COPD
– Dyslipidemia
– Gastrointestinal disease
– Hearing impairment
– Hypertension
– Myocardial infarction
– Pacemaker
– Peripheral vascular disease
– Pre-operative atrial flutter or fibrillation
– Prior angioplasty or stent
– Pulmonary hypertension
– Solid tumor
– Visual impairment
(ii) Physical and emotional measures
– Decline in food intake
– Depression based on the 5-GDS
– Exhaustion based on the two-item CES-D
– Falls in past year
– Inability to complete repeated chair stand test
– Low physical activity based on Paffenbarger Physical Activity Index
– Poor balance
– Self-rating of health
– TUG
– Unintentional weight loss in past 3 months
– Unintentional weight loss >4.5 kg (10 lbs)
– Weak grip
(iii) Functional measures
– Banking, inability to perform
– Cleaning, inability to perform
– Cooking, inability to perform
– Driving, inability to perform
– Shopping, inability to perform 
Frailty Index score=individual's total number of deficits/35
Deficits: each counted as present or absent 
  SPPB  (i) 5-m gait speed measurement
– After two trials, average time:
≤6.5 s: 4 points; 6.6-8.3 s: 3 points; 8.4-11.6 s: 2 points; ≥11.7 s: 1 point; unable: 0 points
(ii) Balance tests
– Side-by-side stand time
≥10 s: 1 point; <10 s: 0 points;
– Semi-tandem stand
≥10 s: 1 point; <10 s: 0 points
– Tandem stand
≥10 s: 2 points; 3-9.99 s: 1 point; <3 s: 0 points
(iii) Repeated chair stand test
– Time to stand up from chair 5 times
≤11.19 s: 4 points; 11.20-13.69 s: 3 points; 13.70-16.69 s: 2 points; 16.70-59.99 s: 1 point; ≥60 s or unable: 0 points 
Patient was deemed frail if composite score ≥9 points 
Uchmanowicz et al.50  TFI  First part:
Sociodemographic characteristics of a participant:
gender, age, marital status, country of origin, educational level, and monthly income
Potential determinants of frailty.
Second part:
Components of frailty (15 self-reported questions, divided into three domains):
- Physical domain (0-8 points): eight questions related to physical health, unexplained weight loss, difficulty in walking, balance problems, hearing problems, vision problems, strength in hands, and physical tiredness.
- Psychological domain (0-4 points): four items related to cognition, depressive symptoms, anxiety, and coping.
- Social domain (0-3 points): three questions related to living alone, social relations, and social support. 
Eleven items from part two of the TFI have two response categories (“yes” and “no”), while the other items have three (“yes”, “no,” and “sometimes”).
“Yes” or “sometimes” responses are scored 1 point each, while “no” responses are scored 0.
The instrument's total score may range from 0 to 15: the higher the score, the higher one's frailty.
Frailty is diagnosed when the total TFI score is >5. 
Dunlay et al.30  31-item deficit index  Need help preparing meals
Need help feeding yourself
Need help dressing yourself
Need help using the toilet
Need help with housekeeping
Need help climbing stairs
Need help bathing
Need help walking
Need help using transportation
Need help getting in and out of bed
Need help managing medications
Depend on assistive devices (walker, cane, etc.) or other people to perform activities of daily life
Dependent on a device for normal breathing
Climb 2 flights of stairs without rest
Myocardial infarction
Diabetes
Peripheral vascular disease
Cerebrovascular disease
COPD
Ulcer
Hemiplegia
Moderate/severe renal insufficiency
History of liver disease
Rheumatologic disease
History of malignancy
History of dementia
Hypertension
Hyperlipidemia
Body mass index
Depression
Anemia 
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0

Yes=1, No=0
No, cannot do at all=1; Yes, with difficulty=0.5; Yes with no difficulty=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Underweight or obese=1; overweight=0.5; normal=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Yes=1, No=0
Patients were divided into tertiles of the deficit index:
Lowest tertile=not frail; middle tertile=intermediate frail; highest tertile=frail 
Afilalo et al.51  Essential Frailty Toolset  (i) Time to stand 5 times from a seated position without using arms: <15 s=0 points; ≥15 s=1 point; unable to complete=2 points
(ii) Cognition: MMSE ≥24: 0 points; MMSE <24: 1 point
(iii) Hemoglobin: ≥13 g/dl (in men) or ≥12 g/dl (in women): 0 points; <13 g/dl (in men) or <12 g/dl (in women): 1 point
(iv) Serum albumin: ≥3.5 g/dl: 0 points; <3.5 g/dl: 1 point 
Composite score: 0-5 

5-GDS: five-item Geriatric Depression Scale; BADL: basic activities of daily living; CAF: Comprehensive Assessment of Frailty score; CES-D: Center for Epidemiologic Studies Depression scale; CFS: Clinical Frailty Scale; COPD: chronic obstructive pulmonary disease; CSHA: Canadian Study of Health and Aging; MMSE: Mini Mental State Exam; MNA: Mini Nutritional Assessment; MoCA: Montreal Cognitive Assessment score; MSSA: 4-item MacArthur Study of Successful Aging frailty scale; SPPB: Short Physical Performance Battery; TFI: Tilburg Frailty Indicator; TUG: Timed Up and Go test.

Kang et al. used the CFS, which was useful in assessment of elderly patients with ACS, predicting all-cause mortality, unscheduled return visit, and in-hospital and recurrent major adverse cardiovascular events.23

Ekerstad et al. used frailty as measured by the CFS to assess short-term outcomes for elderly patients with non-ST-segment elevation myocardial infarction, and showed that the combined use of frailty and other comorbidity tools (such as the coronary artery disease-specific index) may constitute a novel risk prediction concept in regard to cardiovascular patients with complex needs.24

Uchmanowicz et al. investigated the correlation of a scale for assessing frailty – the Tilburg Frailty Indicator and its mental and physical domains – with other screening tools commonly used for CGA in patients with ACS. Significant correlations were demonstrated between the values of the TFI and other scales.50

Boxer et al. also found that the six-minute walk and the five-item Cardiovascular Health Study were independently predictive of mortality in older adults with heart failure, with hazard ratio (HR) 0.82 (95% CI 0.72-0.94) and 1.64 (95% CI 1.19-2.26), respectively, and both could be useful as a measure of frailty.17

In a prospective observational study by Jung et al. in elective cardiac surgery patients, frailty was defined using the seven-item Cardiovascular Health Study score, the Short Physical Performance Battery (SPPB) and a 35-item frailty index. They found that the addition of frailty improved the ability of the EuroSCORE II to predict postoperative delirium, pointing to opportunities for improved prevention and management.29

The CAF is a tool created by Sundermann et al.20 to assess the prognosis of elderly patients before cardiac surgical interventions and accurately predicts mortality. It comprises grip strength, walking speed, balance, and ability to pick up a pen from the floor, rise from a chair three times and put on and remove a jacket, thus combining characteristics of the CHS criteria9 of patient phenotype, physical performance, and laboratory results. According to the authors, a combination of the CAF and traditional scoring systems may facilitate more accurate risk scoring in elderly high-risk patients scheduled for conventional cardiac surgery or transcatheter aortic valve replacement.27 The CAF was preoperatively applied to 400 patients aged ≥74 years admitted to a cardiac surgical department between September 2008 and January 2010. For 213 of these patients one-year follow-up was assessed by telephone interview until April 2010. One hundred and ten male and 103 female patients were included. Twenty-five percent underwent isolated coronary revascularization, 35% isolated valve procedures and 26% underwent combined procedures. One-year mortality was 12.2%. Patients who died within one year had a median frailty score of 16 [5;33] compared to 11 [3;33] in one-year survivors (p=0.001).20 Sundermann et al. showed that the CAF score facilitates prediction of mid-term outcome of high-risk elderly patients and the modified CAF score showed a promising ability to predict one-year mortality in patients undergoing cardiac surgery.20,27

The study by Dunlay et al. assessed the association between preoperative frailty and worse outcomes after implantation of an LVAD. Patients undergoing LVAD implantation as destination therapy at the Mayo Clinic, Rochester, MN between February 2007 and June 2012 were included in this study. Frailty was assessed using a deficit index (including 31 impairments, disabilities and comorbidities) and defined as the proportion of deficits present. Patients were then divided based on tertiles of the deficit index (>0.32=frail, 0.23 to 0.32=intermediate frail, <0.23=not frail). The authors concluded that frailty before destination LVAD implantation, as assessed by their deficit index, is associated with increased risk of death and may represent a significant patient selection consideration.30

Some tools have also been applied to patients undergoing TAVI. Stortecky et al. assessed the Multidimensional Geriatric Assessment (MGA) as a predictor of mortality and MACCE after TAVI. This prospective cohort comprised 100 consecutive patients aged ≥70 years undergoing TAVI. Global risk scores (Society of Thoracic Surgeons [STS] score, EuroSCORE) and MGA-based scores (cognition, nutrition, mobility, activities of daily living [ADL], and frailty index) were assessed as predictors of all-cause mortality and MACCE 30 days and one year after TAVI. This study provides evidence that risk prediction can be improved by adding MGA-based information to global risk scores.31

Schoenenberger et al. used the EuroSCORE, the STS score, and a geriatric baseline examination (based on assessment of cognition, mobility, nutrition, instrumental and basic activities of daily living) to predict functional decline in elderly patients undergoing TAVI. Overall predictive performance was best for the geriatric baseline examination and low for the EuroSCORE and STS score. In univariate analysis, all components of the geriatric baseline examination helped predict functional decline. The authors concluded that the geriatric baseline examination, but not established risk scores, was predictive of functional decline.26

In the 2012 study by Afilalo et al., a total of 152 patients were enrolled in a prospective, multicenter cohort study of elderly patients (>70 years) undergoing CABG and/or valve surgery in the US and Canada. Four different frailty scales, three disability scales, and five cardiac surgery risk scores were measured in all patients. The primary outcome was the STS composite endpoint of in-hospital postoperative mortality or major morbidity. The four frailty scales examined in this study are described in Table 4. The authors concluded that clinicians should use an integrative approach combining frailty, disability, and risk scores to better characterize elderly patients referred for cardiac surgery and identify those that are at increased risk.28

The same author, in a recent study (2017),51 compared the incremental predictive value of seven different frailty scales to predict poor outcomes following TAVI and valve surgery: the Fried criteria (described above),9 Fried+(the Fried criteria plus cognition assessed by the Mini Mental State Exam [MMSE] and mood assessed by the Short-form Geriatric Depression Scale), the Rockwood CFS,39 the SPPB (three physical tests, with each scored 0 to 4 for a composite score of 0 to 12: gait speed, time to stand five times from a seated position without using arms and the ability to stand 10 s with the feet in tandem or side-by-side positions),52 the Bern Scale (six items for a composite score of 0 to 7: gait speed, mobility, cognition, nutrition and disability in activities of daily living and instrumental activities),26,31 the Columbia Scale (four items, with each scored 0 to 3 for a composite score of 0 to 12: gait speed, grip strength, serum albumin and disability),53 and the Essential Frailty Toolset (EFT) (four items for a composite score of 0 to 5: time to stand five times from a seated position without using arms (1 point if ≥15 s, 2 points if unable to complete), cognition (1 point if MMSE <24), hemoglobin (1 point if <13 g/dl in men or <12 g/dl in women), and serum albumin (1 point if <3.5 g/dl).51 Frailty as measured by the EFT was the strongest predictor of death at one year (p<0.001) and of worsening disability at 1 year (adjusted OR:2.13; 95% CI:1.57 to 2.87) and death at 30 days (adjusted OR: 3.29; 95% CI: 1.73 to 6.26).

Some authors, instead of validating existing frailty screening tools, used certain parameters to derive their own frailty score. Green et al. used a modification of the Fried frailty criteria that included gait speed, grip strength, serum albumin, and activities of daily living status to derive a frailty score among older adults with severe aortic stenosis who underwent TAVI. In this study frailty was not associated with increased periprocedural complications in patients selected as candidates to undergo TAVR, but was associated with increased one-year mortality after TAVR.53

Screening tools: critical analysis

We have described individual multiple frailty measurement scales. There have been various studies comparing the most commonly used screening tools, but agreement on which has the best ability to predict prognosis and all-cause mortality is lacking. While some studies found similar prognostic performance in some of these tools,54,55 other studies found significant differences.56 In 2013, a consensus conference identified some of these tools as allowing physicians to objectively recognize frail persons.6 However, they range from short, fast and crude screening tools to sophisticated and time-consuming scales. A source of concern is the fact that many frailty scales have been modified somewhat from their original and validated version, leading to significant differences in frailty classification.33

Since the frailty phenotype and frailty indices are based on different concepts, it is inappropriate to consider them as alternatives and/or interchangeable.57Table 5 describes the main characteristics of these two different instruments.

Table 5.

Comparison of the frailty phenotype and frailty indices.57

Frailty phenotype  Frailty indices 
Performance on five variables  Deficit count or proportion of potential deficits that a person has accumulated 
Signs, symptoms  Diseases, activities of daily living, results of a clinical evaluation 
Possible before a clinical assessment  Doable only after a comprehensive clinical assessment 
Categorical variable  Continuous variable 
Predefined set of criteria  Unspecified set of criteria 
Frailty as a pre-disability syndrome  Frailty as an accumulation of deficits 
Meaningful results potentially restricted to non-disabled older persons  Meaningful results in every individual, independently of functional status or age 
Advantages:
- performance-based
- easy to apply 
Advantages:
- simple approach
- robust indicator of frailty 
Disadvantages:
- floor effect for some variables (immobile patients) 
Disadvantages:
- cumbersome in clinical setting 

The FRAIL screening tool is clinically advantageous due to its simple nature and ability to be obtained from data already included in a CGA.2 It has been found to be predictive of mortality in specific populations, such as patients with CVD.43

The CHS scale (Fried criteria) is a widely used scale applied in multiple epidemiological studies, and has good predictive value for adverse clinical outcomes, including mortality. However, a major factor precluding its clinical application is the inclusion of measurements not routinely used for patient assessment (such as grip strength measured by a dynamometer). Another important limitation of this scale is that it does not include psychosocial components of frailty.9

The CFS has been validated as a predictor of adverse outcomes in hospitalized older people, such as all-cause, in-hospital mortality, one-month mortality and prolonged hospital care.23,24,33

Deficit accumulation-based frailty indices are well validated and are better at predicting adverse clinical events than other frailty measurements in both hospital and community settings. They have been applied to multiple datasets, but can be time-consuming to calculate. The FI-CGA is used as a clinical standard for frailty assessment and has been found to predict patient response in multiple fields, including cardiology.2

The EFS is a valid and reliable measurement tool in the hospital setting and, since it has only nine components, it is much simpler to extract from CGAs than the FI-CGA.42 In a community-based sample, even when administered by non-specialists with no formal training in geriatric care, the EFS compared favorably with the clinical assessment of geriatric specialists who completed a more comprehensive evaluation.42

Compared with other frailty assessment tools, the MPI appears to have greater ability to predict adverse outcomes. Nevertheless, additional research is needed to confirm these results.33,49

The GFI has moderate internal consistency and adequate discriminative ability, and shows good feasibility and reliability as a frailty measurement. Some authors have proposed that it should be used together with a frailty index as part of a two-step screening process.58

The TFI shows good reliability for identifying frailty in community-dwelling older people. However, although its physical components show good ability to predict adverse events, its social components appear to be weak predictors.59,60

The GFST, designed for early recognition of frailty in community-dwelling older people, appears to be a good frailty screening tool; however, it gives no specific guidance for clinicians on how to identify frailty and the clinician's judgment of frailty status is quite subjective.33

Although PRISMA-7 shows good accuracy in identifying frailty in community-dwelling older people, its ability as a screening tool is limited since it has a tendency to over-screen for frailty.59

Some of these tools have also been used in cardiovascular patients, such as the Fried frailty criteria,17,23,24,29 frailty indices,29,30 and the TFI.50

The geriatric baseline examination developed by Schoenenberger et al.,26 the multidimensional geriatric assessment used by Stortecky et al.,31 and the CAF,20,27 developed by Sundermann et al., are three recent frailty tools which have been shown to be useful in predicting mortality and assessing prognosis of elderly patients with CVD or before cardiac surgical interventions.

Some authors, such as Afilalo et al., prefer to use an integrative approach combining frailty, disability, and risk scores to better characterize elderly patients referred for cardiac surgery, which has proved to be useful for identifying those at increased risk.28

The same author recently showed the superiority of the EFT compared to other frailty scales when predicting poor outcomes following TAVI and valve surgery, since it is a relatively simple tool that is neither particularly burdensome nor time-consuming and at the same time captures multiple domains of frailty. The authors suggested it had the highest predictive value for death and worsening disability at one year and recommended its use in this setting.51

Assessment of frailty as a preoperative surgical risk factor has been shown to be useful and may increase the number of elderly patients considered eligible for surgical interventions, since it enables prior screening for risk and prediction of surgical success and safety.

When selecting a screening tool, it is also important to take into account the ecology of its application, since some frailty measurements are more suitable for use in population health studies as screening, whereas others are appropriate in the clinical setting for screening or diagnosis of frailty.42,55,57

Conclusion

Frailty is an important prognostic factor in patients with CVD. It increases the risk of adverse events associated with cardiovascular therapeutic interventions, and therefore needs to be taken into account when considering whether to intervene. Frail patients may have more complications and fewer benefits because of the competing adverse event risk. The clinical relevance of frailty assessment will be even greater in the future because the number of frail patients with CVD is set to grow as populations age. Both successful treatment approaches for frail patients and the inclusion of frailty when assessing patients for CVD intervention require the systematic and routine identification of frailty. Simple and rapid screening tests have been developed and validated to enable the objective recognition of frail persons. There are significant differences between these scales in their nature, validity and feasibility. Further studies are needed to establish their significance regarding overall and cardiovascular mortality. In the CVD field, the two most commonly used and most robust frailty assessment tools for use by clinicians and researchers are the Fried criteria and frailty indices. Other new tools specifically designed for CVD have proved extremely useful for this propose. In line with previous studies, we suggest the use of one simple tool for frailty screening and a second one for a full assessment, and for these purposes we recommend the use of the Fried criteria and a frailty index, respectively. The impact of therapeutic strategies targeting frailty itself is still unclear. Nevertheless, routine screening and objective diagnosis of frailty is bound to improve the therapeutic decision-making process and prognostic assessment of patients with CVD.

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
Heart disease and stroke: the nation's leading killers
[2]
Singh M, Stewart R, White H. Importance of frailty in patients with cardiovascular disease. Eur Heart J. 2014;35:1726-31.
[3]
T. Strandberg, K. Pitkala
Frailty in elderly people
[4]
L. Rodríguez-Mañas, C. Féart, G. Mann
Searching for an operational definition of frailty: a delphi method based consensus statement
Frailty Oper Def Cons Conf Project, 68 (2013), pp. 62-67
[5]
A. Clegg, J. Young, S. Iliffe
Frailty in older people
[6]
J. Morley, B. Vellas, A. Van Kan
Frailty Consensus: a call to action, 14 (2014), pp. 392-397
[7]
L. Ferrucci, C. Cavazzini, A. Corsi
Biomarkers of frailty in older persons
J Endocrinol Invest, 25 (2002), pp. 10-15
[8]
R. Collard, H. Boter, R. Schoevers
Prevalence of frailty in community-dwelling older persons: a systematic review
J Am Geriatr Soc, 60 (2012), pp. 1487-1492 http://dx.doi.org/10.1111/j.1532-5415.2012.04054.x
[9]
L. Fried, C. Tangen, J. Walston, Cardiovascular Health Study Collaborative Research Group
Frailty in older adults: evidence for a phenotype
J Gerontol A Biol Sci Med Sci, 56 (2001), pp. M146-M156
[10]
J. Walston, M. McBurnie, A. Newman
Frailty and activation of the inflammation and coagulation systems with and without clinical comorbidities: results from the Cardiovascular Health Study
Arch Intern Med, 162 (2002), pp. 2333-2341
[11]
P. Chaves, R. Semba, S. Lenga
Impact of anemia and cardiovascular disease on frailty status of community-dwelling older women: the women's health and aging studies I and II
J Gerontol A Biol Sci Med Sci, 60 (2005), pp. 729-735
[12]
A. Cappola, Q. Xue, L. Fried
Multiple hormonal deficiencies in anabolic hormones are found in frail older women: the Women's Health and Aging studies
J Gerontol A Biol Sci Med Sci, 64 (2009), pp. 243-248 http://dx.doi.org/10.1093/gerona/gln026
[13]
R. Varadhan, P. Chaves, L. Lipsitz
Frailty and impaired cardiac autonomic control: new insights from principal components aggregation of traditional heart rate variability indices
J Gerontol A Biol Sci Med Sci, 64 (2009), pp. 682-687 http://dx.doi.org/10.1093/gerona/glp013
[14]
J. Barzilay, C. Blaum, T. Moore
Insulin resistance and inflammation as precursors of frailty: the Cardiovascular Health Study
Arch Intern Med, 167 (2007), pp. 635-641 http://dx.doi.org/10.1001/archinte.167.7.635
[15]
X. Yao, H. Li, S. Leng
Inflammation and immune system alterations in frailty
Clin Geriatr Med, 27 (2011), pp. 79-87 http://dx.doi.org/10.1016/j.cger.2010.08.002
[16]
R. Semba, L. Ferrucci, K. Sun
Oxidative stress and severe walking disability among older women
Am J Med, 120 (2007), pp. 1084-1089 http://dx.doi.org/10.1016/j.amjmed.2007.07.028
[17]
R. Boxer, A. Kleppinger, A. Ahmad
The 6-minute walk is associated with frailty and predicts mortality in older adults with heart failure, 16 (2011), pp. 208-213
[18]
E. Sanchez, M. Vidan, J. Serra
Prevalence of geriatric syndromes and impact on clinical and functional outcomes in older patients with acute cardiac diseases
Heart, 97 (2011), pp. 1602-1606 http://dx.doi.org/10.1136/hrt.2011.227504
[19]
D. Lee, K. Buth, B. Martin
Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery
[20]
S. Sundermann, A. Dademasch, A. Rastan
One-year follow-up of patients undergoing elective cardiac surgery assessed with the Comprehensive Assessment of Frailty test and its simplified form
Interact Cardiovasc Thorac Surg, 13 (2011), pp. 119-123 http://dx.doi.org/10.1510/icvts.2010.251884
[21]
M. Roe, P. Armstrong, K. Fox
Prasugrel versus clopidogrel for acute coronary syndromes without revascularization
N Engl J Med, 367 (2012), pp. 1297-1309 http://dx.doi.org/10.1056/NEJMoa1205512
[22]
S. Volpato, M. Cavalieri, F. Sioulis
Predictive value of the Short Physical Performance Battery following hospitalization in older patients
J Gerontol A Biol Sci Med Sci, 66 (2011), pp. 89-96 http://dx.doi.org/10.1093/gerona/glq167
[23]
L. Kang, S.-Y. Zhang, W.-L. Zhu
Is frailty associated with short-term outcomes for elderly patients with acute coronary syndrome?
J Geriatr Cardiol, 12 (2015), pp. 662-667 http://dx.doi.org/10.11909/j.issn.1671-5411.2015.06.010
[24]
N. Ekerstad, E. Swahn, M. Janzon
Frailty is independently associated with short-term outcomes for elderly patients with non-ST-segment elevation myocardial infarction
Circulation, 124 (2011), pp. 2397-2404 http://dx.doi.org/10.1161/CIRCULATIONAHA.111.025452
[25]
N.A. Ricci, G.S. Pessoa, E. Ferriolli
Frailty and cardiovascular risk in community-dwelling elderly: a population-based study
Clin Interv Aging, 9 (2014), pp. 1677-1685 http://dx.doi.org/10.2147/CIA.S68642
[26]
A. Schoenenberger, S. Stortecky, S. Neumann
Predictors of functional decline in elderly patients undergoing transcatheter aortic valve implantation (TAVI)
Eur Hear J, 34 (2013), pp. 684-692
[27]
S. Sündermann, A. Dademasch, J. Praetorius
Comprehensive assessment of frailty for elderly high-risk patients undergoing cardiac surgery
Eur J Cardiothorac Surg, 39 (2011), pp. 33-37 http://dx.doi.org/10.1016/j.ejcts.2010.04.013
[28]
J. Afilalo, S. Mottillo, M.J. Eisenberg
Addition of frailty and disability to cardiac surgery risk scores identifies elderly patients at high risk of mortality or major morbidity
Circ Cardiovasc Qual Outcomes, 5 (2012), pp. 222-228 http://dx.doi.org/10.1161/CIRCOUTCOMES.111.963157
[29]
P. Jung, M.A. Pereira, B. Hiebert
The impact of frailty on postoperative delirium in cardiac surgery patients
J Thorac Cardiovasc Surg, 149 (2015), pp. 869-875.e2 http://dx.doi.org/10.1016/j.jtcvs.2014.10.118
[30]
S.M. Dunlay, S.J. Park, L.D. Joyce
Frailty and outcomes after implantation of left ventricular assist device as destination therapy
J Hear Lung Transplant, 33 (2014), pp. 359-365
[31]
S. Stortecky, A.W. Schoenenberger, A. Moser
Evaluation of multidimensional geriatric assessment as a predictor of mortality and cardiovascular events after transcatheter aortic valve implantation
JACC Cardiovasc Interv, 5 (2012), pp. 489-496 http://dx.doi.org/10.1016/j.jcin.2012.02.012
[32]
H. Furukawa, K. Tanemoto
Frailty in cardiothoracic surgery: systematic review of the literature
Gen Thorac Cardiovasc Surg, 63 (2015), pp. 425-433 http://dx.doi.org/10.1007/s11748-015-0553-8
[33]
E. Dent, P.K.E. Hoogendijk
Frailty measurement in research and clinical practice: a review
Eur J Intern Med, (2016), pp. S0953 http://dx.doi.org/10.1016/j.ejim.2018.09.010
[34]
J.D. Walston, K. Bandeen-roche
Frailty: a tale of two concepts
[35]
D. Lopez, L. Flicker, A. Dobson
Validation of the frail scale in a cohort of older Australian women
J Am Geriatr Soc, 60 (2012), pp. 171-173 http://dx.doi.org/10.1111/j.1532-5415.2011.03746.x
[36]
J. Morley, T. Malmstrom, D. Miller
A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans
J Nutr Heal Aging, 16 (2012), pp. 601-608
[37]
J. Woo, J. Leung, J. Morley
Comparison of frailty indicators based on clinical phenotype and the multiple deficit approach in predicting mortality and physical limitation
J Am Geriatr Soc, 60 (2012), pp. 1478-1486 http://dx.doi.org/10.1111/j.1532-5415.2012.04074.x
[38]
J. Woo, R. Yu, M. Wong
Frailty screening in the community using the FRAIL scale
J Am Med Dir Assoc, 16 (2015), pp. 412 http://dx.doi.org/10.1016/j.jamda.2015.01.087
[39]
K. Rockwood, X. Song, C. Macknight
A global clinical measure of fitness and frailty in elderly people
CMAJ, 173 (2005), pp. 489-495 http://dx.doi.org/10.1503/cmaj.050051
[40]
K. Rockwood, A. Mitnitski
Frailty defined by deficit accumulation and geriatric medicine defined by frailty
Clin Geriatr Med, 27 (2011), pp. 17-26 http://dx.doi.org/10.1016/j.cger.2010.08.008
[41]
A. Mitnitski, A. Mogilner, K. Rockwood
Accumulation of deficits as a proxy measure of aging
ScientificWorldJournal, 1 (2001), pp. 323-336 http://dx.doi.org/10.1100/tsw.2001.58
[42]
D. Rolfson, S. Majumdar, R. Tsuyuki
Validity and reliability of the Edmonton Frail Scale
Age Ageing, 35 (2006), pp. 526-529 http://dx.doi.org/10.1093/ageing/afl041
[43]
K. Bandeen-Roche, Q. Xue, L. Ferrucci
Phenotype of frailty: characterization in the women's health and aging studies
J Gerontol A Biol Sci Med Sci, 61 (2006), pp. 262-266
[44]
K. Rockwood, A. Mitnitski
Frailty in relation to the accumulation of deficits
J Gerontol A Biol Sci Med Sci, 62 (2007), pp. 722
[45]
H. Schuurmans, N. Steverink, S. Lindenberg
Old or frail: what tells us more?
J Gerontol A Biol Sci Med Sci, 59A (2004), pp. M962-M965
[46]
R. Gobbens, M. van Assen, K. Luijkx
The Tilburg frailty indicator: psychometric properties
J Am Med Dir Assoc, 11 (2010), pp. 344-355 http://dx.doi.org/10.1016/j.jamda.2009.11.003
[47]
J. Subra, S. Gillette-Guyonnet, M. Cesari
The integration of frailty into clinical practice: preliminary results from the Gérontopôle
J Nutr Heal Aging, 16 (2012), pp. 714-720
[48]
M. Raiche, R. Hebert, M. Dubois
PRISMA-7: a case-finding tool to identify older adults with moderate to severe disabilities
Arch Gerontol Geriatr, 47 (2008), pp. 9-18 http://dx.doi.org/10.1016/j.archger.2007.06.004
[49]
A. Pilotto, L. Ferrucci, M. Franceschi
Development and validation of a multidimensional prognostic index for one-year mortality from comprehensive geriatric assessment in hospitalized older patients, 11 (2009), pp. 151-161
[50]
I. Uchmanowicz, M. Lisiak, R. Wontor
Frailty in patients with acute coronary syndrome: comparison between tools for comprehensive geriatric assessment and the Tilburg Frailty Indicator
Clin Interv Aging, 10 (2015), pp. 521-529 http://dx.doi.org/10.2147/CIA.S78365
[51]
J. Afilalo, S. Lauck, D. Kim
Frailty in older adults undergoing aortic valve replacement – the FRAILTY-AVR study
J Am Coll Cardiol, 70 (2017), pp. 689-700 http://dx.doi.org/10.1016/j.jacc.2017.06.024
[52]
J. Guralnik, E. Simonsick, L. Ferrucci
Al. E. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission
J Gerontol, 49 (1994), pp. M85-M94
[53]
P. Green, A.E. Woglom, P. Genereux
The impact of frailty status on survival after transcatheter aortic valve replacement in older adults with severe aortic stenosis: a single-center experience
JACC Cardiovasc Interv, 5 (2012), pp. 974-981 http://dx.doi.org/10.1016/j.jcin.2012.06.011
[54]
D. Kiely, L. Cupples, L. Lipsitz
Validation and comparison of two frailty indexes: the MOBILIZE Boston Study
J Am Geriatr Soc, 57 (2009), pp. 1532-1539 http://dx.doi.org/10.1111/j.1532-5415.2009.02394.x
[55]
K. Ensrud, S. Ewing, B. Taylor
Comparison of 2 frailty indexes for prediction of falls, disability, fractures, and death in older women
Arch Intern Med, 168 (2008), pp. 382 http://dx.doi.org/10.1001/archinternmed.2007.113
[56]
O. Theou, T.D. Brothers, A. Mitnitski
Operationalization of frailty using eight commonly used scales and comparison of their ability to predict all-cause mortality, 61 (2013), pp. 1537-1551
[57]
M. Cesari, G. Gambassi, G. van Kan
The frailty phenotype and the frailty index: different instruments for different purposes
Age Ageing, 43 (2014), pp. 10-12 http://dx.doi.org/10.1093/ageing/aft160
[58]
I. Drubbel, N. Bleijenberg, G. Kranenburg
Identifying frailty: do the Frailty Index and Groningen Frailty Indicator cover different clinical perspectives?. A cross-sectional study
BMC Fam Pr, 14 (2013), pp. 64-69
[59]
A. Clegg, L. Rogers, J. Young
Diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling older people: a systematic review, (2015), http://dx.doi.org/10.1093/ageing/afu157
[60]
H. Karapolat, S. Eyigor, M. Zoghi
Are swimming or aerobic exercise better than conventional exercise in ankylosing spondylitis patients?. A randomized controlled study
Eur J Phys Rehabil Med, 45 (2009), pp. 449-457
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