Frailty in cardiovascular disease: Screening tools | Revista Portuguesa de Cardiologia (English edition)

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Most prognostic models consider age, but do not take into account other related factors, such as frailty, health status, disability and cognition.<a class="elsevierStyleCrossRef" href="#bib0315">2</a> Patients who have lower physiological reserve and functional capacity are at higher risk for homeostatic disruption when facing a stressful event.<a class="elsevierStyleCrossRef" href="#bib0320">3</a> 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 epidemiologyFrailty 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.<a class="elsevierStyleCrossRefs" href="#bib0325">4,5</a> 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.<a class="elsevierStyleCrossRef" href="#bib0335">6</a> 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.<a class="elsevierStyleCrossRef" href="#bib0330">5</a> Thus, it is important to note the difference between biological age and chronological age.<a class="elsevierStyleCrossRef" href="#bib0340">7</a>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.<a class="elsevierStyleCrossRefs" href="#bib0345">8,9</a> 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%.<a class="elsevierStyleCrossRef" href="#bib0350">9</a> Several factors are thought to contribute to the development of frailty, including poor nutrition, reduced exercise tolerance, aging, chronic inflammation and immunological decline.<a class="elsevierStyleCrossRef" href="#bib0340">7</a> Thus, it can potentially be prevented or treated with specific modalities, such as exercise, protein-calorie and vitamin D supplementation, and reduction of polypharmacy.<a class="elsevierStyleCrossRef" href="#bib0335">6</a> However, a common feature of frail persons is mild cognitive impairment, which hampers the application of therapeutic regimens, especially exercise programs.PathophysiologyFrailty 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,<a class="elsevierStyleCrossRef" href="#bib0355">10</a> sarcopenia,<a class="elsevierStyleCrossRef" href="#bib0340">7</a> anemia,<a class="elsevierStyleCrossRef" href="#bib0360">11</a> anabolic hormone deficiencies,<a class="elsevierStyleCrossRefs" href="#bib0365">12,13</a> insulin resistance,<a class="elsevierStyleCrossRef" href="#bib0375">14</a> significant immune system alterations,<a class="elsevierStyleCrossRef" href="#bib0380">15</a> and oxidative stress.<a class="elsevierStyleCrossRef" href="#bib0385">16</a>The importance of diagnosing frailty in patients with cardiovascular diseaseThe 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 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) and of patients undergoing cardiac surgery and other cardiovascular interventions, and can reduce the net benefits of some cardiac interventions because of competing risks.<a class="elsevierStyleCrossRefs" href="#bib0580">17,18</a> Frailty also increases the risk of cardiovascular and non-cardiovascular mortality and the need for rehabilitation and institutional care.<a class="elsevierStyleCrossRefs" href="#bib0315">2,19,20</a> 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).<a class="elsevierStyleCrossRef" href="#bib0600">21</a> 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.<a class="elsevierStyleCrossRef" href="#bib0605">22</a> Kang et al. found that frailty was strongly and independently associated with short-term outcomes for elderly patients with ACS.<a class="elsevierStyleCrossRef" href="#bib0610">23</a> 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.<a class="elsevierStyleCrossRef" href="#bib0615">24</a> 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.<a class="elsevierStyleCrossRef" href="#bib0620">25</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Similarly, frailty is associated with higher mortality and morbidity and greater need for health care in patients with valvular disease undergoing cardiac surgery.<a class="elsevierStyleCrossRefs" href="#bib0595">20,26</a>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.<a class="elsevierStyleCrossRef" href="#bib0595">20</a> 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).<a class="elsevierStyleCrossRef" href="#bib0635">28</a> 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.<a class="elsevierStyleCrossRef" href="#bib0640">29</a> 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.<a class="elsevierStyleCrossRef" href="#bib0645">30</a> 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).<a class="elsevierStyleCrossRef" href="#bib0625">26</a> 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).<a class="elsevierStyleCrossRef" href="#bib0650">31</a>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.<a class="elsevierStyleCrossRef" href="#bib0655">32</a>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.<a class="elsevierStyleCrossRefs" href="#bib0315">2,32</a>How to screen for frailtyAn 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.<a class="elsevierStyleCrossRef" href="#bib0660">33</a> 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.<a class="elsevierStyleCrossRef" href="#bib0665">34</a> 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,<a class="elsevierStyleCrossRefs" href="#bib0670">35–38</a> the Cardiovascular Health Study Frailty Screening Scale (Fried criteria),<a class="elsevierStyleCrossRef" href="#bib0350">9</a> the Clinical Frailty Scale (CFS),<a class="elsevierStyleCrossRef" href="#bib0690">39</a> frailty indices,<a class="elsevierStyleCrossRefs" href="#bib0695">40,41</a> and the Edmonton Frail Scale<a class="elsevierStyleCrossRef" href="#bib0705">42</a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The FRAIL Questionnaire screening toolThe 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 frailtyThe 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.<a class="elsevierStyleCrossRef" href="#bib0350">9</a> 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.<a class="elsevierStyleCrossRefs" href="#bib0350">9,43</a> 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.<a class="elsevierStyleCrossRef" href="#bib0640">29</a>Clinical Frailty ScaleThe 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.<a class="elsevierStyleCrossRef" href="#bib0690">39</a> 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).<a class="elsevierStyleCrossRef" href="#bib0690">39</a>Frailty indicesFrailty 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.<a class="elsevierStyleCrossRef" href="#bib0715">44</a> 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 (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). 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.<a class="elsevierStyleCrossRefs" href="#bib0690">39–41</a> Rockwood and Mitnitski<a class="elsevierStyleCrossRef" href="#bib0715">44</a> 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.<a class="elsevierStyleCrossRef" href="#bib0660">33</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Edmonton Frail ScaleThe 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 toolsThe 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.<a class="elsevierStyleCrossRef" href="#bib0535">45</a>The Tilburg Frailty Indicator contains 15 self-reported items in physical, psychological, and social domains.<a class="elsevierStyleCrossRef" href="#bib0720">46</a>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.<a class="elsevierStyleCrossRef" href="#bib0725">47</a>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.<a class="elsevierStyleCrossRef" href="#bib0730">48</a>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.<a class="elsevierStyleCrossRef" href="#bib0735">49</a>Frailty assessment tools used in cardiovascular diseaseSome frailty assessment tools have been designed to be used specifically in the setting of CVD (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). Some of the tools described above are also used for this purpose.<a class="elsevierStyleCrossRefs" href="#bib0610">23,24,50</a><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>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.<a class="elsevierStyleCrossRef" href="#bib0610">23</a>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.<a class="elsevierStyleCrossRef" href="#bib0615">24</a>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.<a class="elsevierStyleCrossRef" href="#bib0740">50</a>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.<a class="elsevierStyleCrossRef" href="#bib0580">17</a>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.<a class="elsevierStyleCrossRef" href="#bib0640">29</a>The CAF is a tool created by Sundermann et al.<a class="elsevierStyleCrossRef" href="#bib0595">20</a> 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 criteria<a class="elsevierStyleCrossRef" href="#bib0350">9</a> 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.<a class="elsevierStyleCrossRef" href="#bib0630">27</a> 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).<a class="elsevierStyleCrossRef" href="#bib0595">20</a> 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.<a class="elsevierStyleCrossRefs" href="#bib0595">20,27</a>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.<a class="elsevierStyleCrossRef" href="#bib0645">30</a>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.<a class="elsevierStyleCrossRef" href="#bib0650">31</a>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.<a class="elsevierStyleCrossRef" href="#bib0625">26</a>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 <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>. 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.<a class="elsevierStyleCrossRef" href="#bib0635">28</a>The same author, in a recent study (2017),<a class="elsevierStyleCrossRef" href="#bib0745">51</a> compared the incremental predictive value of seven different frailty scales to predict poor outcomes following TAVI and valve surgery: the Fried criteria (described above),<a class="elsevierStyleCrossRef" href="#bib0350">9</a> 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,<a class="elsevierStyleCrossRef" href="#bib0690">39</a> 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),<a class="elsevierStyleCrossRef" href="#bib0750">52</a> 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),<a class="elsevierStyleCrossRefs" href="#bib0625">26,31</a> 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),<a class="elsevierStyleCrossRef" href="#bib0575">53</a> 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).<a class="elsevierStyleCrossRef" href="#bib0745">51</a> 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.<a class="elsevierStyleCrossRef" href="#bib0575">53</a>Screening tools: critical analysisWe 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,<a class="elsevierStyleCrossRefs" href="#bib0755">54,55</a> other studies found significant differences.<a class="elsevierStyleCrossRef" href="#bib0765">56</a> In 2013, a consensus conference identified some of these tools as allowing physicians to objectively recognize frail persons.<a class="elsevierStyleCrossRef" href="#bib0335">6</a> 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.<a class="elsevierStyleCrossRef" href="#bib0660">33</a>Since the frailty phenotype and frailty indices are based on different concepts, it is inappropriate to consider them as alternatives and/or interchangeable.<a class="elsevierStyleCrossRef" href="#bib0770">57</a><a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> describes the main characteristics of these two different instruments.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>The FRAIL screening tool is clinically advantageous due to its simple nature and ability to be obtained from data already included in a CGA.<a class="elsevierStyleCrossRef" href="#bib0315">2</a> It has been found to be predictive of mortality in specific populations, such as patients with CVD.<a class="elsevierStyleCrossRef" href="#bib0710">43</a>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.<a class="elsevierStyleCrossRef" href="#bib0350">9</a>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.<a class="elsevierStyleCrossRefs" href="#bib0610">23,24,33</a>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.<a class="elsevierStyleCrossRef" href="#bib0315">2</a>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.<a class="elsevierStyleCrossRef" href="#bib0705">42</a> 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.<a class="elsevierStyleCrossRef" href="#bib0705">42</a>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.<a class="elsevierStyleCrossRefs" href="#bib0660">33,49</a>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.<a class="elsevierStyleCrossRef" href="#bib0775">58</a>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.<a class="elsevierStyleCrossRefs" href="#bib0780">59,60</a>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.<a class="elsevierStyleCrossRef" href="#bib0660">33</a>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.<a class="elsevierStyleCrossRef" href="#bib0780">59</a>Some of these tools have also been used in cardiovascular patients, such as the Fried frailty criteria,<a class="elsevierStyleCrossRefs" href="#bib0580">17,23,24,29</a> frailty indices,<a class="elsevierStyleCrossRefs" href="#bib0640">29,30</a> and the TFI.<a class="elsevierStyleCrossRef" href="#bib0740">50</a>The geriatric baseline examination developed by Schoenenberger et al.,<a class="elsevierStyleCrossRef" href="#bib0625">26</a> the multidimensional geriatric assessment used by Stortecky et al.,<a class="elsevierStyleCrossRef" href="#bib0650">31</a> and the CAF,<a class="elsevierStyleCrossRefs" href="#bib0595">20,27</a> 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.<a class="elsevierStyleCrossRef" href="#bib0635">28</a>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.<a class="elsevierStyleCrossRef" href="#bib0745">51</a>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.<a class="elsevierStyleCrossRefs" href="#bib0705">42,55,57</a>ConclusionFrailty 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 interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1178798" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1100253" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1178797" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1100252" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Frailty" "secciones" => array:12 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Definition and epidemiology" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Pathophysiology" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "The importance of diagnosing frailty in patients with cardiovascular disease" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "How to screen for frailty" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "The FRAIL Questionnaire screening tool" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Fried criteria for frailty" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Clinical Frailty Scale" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Frailty indices" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Edmonton Frail Scale" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Other screening tools" ] 10 => array:2 [ "identificador" => "sec0065" "titulo" => "Frailty assessment tools used in cardiovascular disease" ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "Screening tools: critical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0075" "titulo" => "Conclusion" ] 7 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-09-24" "fechaAceptado" => "2018-05-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1100253" "palabras" => array:4 [ 0 => "Frailty" 1 => "Cardiovascular disease" 2 => "Assessment" 3 => "Screening" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1100252" "palabras" => array:4 [ 0 => "Fragilidade" 1 => "Doenças cardiovasculares" 2 => "Avaliação" 3 => "Rastreio" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "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." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "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." ] ] "nomenclatura" => array:1 [ 0 => array:3 [ "identificador" => "nom0005" "titulo" => "List of abbreviations" "listaDefinicion" => array:1 [ 0 => array:1 [ "definicion" => array:23 [ 0 => array:2 [ "termino" => "ACS" "descripcion" => "acute coronary syndrome" ] 1 => array:2 [ "termino" => "BADL" "descripcion" => "basic activities of daily living" ] 2 => array:2 [ "termino" => "CABG" "descripcion" => "coronary artery bypass grafting" ] 3 => array:2 [ "termino" => "CAF" "descripcion" => "Comprehensive Assessment of Frailty" ] 4 => array:2 [ "termino" => "CFS" "descripcion" => "Clinical Frailty Scale" ] 5 => array:2 [ "termino" => "CHS" "descripcion" => "Cardiovascular Health Study" ] 6 => array:2 [ "termino" => "CSHA" "descripcion" => "Canadian Study of Health and Aging" ] 7 => array:2 [ "termino" => "CVD" "descripcion" => "cardiovascular disease" ] 8 => array:2 [ "termino" => "EFS" "descripcion" => "Edmonton Frail Scale" ] 9 => array:2 [ "termino" => "EFT" "descripcion" => "Essential Frailty Toolset" ] 10 => array:2 [ "termino" => "EuroSCORE" "descripcion" => "European System for Cardiac Operative Risk Evaluation" ] 11 => array:2 [ "termino" => "GFI" "descripcion" => "Groningen Frailty Indicator" ] 12 => array:2 [ "termino" => "GFST" "descripcion" => "Gérontopôle Frailty Screening Tool" ] 13 => array:2 [ "termino" => "LVAD" "descripcion" => "left ventricular assist device" ] 14 => array:2 [ "termino" => "MACCE" "descripcion" => "major adverse cardiovascular and cerebrovascular events" ] 15 => array:2 [ "termino" => "MMSE" "descripcion" => "Mini-Mental State Exam" ] 16 => array:2 [ "termino" => "MNA" "descripcion" => "Mini Nutritional Assessment" ] 17 => array:2 [ "termino" => "MPI" "descripcion" => "Multidimensional Prognostic Instrument" ] 18 => array:2 [ "termino" => "MSSA" "descripcion" => "MacArthur Study of Successful Aging" ] 19 => array:2 [ "termino" => "STS" "descripcion" => "Society of Thoracic Surgeons" ] 20 => array:2 [ "termino" => "TAVI" "descripcion" => "transcatheter aortic valve implantation" ] 21 => array:2 [ "termino" => "TFI" "descripcion" => "Tilburg Frailty Indicator" ] 22 => array:2 [ "termino" => "TUG" "descripcion" => "Timed Up and Go" ] ] ] ] ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "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." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CVD and population \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Screening tools for frailty \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Other tools \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Results \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kang et al.<a class="elsevierStyleCrossRef" href="#bib0610">23</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ACS 352 patients, age >65 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CFS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CGA CAD-specific index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Uchmanowicz et al.<a class="elsevierStyleCrossRef" href="#bib0740">50</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ACS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TFI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CGA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Significant correlations were demonstrated between the values of the TFI and other scales. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ekerstad et al.<a class="elsevierStyleCrossRef" href="#bib0615">24</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ACS 307 patients, age >75 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CFS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CAD-specific index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Boxer et al.<a class="elsevierStyleCrossRef" href="#bib0580">17</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 MW \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Both tools were associated with mortality (p=0.005) and highly correlated. The 6 MW may be useful as a measure of frailty. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Invasive cardiac interventions</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Afilalo et al.<a class="elsevierStyleCrossRef" href="#bib0745">51</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TAVI and valve surgery 1020 patients, median age 82 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">EFT CHS Fried+<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CFS PPB Bern Scale Columbia Scale \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jung et al.<a class="elsevierStyleCrossRef" href="#bib0640">29</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Elective cardiac surgery, 133 patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MFC 35-item Frailty Index SPPB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SPBB EuroSCORE II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dunlay et al.<a class="elsevierStyleCrossRef" href="#bib0645">30</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LVAD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31-item Frailty Index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Frailty before destination LVAD implantation is associated with increased risk of death and may represent a significant patient selection consideration. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Schoenenberger et al.<a class="elsevierStyleCrossRef" href="#bib0625">26</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TAVI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Geriatric baseline examination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">EuroSCORE STS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The geriatric baseline examination, but not established risk scores, was predictive of functional decline. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Green et al.<a class="elsevierStyleCrossRef" href="#bib0575">53</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TAVI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MFC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Frailty was associated with increased 1-year mortality after TAVI. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stortecky et al.<a class="elsevierStyleCrossRef" href="#bib0650">31</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TAVI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MGA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">EuroSCORE STS MACCE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Risk prediction can be improved by adding multidimensional geriatric assessment-based information to global risk scores. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Afilalo et al.<a class="elsevierStyleCrossRef" href="#bib0635">28</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CABG and/or valve surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Simplified Fried criteria (5-item) Fried criteria (7-item) MSSA Five-meter gait speed test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Disability scales<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> Surgical risk scoresc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sundermann et al.<a class="elsevierStyleCrossRef" href="#bib0595">20</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CABG (25%) vs. valve surgery (35%) vs. combined procedures (26%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CAF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">EuroSCORE STS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2008676.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Fried+: Fried criteria+cognition and mood assessment." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "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." ] ] ] "descripcion" => array:1 [ "en" => "Studies of frailty in cardiovascular disease." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "IADLs: instrumental activities of daily living." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Screening tool \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Measurement method \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criteria for frailty \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Simple FRAIL Questionnaire</td><td class="td" title="table-entry " align="left" valign="top">1. Fatigue: are you fatigued? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Frail: ≥3 Pre-frail: 1 or 2</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Resistance: cannot walk up 1 flight of stairs? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Aerobic: cannot walk 1 block? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Illnesses: do you have more than 5 illnesses? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. Loss of weight: Have you lost more than 5% of your weight in the past 6 months? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Cardiovascular Health Study Frailty Screening Scale</td><td class="td" title="table-entry " align="left" valign="top">1. Weight loss – loss of 10 pounds unintentionally in past year or weight at age 60-weight at exam ≥10% of age 60 weight. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Frail: ≥3 Pre-frail: 1 or 2</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Exhaustion – self-report of fatigue or felt unusually tired or weak in the past month. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. Weakness – grip strength (kg) for body mass index (kg/m2)<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="10" align="left" valign="top">Clinical Frailty Scale</td><td class="td" title="table-entry " align="left" valign="top">1. Very fit – people who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">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. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Managing well – people whose medical problems are well controlled, but are not regularly active beyond routine walking. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">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. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">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. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">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. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">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). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8. Very severely frail – completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">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. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">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. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="9" align="left" valign="top">Edmonton Frail Scale</td><td class="td" title="table-entry " align="left" valign="top">Cognition 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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="9" align="left" valign="top">0-5=Not frail 6-7=Vulnerable 8-9=Mild frailty 10-11=Moderate frailty 12-17=Severe frailty </td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nutrition Have you recently lost weight such that your clothing has become looser? No=0; Yes=1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mood Do you often feel sad or depressed? No=0; Yes=1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Continence Do you have a problem with losing control of urine when you don’t want to? No=0; Yes=1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2008674.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "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." ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of the most commonly used frailty scales." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Changes in everyday activities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Problems going out alone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Poor limb coordination \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Head and neck problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Impaired mobility \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Poor coordination, trunk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Facial bradykinesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Musculoskeletal problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Poor standing posture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Poor muscle tone in neck \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bradykinesia of the limbs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Irregular gait pattern \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Problems getting dressed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Poor muscle tone in limbs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Falls \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Problems with bathing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Impaired vibration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mood problems \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Problems carrying out personal grooming \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tremor at rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Feeling sad, blue, depressed \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urinary incontinence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Postural tremor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">History of depressed mood \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Toileting problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intention tremor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tiredness all the time \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bulk difficulties \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">History of Parkinson's disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Depression (clinical impression) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rectal problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Family history of degenerative disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sleep changes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gastrointestinal problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Seizures, partial complex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Restlessness \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Problems cooking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Seizures, generalized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Memory changes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sucking problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Syncope or blackouts \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Short-term memory impairment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Skin problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Peripheral pulses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Long-term memory impairment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Malignant disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cardiac problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Changes in general mental functioning \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breast problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Myocardial infarction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Onset of cognitive symptoms \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abdominal problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arrhythmia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clouding or delirium \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Presence of snout reflex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Congestive heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Paranoid features \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Presence of the palmomental reflex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">History relevant to cognitive impairment or loss \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">History of thyroid disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Respiratory problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Family history relevant to cognitive impairment or loss \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thyroid problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">History of diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Headache \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">History of stroke \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arterial hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cerebrovascular problems \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other medical history \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2008672.png" ] ] ] ] "descripcion" => array:1 [ "en" => "List of variables used by the Canadian Study of Health and Aging (CSHA) to construct the 70-item CSHA Frailty Index.<a class="elsevierStyleCrossRef" href="#bib0690">39</a>" ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "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." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tool \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Measurement method \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criteria for frailty \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sundermann et al.<a class="elsevierStyleCrossRef" href="#bib0595">20</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CAF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Green et al.<a class="elsevierStyleCrossRef" href="#bib0575">53</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Modified Fried frailty criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Afilalo et al.<a class="elsevierStyleCrossRef" href="#bib0635">28</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 scales used: • 5-item Modified Fried Criteria • 7-item expanded Modified Fried Criteria • 4-item MSSA • Five-Meter Gait Speed Test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Defined as frail if any of the 4 scales deemed patient as frail \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stortecky et al.<a class="elsevierStyleCrossRef" href="#bib0650">31</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multidimensional Geriatric Assessment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Schoenenberger et al.<a class="elsevierStyleCrossRef" href="#bib0625">26</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Geriatric baseline examination  \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jung et al.<a class="elsevierStyleCrossRef" href="#bib0640">29</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Modified Fried Frailty Criteria definition of frailty \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patient was deemed frail if at least 3 of the 7 criteria were present \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35-item Frailty Index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Frailty Index score=individual's total number of deficits/35 Deficits: each counted as present or absent \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SPPB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patient was deemed frail if composite score ≥9 points \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Uchmanowicz et al.<a class="elsevierStyleCrossRef" href="#bib0740">50</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TFI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dunlay et al.<a class="elsevierStyleCrossRef" href="#bib0645">30</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31-item deficit index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Afilalo et al.<a class="elsevierStyleCrossRef" href="#bib0745">51</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Essential Frailty Toolset \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Composite score: 0-5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2008675.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Tools used to assess frailty in cardiovascular disease." ] ] 4 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Frailty phenotype \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Frailty indices \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Performance on five variables \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Deficit count or proportion of potential deficits that a person has accumulated \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Signs, symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diseases, activities of daily living, results of a clinical evaluation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Possible before a clinical assessment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Doable only after a comprehensive clinical assessment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Categorical variable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Continuous variable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Predefined set of criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unspecified set of criteria \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Frailty as a pre-disability syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Frailty as an accumulation of deficits \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Meaningful results potentially restricted to non-disabled older persons \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Meaningful results in every individual, independently of functional status or age \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Advantages: - performance-based - easy to apply \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Advantages: - simple approach - robust indicator of frailty \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Disadvantages: - floor effect for some variables (immobile patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Disadvantages: - cumbersome in clinical setting \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2008673.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comparison of the frailty phenotype and frailty indices.<a class="elsevierStyleCrossRef" href="#bib0770">57</a>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:60 [ 0 => array:3 [ "identificador" => "bib0310" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Heart disease and stroke: the nation's leading killers" ] ] "host" => array:2 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2005" ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "http://www.cdc.gov" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0315" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Singh M, Stewart R, White H. 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Frailty in cardiovascular disease: Screening tools

Fragilidade nas doenças cardiovasculares: instrumentos de rastreio

Ana Zãoa,

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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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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0120" class="elsevierStylePara elsevierViewall">Cardiovascular disease &#40;CVD&#41; is the leading cause of death in developed countries and disproportionately affects older adults&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">1</span></a> Age by itself is a strong predictor of adverse events in acute coronary syndrome &#40;ACS&#41; and other CVD&#46; Most prognostic models consider age&#44; but do not take into account other related factors&#44; such as frailty&#44; health status&#44; disability and cognition&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">2</span></a> Patients who have lower physiological reserve and functional capacity are at higher risk for homeostatic disruption when facing a stressful event&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">3</span></a> 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&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">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&#46; We discuss the advantages and limitations of each tool&#44; as well as the potential impact of their use in clinical practice&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Frailty</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Definition and epidemiology</span><p id="par0130" class="elsevierStylePara elsevierViewall">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&#44; such as disability&#44; hospitalization and&#47;or mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">4&#44;5</span></a> This is often manifested by maladaptive response to stressors&#44; leading to a vicious cycle toward functional decline and other serious adverse health outcomes&#46; It is characterized by diminished strength&#44; endurance and physiological reserve across the neuromuscular&#44; metabolic and immune systems&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">6</span></a> It is important to note that old age itself does not define frailty&#44; because some patients remain vigorous despite advanced age&#44; while others can have functional decline in the absent of apparent stress factors or failure to rebound following hospitalization or illness&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">5</span></a> Thus&#44; it is important to note the difference between biological age and chronological age&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">7</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The prevalence of frailty ranges from 4&#37; to 17&#37;&#44; and is higher among women &#40;almost double that in men&#41;&#44; increasing significantly in patients older than 80 years of age&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">8&#44;9</span></a> Pre-frailty &#40;which describes patients at risk for frailty who fulfill some&#44; but not all&#44; criteria for frailty&#41; has been also been the subject of various studies&#44; which show a prevalence around 28-44&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">9</span></a> Several factors are thought to contribute to the development of frailty&#44; including poor nutrition&#44; reduced exercise tolerance&#44; aging&#44; chronic inflammation and immunological decline&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">7</span></a> Thus&#44; it can potentially be prevented or treated with specific modalities&#44; such as exercise&#44; protein-calorie and vitamin D supplementation&#44; and reduction of polypharmacy&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">6</span></a> However&#44; a common feature of frail persons is mild cognitive impairment&#44; which hampers the application of therapeutic regimens&#44; especially exercise programs&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pathophysiology</span><p id="par0140" class="elsevierStylePara elsevierViewall">Frailty is a multifactorial condition&#46; The literature shows that certain changes in physiological systems are associated with an increased risk for frailty&#44; including a proinflammatory state and elevated markers of blood clotting&#44;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">10</span></a> sarcopenia&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">7</span></a> anemia&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">11</span></a> anabolic hormone deficiencies&#44;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">12&#44;13</span></a> insulin resistance&#44;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">14</span></a> significant immune system alterations&#44;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">15</span></a> and oxidative stress&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">The importance of diagnosing frailty in patients with cardiovascular disease</span><p id="par0145" class="elsevierStylePara elsevierViewall">The aging of populations is increasing the number of frail patients with CVD&#46; Thus&#44; identifying frailty has important implications for clinical care&#46; Frailty worsens prognosis in patients with CVD &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; and of patients undergoing cardiac surgery and other cardiovascular interventions&#44; and can reduce the net benefits of some cardiac interventions because of competing risks&#46;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">17&#44;18</span></a> Frailty also increases the risk of cardiovascular and non-cardiovascular mortality and the need for rehabilitation and institutional care&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">2&#44;19&#44;20</span></a> In the large TRILOGY ACS trial&#44; which included 4671 patients older than 65 years with ACS&#44; 25&#37; were considered pre-frail and 5&#37; frail &#40;according to the Fried score&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">21</span></a> Frail patients were more likely to suffer stroke or cardiovascular death after adjusting for the Global Registry of Acute Coronary Events &#40;GRACE&#41; score&#46; Frailty is also a strong independent predictor of mortality in heart failure patients&#46; One study found a population-attributable risk associated with frailty for emergency department visits of 35&#37; and for hospitalizations of 19&#37; among patients with heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">22</span></a> Kang et al&#46; found that frailty was strongly and independently associated with short-term outcomes for elderly patients with ACS&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">23</span></a> In a study by Ekerstad et al&#46; frailty was strongly and independently associated with in-hospital mortality&#44; one-month mortality&#44; prolonged hospital care&#44; and the primary composite outcome in patients with non-ST-segment elevation myocardial infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">24</span></a> Ricci et al&#46; also found that frail and pre-frail older individuals accounted for a substantial proportion of those with more cardiovascular risk factors&#44; especially diabetes&#44; highlighting the need for preventive strategies in order to avoid the co-occurrence of CVD and frailty&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">25</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">Similarly&#44; frailty is associated with higher mortality and morbidity and greater need for health care in patients with valvular disease undergoing cardiac surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">20&#44;26</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The number of elderly patients undergoing cardiac surgery is increasing&#46; Frailty screening may be useful to identify patients with increased risk of adverse outcomes&#46; Sundermann et al&#46; found that patients who died within one year had a median Comprehensive Assessment of Frailty &#40;CAF&#41; score of 16 &#91;5&#59;33&#93; compared to 11 &#91;3&#59;33&#93; in one-year survivors &#40;p&#61;0&#46;001&#41;&#44; proving the prognostic value of frailty in cardiac surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">20</span></a> Afilalo et al&#46; also demonstrated the association between frailty and mortality or major morbidity after coronary artery bypass grafting &#40;CABG&#41; and&#47;or valve surgery &#40;odds ratio &#91;OR&#93; 2&#46;63&#59; 95&#37; confidence interval &#91;CI&#93; 1&#46;17-5&#46;90&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">28</span></a> In a study by Jung et al&#46;&#44; frailty was associated with a 3- to 8-fold increase in risk of postoperative delirium&#46; According to these authors&#44; &#8216;frail&#8217; and &#8216;fit&#8217; may be considered two ends of a continuum&#44; and the risk of postoperative delirium grows as one becomes increasingly frail&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">29</span></a> There has also been interest in understanding whether preoperative frailty is associated with worse outcomes after implantation of a left ventricular assist device &#40;LVAD&#41; as destination therapy&#46; A study by Dunlay et al&#46; using a deficit index to assess frailty found that patients who were intermediate frail &#40;adjusted HR 1&#46;70&#44; 95&#37; CI 0&#46;71-4&#46;31&#41; and frail &#40;HR 3&#46;08&#44; 95&#37; CI 1&#46;40-7&#46;48&#41; were at increased risk for death &#40;p&#61;0&#46;004 for trend&#41;&#46; The mean number of days alive out of hospital the first year after LVAD implantation was higher for patients who were not frail&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">30</span></a> Schoenenberger et al&#46; studied elderly patients undergoing transcatheter aortic valve implantation &#40;TAVI&#41; and showed that all the components of their geriatric baseline examination helped predict functional decline after intervention &#40;OR&#58; 3&#46;31&#59; 95&#37; CI 1&#46;21-9&#46;03&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a> Stortecky et al&#46; found that frailty was associated with increased all-cause mortality &#40;OR&#58; 3&#46;68&#59; 95&#37; CI 1&#46;21-11&#46;19&#41;&#44; and with increased major adverse cardiovascular and cerebrovascular events &#40;MACCE&#41; &#40;OR&#58; 4&#46;89&#59; 95&#37; CI 1&#46;64-14&#46;60&#41; one year after TAVI &#40;OR&#58; 3&#46;68&#59; 95&#37; CI 1&#46;21-11&#46;19&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">31</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Pre-frailty&#44; which is a potentially reversible state&#44; also appears to have some prognostic value&#46; The findings of Sergi et al&#46; suggest that pre-frailty is independently associated with a higher risk of older adults developing CVD&#46; Among the physical domains of pre-frailty&#44; low gait speed seems to be the best predictor of future CVD&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">32</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Assessment of frailty may lead to patients being reclassified to different clinical risk categories&#44; suggesting it signals risk not captured by currently used risk assessment scores&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">2&#44;32</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">How to screen for frailty</span><p id="par0170" class="elsevierStylePara elsevierViewall">An ideal frailty screening tool should &#40;1&#41; be able to accurately identify frailty&#59; &#40;2&#41; predict the response of frail patients to potential therapies&#59; and &#40;3&#41; be simple and easy to apply and have low cost&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">33</span></a> Simple and rapid screening tests have been developed and validated to enable the objective recognition of frail persons&#46; They differ mainly in the nature and number of de&#64257;cits they measure&#44; in line with two contrasting conceptual models&#58; the frailty phenotype&#44; or physical frailty&#44; and the frailty index or deficit accumulation&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">34</span></a> The phenotype concept considers frailty as a syndrome&#44; consisting of a small number of highly speci&#64257;c de&#64257;cits in health&#44; such as unintentional weight loss&#44; exhaustion&#44; slowness&#44; low physical activity and impaired grip strength&#46; Further speci&#64257;c health de&#64257;cits&#44; such as cognitive deficits&#44; have been proposed as part of a frailty phenotype scale&#46; By contrast&#44; frailty indices are based on the concept of cumulative de&#64257;cit&#44; assessing frailty through a larger number of unspecified age-associated health de&#64257;cits &#40;usually at least 30&#41;&#46; The most commonly used are the FRAIL Questionnaire screening tool&#44;<a class="elsevierStyleCrossRefs" href="#bib0670"><span class="elsevierStyleSup">35&#8211;38</span></a> the Cardiovascular Health Study Frailty Screening Scale &#40;Fried criteria&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">9</span></a> the Clinical Frailty Scale &#40;CFS&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">39</span></a> frailty indices&#44;<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">40&#44;41</span></a> and the Edmonton Frail Scale<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">42</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">The FRAIL Questionnaire screening tool</span><p id="par0175" class="elsevierStylePara elsevierViewall">The FRAIL Questionnaire screening tool considers deficits accumulated in five domains&#44; forming its acronym&#58; <span class="elsevierStyleBold">F</span>atigue &#40;self-reported&#41;&#44; <span class="elsevierStyleBold">R</span>esistance&#44; <span class="elsevierStyleBold">A</span>mbulation &#40;slow walking speed&#41;&#44; <span class="elsevierStyleBold">I</span>llnesses&#44; and <span class="elsevierStyleBold">L</span>oss of weight &#40;5&#37; or more in the past year&#41;&#46; The five domains are weighted equally&#46; Individuals with two deficits are considered pre-frail&#44; and those with three or more deficits are classified as frail&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Fried criteria for frailty</span><p id="par0180" class="elsevierStylePara elsevierViewall">The Fried criteria for frailty &#40;also known as the Cardiovascular Health Study Frailty Screening Scale&#44; the Physical Frailty Phenotype and the Hopkins Frailty Phenotype&#41; was first developed in the Cardiovascular Health Study&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">9</span></a> It assesses physical characteristics or phenotype&#44; which include five domains&#58; unintentional weight loss &#40;4&#46;5 kg or more in the last year&#41;&#44; exhaustion &#40;self-reported&#41;&#44; low physical activity&#44; weakness &#40;low grip strength&#41;&#44; and walking speed&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">9&#44;43</span></a> Low physical activity is assessed through the frequency of moderate intensity activities&#44; such as gardening or household chores&#46; Similarly to the previous scale&#44; individuals with two deficits are considered pre-frail&#44; and those with three or more deficits are classified as frail&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Clinical Frailty Scale</span><p id="par0185" class="elsevierStylePara elsevierViewall">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&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">39</span></a> Each point on its scale has a visual chart and a written description of frailty to assist the classification process&#46; Scoring is based on clinical judgment and ranges from 1 &#40;very fit&#41; to 9 &#40;terminally ill&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">39</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Frailty indices</span><p id="par0190" class="elsevierStylePara elsevierViewall">Frailty indices are based on the deficit accumulation approach to measuring frailty&#44; and are commonly used tools to assess frailty in order to estimate the related risk for adverse health outcomes&#44; such as mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">44</span></a> A frailty index is based on the concept that frailty is a consequence of interacting physical&#44; psychological&#44; and social factors&#46; As deficits accumulate&#44; people become increasingly vulnerable to adverse outcomes&#46; The subject answers 20 or more questions related to medical and functional issues&#46; The tool can be adapted to information available in the medical record and does not require a patient interview or exam to assess frailty&#46; The 70 items of the original version are not to be considered a fixed set of variables &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; It has been reported that estimates of risk are stronger when a minimum of 50 items are considered&#44; but shorter versions &#40;as few as 20 items&#41; have also been studied&#46;<a class="elsevierStyleCrossRefs" href="#bib0690"><span class="elsevierStyleSup">39&#8211;41</span></a> Rockwood and Mitnitski<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">44</span></a> proposed a deficit accumulation-based frailty index using a comprehensive geriatric assessment &#40;FI-CGA&#41;&#46; This involves the accumulation of 30 or more comorbidities&#44; symptoms&#44; diseases&#44; 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&#59; the greater the number of deficits&#44; the higher the score&#46; The comprehensive geriatric assessment &#40;CGA&#41; includes medical&#44; nutritional&#44; functional and psychological assessments by a multidimensional team&#46; The FI-CGA was initially developed as a ten-domain index with 14 CGA components and was later expanded to include 52 CGA components&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">33</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Edmonton Frail Scale</span><p id="par0195" class="elsevierStylePara elsevierViewall">The Edmonton Frail Scale &#40;EFS&#41; was developed to be practical and usable in the community setting or at the bedside&#46; It is scored out of 17 and contains the following components&#58; cognition&#44; general health status&#44; self-reported health&#44; functional independence&#44; social support&#44; nutrition&#44; mood&#44; continence&#44; and functional performance&#46; The component scores are summed and the following cut-offs are used to classify frailty severity&#58; not frail &#40;0-5&#41;&#44; apparently vulnerable &#40;6-7&#41;&#44; mildly frail &#40;8-9&#41;&#44; moderately frail &#40;10-11&#41; and severely frail &#40;12-17&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Other screening tools</span><p id="par0200" class="elsevierStylePara elsevierViewall">The scales described above are those most commonly used to assess frailty&#46; However&#44; other frailty scales are available&#44; as listed below&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">The Groningen Frailty Indicator &#40;GFI&#41; considers 15 dichotomous self-reported deficits in four domains&#58; physical&#44; cognitive&#44; social&#44; and psychological&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">45</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">The Tilburg Frailty Indicator contains 15 self-reported items in physical&#44; psychological&#44; and social domains&#46;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">46</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">The G&#233;rontop&#244;le Frailty Screening Tool &#40;GFST&#41; comprises two steps&#58; an initial questionnaire &#40;containing six components&#58; living alone&#44; involuntary weight loss&#44; fatigability&#44; mobility&#44; memory complaints and slow gait speed&#41; followed by the clinician&#39;s judgment of frailty status&#46;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">47</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">PRISMA-7 contains seven self-reported components&#58; older than 85 years&#59; male&#59; health problems which limit activities&#59; health problems requiring staying at home&#59; support of another person needed&#59; social support&#59; and use of a cane or walker or wheelchair&#46; Frailty is defined by a score of 3 or more&#46;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">48</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">The Multidimensional Prognostic Instrument &#40;MPI&#41; is a multidimensional prognostic tool used for hospitalized older patients&#46; It includes eight CGA components&#58; ADL&#44; instrumental ADL&#44; risk of developing pressure sores&#44; comorbidity&#44; medication number&#44; nutritional status&#44; cognitive status&#44; and living status&#46;<a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">49</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Frailty assessment tools used in cardiovascular disease</span><p id="par0235" class="elsevierStylePara elsevierViewall">Some frailty assessment tools have been designed to be used specifically in the setting of CVD &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; Some of the tools described above are also used for this purpose&#46;<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">23&#44;24&#44;50</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0240" class="elsevierStylePara elsevierViewall">Kang et al&#46; used the CFS&#44; which was useful in assessment of elderly patients with ACS&#44; predicting all-cause mortality&#44; unscheduled return visit&#44; and in-hospital and recurrent major adverse cardiovascular events&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">23</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Ekerstad et al&#46; used frailty as measured by the CFS to assess short-term outcomes for elderly patients with non-ST-segment elevation myocardial infarction&#44; and showed that the combined use of frailty and other comorbidity tools &#40;such as the coronary artery disease-specific index&#41; may constitute a novel risk prediction concept in regard to cardiovascular patients with complex needs&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">24</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Uchmanowicz et al&#46; investigated the correlation of a scale for assessing frailty &#8211; the Tilburg Frailty Indicator and its mental and physical domains &#8211; with other screening tools commonly used for CGA in patients with ACS&#46; Significant correlations were demonstrated between the values of the TFI and other scales&#46;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">50</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Boxer et al&#46; 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&#44; with hazard ratio &#40;HR&#41; 0&#46;82 &#40;95&#37; CI 0&#46;72-0&#46;94&#41; and 1&#46;64 &#40;95&#37; CI 1&#46;19-2&#46;26&#41;&#44; respectively&#44; and both could be useful as a measure of frailty&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">17</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">In a prospective observational study by Jung et al&#46; in elective cardiac surgery patients&#44; frailty was defined using the seven-item Cardiovascular Health Study score&#44; the Short Physical Performance Battery &#40;SPPB&#41; and a 35-item frailty index&#46; They found that the addition of frailty improved the ability of the EuroSCORE II to predict postoperative delirium&#44; pointing to opportunities for improved prevention and management&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">29</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">The CAF is a tool created by Sundermann et al&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">20</span></a> to assess the prognosis of elderly patients before cardiac surgical interventions and accurately predicts mortality&#46; It comprises grip strength&#44; walking speed&#44; balance&#44; and ability to pick up a pen from the floor&#44; rise from a chair three times and put on and remove a jacket&#44; thus combining characteristics of the CHS criteria<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">9</span></a> of patient phenotype&#44; physical performance&#44; and laboratory results&#46; According to the authors&#44; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">27</span></a> The CAF was preoperatively applied to 400 patients aged &#8805;74 years admitted to a cardiac surgical department between September 2008 and January 2010&#46; For 213 of these patients one-year follow-up was assessed by telephone interview until April 2010&#46; One hundred and ten male and 103 female patients were included&#46; Twenty-five percent underwent isolated coronary revascularization&#44; 35&#37; isolated valve procedures and 26&#37; underwent combined procedures&#46; One-year mortality was 12&#46;2&#37;&#46; Patients who died within one year had a median frailty score of 16 &#91;5&#59;33&#93; compared to 11 &#91;3&#59;33&#93; in one-year survivors &#40;p&#61;0&#46;001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">20</span></a> Sundermann et al&#46; 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&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">20&#44;27</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">The study by Dunlay et al&#46; assessed the association between preoperative frailty and worse outcomes after implantation of an LVAD&#46; Patients undergoing LVAD implantation as destination therapy at the Mayo Clinic&#44; Rochester&#44; MN between February 2007 and June 2012 were included in this study&#46; Frailty was assessed using a deficit index &#40;including 31 impairments&#44; disabilities and comorbidities&#41; and defined as the proportion of deficits present&#46; Patients were then divided based on tertiles of the deficit index &#40;&#62;0&#46;32&#61;frail&#44; 0&#46;23 to 0&#46;32&#61;intermediate frail&#44; &#60;0&#46;23&#61;not frail&#41;&#46; The authors concluded that frailty before destination LVAD implantation&#44; as assessed by their deficit index&#44; is associated with increased risk of death and may represent a significant patient selection consideration&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">30</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">Some tools have also been applied to patients undergoing TAVI&#46; Stortecky et al&#46; assessed the Multidimensional Geriatric Assessment &#40;MGA&#41; as a predictor of mortality and MACCE after TAVI&#46; This prospective cohort comprised 100 consecutive patients aged &#8805;70 years undergoing TAVI&#46; Global risk scores &#40;Society of Thoracic Surgeons &#91;STS&#93; score&#44; EuroSCORE&#41; and MGA-based scores &#40;cognition&#44; nutrition&#44; mobility&#44; activities of daily living &#91;ADL&#93;&#44; and frailty index&#41; were assessed as predictors of all-cause mortality and MACCE 30 days and one year after TAVI&#46; This study provides evidence that risk prediction can be improved by adding MGA-based information to global risk scores&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">31</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">Schoenenberger et al&#46; used the EuroSCORE&#44; the STS score&#44; and a geriatric baseline examination &#40;based on assessment of cognition&#44; mobility&#44; nutrition&#44; instrumental and basic activities of daily living&#41; to predict functional decline in elderly patients undergoing TAVI&#46; Overall predictive performance was best for the geriatric baseline examination and low for the EuroSCORE and STS score&#46; In univariate analysis&#44; all components of the geriatric baseline examination helped predict functional decline&#46; The authors concluded that the geriatric baseline examination&#44; but not established risk scores&#44; was predictive of functional decline&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">In the 2012 study by Afilalo et al&#46;&#44; a total of 152 patients were enrolled in a prospective&#44; multicenter cohort study of elderly patients &#40;&#62;70 years&#41; undergoing CABG and&#47;or valve surgery in the US and Canada&#46; Four different frailty scales&#44; three disability scales&#44; and five cardiac surgery risk scores were measured in all patients&#46; The primary outcome was the STS composite endpoint of in-hospital postoperative mortality or major morbidity&#46; The four frailty scales examined in this study are described in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; The authors concluded that clinicians should use an integrative approach combining frailty&#44; disability&#44; and risk scores to better characterize elderly patients referred for cardiac surgery and identify those that are at increased risk&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">28</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">The same author&#44; in a recent study &#40;2017&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">51</span></a> compared the incremental predictive value of seven different frailty scales to predict poor outcomes following TAVI and valve surgery&#58; the Fried criteria &#40;described above&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">9</span></a> Fried&#43;&#40;the Fried criteria plus cognition assessed by the Mini Mental State Exam &#91;MMSE&#93; and mood assessed by the Short-form Geriatric Depression Scale&#41;&#44; the Rockwood CFS&#44;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">39</span></a> the SPPB &#40;three physical tests&#44; with each scored 0 to 4 for a composite score of 0 to 12&#58; gait speed&#44; 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&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">52</span></a> the Bern Scale &#40;six items for a composite score of 0 to 7&#58; gait speed&#44; mobility&#44; cognition&#44; nutrition and disability in activities of daily living and instrumental activities&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">26&#44;31</span></a> the Columbia Scale &#40;four items&#44; with each scored 0 to 3 for a composite score of 0 to 12&#58; gait speed&#44; grip strength&#44; serum albumin and disability&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">53</span></a> and the Essential Frailty Toolset &#40;EFT&#41; &#40;four items for a composite score of 0 to 5&#58; time to stand five times from a seated position without using arms &#40;1 point if &#8805;15 s&#44; 2 points if unable to complete&#41;&#44; cognition &#40;1 point if MMSE &#60;24&#41;&#44; hemoglobin &#40;1 point if &#60;13 g&#47;dl in men or &#60;12 g&#47;dl in women&#41;&#44; and serum albumin &#40;1 point if &#60;3&#46;5 g&#47;dl&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">51</span></a> Frailty as measured by the EFT was the strongest predictor of death at one year &#40;p&#60;0&#46;001&#41; and of worsening disability at 1 year &#40;adjusted OR&#58;2&#46;13&#59; 95&#37; CI&#58;1&#46;57 to 2&#46;87&#41; and death at 30 days &#40;adjusted OR&#58; 3&#46;29&#59; 95&#37; CI&#58; 1&#46;73 to 6&#46;26&#41;&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Some authors&#44; instead of validating existing frailty screening tools&#44; used certain parameters to derive their own frailty score&#46; Green et al&#46; used a modification of the Fried frailty criteria that included gait speed&#44; grip strength&#44; serum albumin&#44; and activities of daily living status to derive a frailty score among older adults with severe aortic stenosis who underwent TAVI&#46; In this study frailty was not associated with increased periprocedural complications in patients selected as candidates to undergo TAVR&#44; but was associated with increased one-year mortality after TAVR&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">53</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Screening tools&#58; critical analysis</span><p id="par0300" class="elsevierStylePara elsevierViewall">We have described individual multiple frailty measurement scales&#46; There have been various studies comparing the most commonly used screening tools&#44; but agreement on which has the best ability to predict prognosis and all-cause mortality is lacking&#46; While some studies found similar prognostic performance in some of these tools&#44;<a class="elsevierStyleCrossRefs" href="#bib0755"><span class="elsevierStyleSup">54&#44;55</span></a> other studies found significant differences&#46;<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">56</span></a> In 2013&#44; a consensus conference identified some of these tools as allowing physicians to objectively recognize frail persons&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">6</span></a> However&#44; they range from short&#44; fast and crude screening tools to sophisticated and time-consuming scales&#46; A source of concern is the fact that many frailty scales have been modified somewhat from their original and validated version&#44; leading to significant differences in frailty classification&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">33</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">Since the frailty phenotype and frailty indices are based on different concepts&#44; it is inappropriate to consider them as alternatives and&#47;or interchangeable&#46;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">57</span></a><a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> describes the main characteristics of these two different instruments&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0310" class="elsevierStylePara elsevierViewall">The FRAIL screening tool is clinically advantageous due to its simple nature and ability to be obtained from data already included in a CGA&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">2</span></a> It has been found to be predictive of mortality in specific populations&#44; such as patients with CVD&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">43</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall">The CHS scale &#40;Fried criteria&#41; is a widely used scale applied in multiple epidemiological studies&#44; and has good predictive value for adverse clinical outcomes&#44; including mortality&#46; However&#44; a major factor precluding its clinical application is the inclusion of measurements not routinely used for patient assessment &#40;such as grip strength measured by a dynamometer&#41;&#46; Another important limitation of this scale is that it does not include psychosocial components of frailty&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">9</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">The CFS has been validated as a predictor of adverse outcomes in hospitalized older people&#44; such as all-cause&#44; in-hospital mortality&#44; one-month mortality and prolonged hospital care&#46;<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">23&#44;24&#44;33</span></a></p><p id="par0325" class="elsevierStylePara elsevierViewall">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&#46; They have been applied to multiple datasets&#44; but can be time-consuming to calculate&#46; The FI-CGA is used as a clinical standard for frailty assessment and has been found to predict patient response in multiple fields&#44; including cardiology&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">2</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall">The EFS is a valid and reliable measurement tool in the hospital setting and&#44; since it has only nine components&#44; it is much simpler to extract from CGAs than the FI-CGA&#46;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">42</span></a> In a community-based sample&#44; even when administered by non-specialists with no formal training in geriatric care&#44; the EFS compared favorably with the clinical assessment of geriatric specialists who completed a more comprehensive evaluation&#46;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">42</span></a></p><p id="par0335" class="elsevierStylePara elsevierViewall">Compared with other frailty assessment tools&#44; the MPI appears to have greater ability to predict adverse outcomes&#46; Nevertheless&#44; additional research is needed to confirm these results&#46;<a class="elsevierStyleCrossRefs" href="#bib0660"><span class="elsevierStyleSup">33&#44;49</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">The GFI has moderate internal consistency and adequate discriminative ability&#44; and shows good feasibility and reliability as a frailty measurement&#46; Some authors have proposed that it should be used together with a frailty index as part of a two-step screening process&#46;<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">58</span></a></p><p id="par0345" class="elsevierStylePara elsevierViewall">The TFI shows good reliability for identifying frailty in community-dwelling older people&#46; However&#44; although its physical components show good ability to predict adverse events&#44; its social components appear to be weak predictors&#46;<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">59&#44;60</span></a></p><p id="par0350" class="elsevierStylePara elsevierViewall">The GFST&#44; designed for early recognition of frailty in community-dwelling older people&#44; appears to be a good frailty screening tool&#59; however&#44; it gives no specific guidance for clinicians on how to identify frailty and the clinician&#39;s judgment of frailty status is quite subjective&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">33</span></a></p><p id="par0355" class="elsevierStylePara elsevierViewall">Although PRISMA-7 shows good accuracy in identifying frailty in community-dwelling older people&#44; its ability as a screening tool is limited since it has a tendency to over-screen for frailty&#46;<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">59</span></a></p><p id="par0360" class="elsevierStylePara elsevierViewall">Some of these tools have also been used in cardiovascular patients&#44; such as the Fried frailty criteria&#44;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">17&#44;23&#44;24&#44;29</span></a> frailty indices&#44;<a class="elsevierStyleCrossRefs" href="#bib0640"><span class="elsevierStyleSup">29&#44;30</span></a> and the TFI&#46;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">50</span></a></p><p id="par0365" class="elsevierStylePara elsevierViewall">The geriatric baseline examination developed by Schoenenberger et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a> the multidimensional geriatric assessment used by Stortecky et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">31</span></a> and the CAF&#44;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">20&#44;27</span></a> developed by Sundermann et al&#46;&#44; 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&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall">Some authors&#44; such as Afilalo et al&#46;&#44; prefer to use an integrative approach combining frailty&#44; disability&#44; and risk scores to better characterize elderly patients referred for cardiac surgery&#44; which has proved to be useful for identifying those at increased risk&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">28</span></a></p><p id="par0375" class="elsevierStylePara elsevierViewall">The same author recently showed the superiority of the EFT compared to other frailty scales when predicting poor outcomes following TAVI and valve surgery&#44; 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&#46; The authors suggested it had the highest predictive value for death and worsening disability at one year and recommended its use in this setting&#46;<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">51</span></a></p><p id="par0380" class="elsevierStylePara elsevierViewall">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&#44; since it enables prior screening for risk and prediction of surgical success and safety&#46;</p><p id="par0385" class="elsevierStylePara elsevierViewall">When selecting a screening tool&#44; it is also important to take into account the ecology of its application&#44; since some frailty measurements are more suitable for use in population health studies as screening&#44; whereas others are appropriate in the clinical setting for screening or diagnosis of frailty&#46;<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">42&#44;55&#44;57</span></a></p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusion</span><p id="par0390" class="elsevierStylePara elsevierViewall">Frailty is an important prognostic factor in patients with CVD&#46; It increases the risk of adverse events associated with cardiovascular therapeutic interventions&#44; and therefore needs to be taken into account when considering whether to intervene&#46; Frail patients may have more complications and fewer benefits because of the competing adverse event risk&#46; 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&#46; 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&#46; Simple and rapid screening tests have been developed and validated to enable the objective recognition of frail persons&#46; There are significant differences between these scales in their nature&#44; validity and feasibility&#46; Further studies are needed to establish their significance regarding overall and cardiovascular mortality&#46; In the CVD field&#44; the two most commonly used and most robust frailty assessment tools for use by clinicians and researchers are the Fried criteria and frailty indices&#46; Other new tools specifically designed for CVD have proved extremely useful for this propose&#46; In line with previous studies&#44; we suggest the use of one simple tool for frailty screening and a second one for a full assessment&#44; and for these purposes we recommend the use of the Fried criteria and a frailty index&#44; respectively&#46; The impact of therapeutic strategies targeting frailty itself is still unclear&#46; Nevertheless&#44; routine screening and objective diagnosis of frailty is bound to improve the therapeutic decision-making process and prognostic assessment of patients with CVD&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0395" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "identificador" => "xres1178798"
          "titulo" => "Abstract"
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              "identificador" => "abst0005"
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        1 => array:2 [
          "identificador" => "xpalclavsec1100253"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres1178797"
          "titulo" => "Resumo"
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            0 => array:1 [
              "identificador" => "abst0010"
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        3 => array:2 [
          "identificador" => "xpalclavsec1100252"
          "titulo" => "Palavras-chave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Frailty"
          "secciones" => array:12 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Definition and epidemiology"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Pathophysiology"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "The importance of diagnosing frailty in patients with cardiovascular disease"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "How to screen for frailty"
            ]
            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "The FRAIL Questionnaire screening tool"
            ]
            5 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Fried criteria for frailty"
            ]
            6 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Clinical Frailty Scale"
            ]
            7 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Frailty indices"
            ]
            8 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Edmonton Frail Scale"
            ]
            9 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Other screening tools"
            ]
            10 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Frailty assessment tools used in cardiovascular disease"
            ]
            11 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Screening tools&#58; critical analysis"
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Conclusion"
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        7 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Conflicts of interest"
        ]
        8 => array:1 [
          "titulo" => "References"
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      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2017-09-24"
    "fechaAceptado" => "2018-05-19"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1100253"
          "palabras" => array:4 [
            0 => "Frailty"
            1 => "Cardiovascular disease"
            2 => "Assessment"
            3 => "Screening"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec1100252"
          "palabras" => array:4 [
            0 => "Fragilidade"
            1 => "Doen&#231;as cardiovasculares"
            2 => "Avalia&#231;&#227;o"
            3 => "Rastreio"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cardiovascular disease &#40;CVD&#41; is the leading cause of death in developed countries and disproportionately affects older adults&#46; 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&#44; such as disability&#44; hospitalization and mortality&#46; Frailty is an important prognostic factor in patients with CVD&#44; and so identifying this feature when assessing these patients may help to individually tailor cardiovascular treatment&#46; The first step is to identify frailty&#46; Several tools have been validated as screening methods for frailty&#46; However&#44; they diverge with regard to complexity&#44; nature&#44; feasibility and the outcome they can predict&#46; The aim of this review is to describe the available screening tools for frailty and to examine their usefulness in patients with CVD&#46;</p></span>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">As doen&#231;as cardiovasculares &#40;DCV&#41; constituem a principal causa de morte nos pa&#237;ses desenvolvidos e afetam desproporcionalmente os indiv&#237;duos idosos&#46; A fragilidade &#233; definida como uma s&#237;ndrome cl&#237;nica complexa com m&#250;ltiplos fatores predisponentes e caraterizada por um aumento da vulnerabilidade e maior risco de desfechos adversos&#44; nomeadamente&#44; incapacidade&#44; institucionaliza&#231;&#227;o e&#47;ou mortalidade&#46; Parece ser um fator progn&#243;stico importante em doentes com DCV&#44; pelo que o reconhecimento dos doentes com fragilidade pode permitir identificar os doentes com maior risco e assim orientar a estrat&#233;gia terap&#234;utica cardiovascular mais segura e eficaz&#46; Assim&#44; primeiramente &#233; fundamental identificar a fragilidade&#46; V&#225;rios instrumentos foram validados como m&#233;todos de rastreio de fragilidade&#46; No entanto&#44; eles divergem quanto &#224; complexidade&#44; natureza&#44; viabilidade e resultados que podem prever&#46; O objetivo desta revis&#227;o &#233; descrever as ferramentas dispon&#237;veis para rastreio de fragilidade e avaliar as suas diferen&#231;as e utilidade nos doentes com DCV&#46;</p></span>"
      ]
    ]
    "nomenclatura" => array:1 [
      0 => array:3 [
        "identificador" => "nom0005"
        "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0025">List of abbreviations</span>"
        "listaDefinicion" => array:1 [
          0 => array:1 [
            "definicion" => array:23 [
              0 => array:2 [
                "termino" => "ACS"
                "descripcion" => "<p id="par0405" class="elsevierStylePara elsevierViewall">acute coronary syndrome</p>"
              ]
              1 => array:2 [
                "termino" => "BADL"
                "descripcion" => "<p id="par0410" class="elsevierStylePara elsevierViewall">basic activities of daily living</p>"
              ]
              2 => array:2 [
                "termino" => "CABG"
                "descripcion" => "<p id="par0415" class="elsevierStylePara elsevierViewall">coronary artery bypass grafting</p>"
              ]
              3 => array:2 [
                "termino" => "CAF"
                "descripcion" => "<p id="par0420" class="elsevierStylePara elsevierViewall">Comprehensive Assessment of Frailty</p>"
              ]
              4 => array:2 [
                "termino" => "CFS"
                "descripcion" => "<p id="par0425" class="elsevierStylePara elsevierViewall">Clinical Frailty Scale</p>"
              ]
              5 => array:2 [
                "termino" => "CHS"
                "descripcion" => "<p id="par0430" class="elsevierStylePara elsevierViewall">Cardiovascular Health Study</p>"
              ]
              6 => array:2 [
                "termino" => "CSHA"
                "descripcion" => "<p id="par0435" class="elsevierStylePara elsevierViewall">Canadian Study of Health and Aging</p>"
              ]
              7 => array:2 [
                "termino" => "CVD"
                "descripcion" => "<p id="par0440" class="elsevierStylePara elsevierViewall">cardiovascular disease</p>"
              ]
              8 => array:2 [
                "termino" => "EFS"
                "descripcion" => "<p id="par0445" class="elsevierStylePara elsevierViewall">Edmonton Frail Scale</p>"
              ]
              9 => array:2 [
                "termino" => "EFT"
                "descripcion" => "<p id="par0450" class="elsevierStylePara elsevierViewall">Essential Frailty Toolset</p>"
              ]
              10 => array:2 [
                "termino" => "EuroSCORE"
                "descripcion" => "<p id="par0455" class="elsevierStylePara elsevierViewall">European System for Cardiac Operative Risk Evaluation</p>"
              ]
              11 => array:2 [
                "termino" => "GFI"
                "descripcion" => "<p id="par0460" class="elsevierStylePara elsevierViewall">Groningen Frailty Indicator</p>"
              ]
              12 => array:2 [
                "termino" => "GFST"
                "descripcion" => "<p id="par0465" class="elsevierStylePara elsevierViewall">G&#233;rontop&#244;le Frailty Screening Tool</p>"
              ]
              13 => array:2 [
                "termino" => "LVAD"
                "descripcion" => "<p id="par0470" class="elsevierStylePara elsevierViewall">left ventricular assist device</p>"
              ]
              14 => array:2 [
                "termino" => "MACCE"
                "descripcion" => "<p id="par0475" class="elsevierStylePara elsevierViewall">major adverse cardiovascular and cerebrovascular events</p>"
              ]
              15 => array:2 [
                "termino" => "MMSE"
                "descripcion" => "<p id="par0480" class="elsevierStylePara elsevierViewall">Mini-Mental State Exam</p>"
              ]
              16 => array:2 [
                "termino" => "MNA"
                "descripcion" => "<p id="par0485" class="elsevierStylePara elsevierViewall">Mini Nutritional Assessment</p>"
              ]
              17 => array:2 [
                "termino" => "MPI"
                "descripcion" => "<p id="par0490" class="elsevierStylePara elsevierViewall">Multidimensional Prognostic Instrument</p>"
              ]
              18 => array:2 [
                "termino" => "MSSA"
                "descripcion" => "<p id="par0495" class="elsevierStylePara elsevierViewall">MacArthur Study of Successful Aging</p>"
              ]
              19 => array:2 [
                "termino" => "STS"
                "descripcion" => "<p id="par0500" class="elsevierStylePara elsevierViewall">Society of Thoracic Surgeons</p>"
              ]
              20 => array:2 [
                "termino" => "TAVI"
                "descripcion" => "<p id="par0505" class="elsevierStylePara elsevierViewall">transcatheter aortic valve implantation</p>"
              ]
              21 => array:2 [
                "termino" => "TFI"
                "descripcion" => "<p id="par0510" class="elsevierStylePara elsevierViewall">Tilburg Frailty Indicator</p>"
              ]
              22 => array:2 [
                "termino" => "TUG"
                "descripcion" => "<p id="par0515" class="elsevierStylePara elsevierViewall">Timed Up and Go</p>"
              ]
            ]
          ]
        ]
      ]
    ]
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        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">6 MW&#58; six-minute walk test&#59; ACS&#58; acute coronary syndrome&#59; CABG&#58; coronary artery bypass grafting&#59; CAD&#58; coronary artery disease&#59; CAF&#58; Comprehensive Assessment of Frailty score&#59; CFS&#58; Clinical Frailty Scale&#59; CGA&#58; Comprehensive Geriatric Assessment&#59; CHS&#58; Cardiovascular Health Study scale&#59; CVD&#58; cardiovascular disease&#59; EFT&#58; Essential Frailty Toolset&#59; EuroSCORE&#58; European System for Cardiac Operative Risk Evaluation&#59; LVAD&#58; left ventricular assist device&#59; MACCE&#58; major adverse cardiovascular and cerebral events&#59; MFC&#58; Modified Fried Criteria&#59; MSSA&#58; 4-item MacArthur Study of Successful Aging frailty scale&#59; MGA&#58; Multidimensional Geriatric Assessment&#59; PPB&#58; Physical Performance Battery&#59; SPPB&#58; Short Physical Performance Battery&#59; STS&#58; Society of Thoracic Surgeons risk score&#59; TAVI&#58; Transcatheter aortic valve implantation&#59; TFI&#58; Tilburg Frailty Indicator&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CVD and population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Screening tools for frailty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Other tools&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Results&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">23</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ACS<br>352 patients&#44; age &#62;65 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CFS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CGA<br>CAD-specific index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CFS was useful in evaluation of elderly patients with ACS&#46; Frailty was strongly and independently associated with short-term outcomes for elderly patients with ACS&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Uchmanowicz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">50</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ACS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TFI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CGA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Significant correlations were demonstrated between the values of the TFI and other scales&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ekerstad et al&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">24</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ACS<br>307 patients&#44; age &#62;75 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CFS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CAD-specific index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frailty was strongly and independently associated with in-hospital mortality&#44; 1-month mortality&#44; prolonged hospital care and the primary composite outcome&#46; The combined use of frailty and comorbidity may constitute a novel risk prediction concept in regard to cardiovascular patients with complex needs&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Boxer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">17</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CHS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 MW&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Both tools were associated with mortality &#40;p&#61;0&#46;005&#41; and highly correlated&#46; The 6 MW may be useful as a measure of frailty&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Invasive cardiac interventions</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Afilalo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">51</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TAVI and valve surgery<br>1020 patients&#44; median age 82 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EFT<br>CHS<br>Fried&#43;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CFS<br>PPB<br>Bern Scale<br>Columbia Scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frailty is a risk factor for death and disability following TAVI and valve surgery&#46; The EFT outperformed other frailty scales and is recommended for use in this setting&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jung et al&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elective cardiac surgery&#44; 133 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">MFC<br>35-item Frailty Index<br>SPPB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SPBB<br>EuroSCORE II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frailty results in a 3- to 8-fold increase in risk of postoperative delirium&#44; independent of the EuroSCORE II&#46; The addition of frailty improves the ability of the EuroSCORE II to predict postoperative delirium&#44; pointing to opportunities for improved prevention and management&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dunlay et al&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LVAD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">31-item Frailty Index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frailty before destination LVAD implantation is associated with increased risk of death and may represent a significant patient selection consideration&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Schoenenberger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TAVI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Geriatric baseline examination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EuroSCORE<br>STS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The geriatric baseline examination&#44; but not established risk scores&#44; was predictive of functional decline&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Green et al&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">53</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TAVI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">MFC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frailty was associated with increased 1-year mortality after TAVI&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stortecky et al&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">31</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TAVI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">MGA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EuroSCORE<br>STS<br>MACCE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Risk prediction can be improved by adding multidimensional geriatric assessment-based information to global risk scores&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Afilalo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CABG and&#47;or valve surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Simplified Fried criteria &#40;5-item&#41;<br>Fried criteria &#40;7-item&#41;<br>MSSA<br>Five-meter gait speed test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Disability scales<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><br>Surgical risk scores<span class="elsevierStyleSup">c</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clinicians should use an integrative approach combining frailty&#44; disability&#44; and risk scores to better characterize elderly patients referred for cardiac surgery and identify those that are at increased risk&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sundermann et al&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CABG &#40;25&#37;&#41; vs&#46; valve surgery &#40;35&#37;&#41; vs&#46; combined procedures &#40;26&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CAF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EuroSCORE<br>STS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CAF is an additional tool to assess prognosis of elderly patients before cardiac surgical interventions&#46; The CAF score facilitates prediction of 30-day outcome of high-risk elderly patients&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "identificador" => "tblfn0010"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Disability scales&#58; 6-item Katz Activities of Daily Living scale&#59; 7-item Older Americans Research and Services Instrumental Activities of Daily Living scale&#59; 7-item Nagi scale&#46;</p> <p class="elsevierStyleNotepara" id="npar0015"><span class="elsevierStyleSup">c</span> Surgical risk scores&#58; the Society of Thoracic Surgeons Predicted Risk of Mortality&#44; the Society of Thoracic Surgeons Predicted Risk of Mortality or Major Morbidity&#59; EuroSCORE&#59; revised Parsonnet score&#59; Age-Creatinine-Ejection Fraction score&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Studies of frailty in cardiovascular disease&#46;</p>"
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">IADLs&#58; instrumental activities of daily living&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Screening tool&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Measurement method&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criteria for frailty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Simple FRAIL Questionnaire</td><td class="td" title="table-entry  " align="left" valign="top">1&#46; Fatigue&#58; are you fatigued&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Frail&#58; &#8805;3<br>Pre-frail&#58; 1 or 2</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&#46; Resistance&#58; cannot walk up 1 flight of stairs&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&#46; Aerobic&#58; cannot walk 1 block&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&#46; Illnesses&#58; do you have more than 5 illnesses&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&#46; Loss of weight&#58; Have you lost more than 5&#37; of your weight in the past 6 months&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Cardiovascular Health Study Frailty Screening Scale</td><td class="td" title="table-entry  " align="left" valign="top">1&#46; Weight loss &#8211; loss of 10 pounds unintentionally in past year or weight at age 60-weight at exam &#8805;10&#37; of age 60 weight&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Frail&#58; &#8805;3<br>Pre-frail&#58; 1 or 2</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&#46; Exhaustion &#8211; self-report of fatigue or felt unusually tired or weak in the past month&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&#46; Low activity &#8211; frequency and duration of physical activities &#40;walking&#44; doing strenuous household chores&#44; doing strenuous outdoor chores&#44; dancing&#44; bowling&#44; exercise&#41;&#46;<br>- Men&#58; &#60;383 kcal&#47;week&#61;1<br>- Women&#58; &#60;270 kcal&#47;week&#61;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&#46; Slowness&#58;<br>- Men&#58; walking 4 m &#8805;7 s if height &#8804;173 cm or &#8805;6 s if height &#8805;173 cm&#61;1<br>- Women&#58; walking 4 m &#8805;7 s if height &#8804;159 cm or &#8805;6 s if height &#8805;159 cm&#61;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&#46; Weakness &#8211; grip strength &#40;kg&#41; for body mass index &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="10" align="left" valign="top">Clinical Frailty Scale</td><td class="td" title="table-entry  " align="left" valign="top">1&#46; Very fit &#8211; people who are robust&#44; active&#44; energetic and motivated&#46; These people commonly exercise regularly&#46; They are among the fittest for their age&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&#46; Well &#8211; people who have no active disease symptoms but are less fit than category 1&#46; Often&#44; they exercise or are very active occasionally&#44; e&#46;g&#46; seasonally&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&#46; Managing well &#8211; people whose medical problems are well controlled&#44; but are not regularly active beyond routine walking&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&#46; Vulnerable &#8211; while not dependent on others for daily help&#44; often symptoms limit activities&#46; A common complaint is being &#8220;slowed up&#8221;&#44; and&#47;or being tired during the day&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&#46; Mildly frail &#8211; these people often have more evident slowing&#44; and need help in high order IADLs &#40;finances&#44; transportation&#44; heavy housework&#44; medications&#41;&#46; Typically&#44; mild frailty progressively impairs shopping and walking outside alone&#44; meal preparation and housework&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&#46; Moderately frail &#8211; people need help with all outside activities and with keeping house&#46; Inside&#44; they often have problems with stairs and need help with bathing and might need minimal assistance &#40;cuing&#44; standby&#41; with dressing&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&#46; Severely frail &#8211; completely dependent for personal care&#44; from whatever cause &#40;physical or cognitive&#41;&#46; Even so&#44; they seem stable and not at high risk of dying &#40;within &#8764;6 months&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&#46; Very severely frail &#8211; completely dependent&#44; approaching the end of life&#46; Typically&#44; they could not recover even from a minor illness&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&#46; Terminally ill - approaching the end of life&#46; This category applies to people with a life expectancy &#60;6 months&#44; who are not otherwise evidently frail&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Scoring frailty in people with dementia&#58;<br>- The degree of frailty corresponds to the degree of dementia&#46;<br>- Common symptoms in mild dementia include forgetting the details of a recent event&#44; though still remembering the event itself&#44; repeating the same question&#47;story and social withdrawal&#46;<br>- In moderate dementia&#44; recent memory is very impaired&#44; even though they seemingly can remember their past life events well&#46; They can do personal care with prompting&#46;<br>- In severe dementia&#44; they cannot do personal care without help&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="9" align="left" valign="top">Edmonton Frail Scale</td><td class="td" title="table-entry  " align="left" valign="top">Cognition<br>Please imagine that this pre-drawn circle is a clock&#46; I would like you to place the numbers in the correct positions then place the hands to indicate a time of &#8216;ten after eleven&#8217;<br>No errors&#61;0&#59; Minor spacing errors&#61;1&#59; Other errors&#61;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="9" align="left" valign="top">0-5&#61;Not frail<br>6-7&#61;Vulnerable<br>8-9&#61;Mild frailty<br>10-11&#61;Moderate frailty<br>12-17&#61;Severe frailty<br></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">General health status<br>- In the past year&#44; how many times have you been admitted to a hospital&#63;<br>- 0 times&#61;0&#59; 1-2 times&#61;1&#59; &#62;2 times&#61;2- In general&#44; how would you describe your health&#63; Excellent&#44; very good&#44; good&#61;0&#59; Fair&#61;1&#59; Poor&#61;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Functional independence<br>With how many of the following activities do you require help&#63; &#40;meal preparation&#44; shopping&#44; transportation&#44; telephone&#44; housekeeping&#44; laundry&#44; managing money&#44; taking medications&#41;<br>0-1 activities&#61;0&#59; 2-4 activities&#61;1&#59; 5-8 activities&#61;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Social support<br>When you need help&#44; can you count on someone who is willing and able to meet your needs&#63;<br>Always&#61;0&#59; Sometimes&#61;1&#59; Never&#61;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Medication use<br>- Do you use five or more different prescriptions on a regular basis&#63;<br>No&#61;0&#59; Yes&#61;1<br>- At times do you forget to take your prescription<br>medication&#63;<br>No&#61;0&#59; Yes&#61;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nutrition<br>Have you recently lost weight such that your clothing has become looser&#63;<br>No&#61;0&#59; Yes&#61;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mood<br>Do you often feel sad or depressed&#63;<br>No&#61;0&#59; Yes&#61;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Continence<br>Do you have a problem with losing control of urine when you don&#8217;t want to&#63;<br>No&#61;0&#59; Yes&#61;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Functional performance<br>I would like you to sit in this chair with your back and arms resting&#46; Then&#44; when I say &#8216;GO&#44;&#8217; please stand up and walk at a safe and comfortable pace to the mark on the floor &#40;approximately 3 m away&#41;&#44; return to the chair and sit down<br>0-10 s&#61;0&#59; 11-20 s&#61;1&#59; &#62;20 s or patient unwilling&#44; or requires assistance&#61;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0015"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Men&#58; Body mass index &#40;BMI&#41; &#8804;24 and grip strength &#8804;29 kg&#61;1&#59; BMI 24&#46;1-26 and grip strength &#8804;30 kg&#61;1&#59; BMI 26&#46;1-28 kg and grip strength &#8804;30 kg&#61;1&#59; BMI &#62;28 and strength &#8804;32 kg&#61;1&#59; women&#58; BMI &#8804;23 and grip strength &#8804;17 kg&#61;1&#59; BMI 23&#46;1-26 and grip strength &#8804;17&#46;3 kg&#61;1&#59; BMI 26&#46;1-29 and grip strength &#8804;18 kg&#61;1&#59; BMI &#62;29 and grip strength &#8804;21 kg&#61;1&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Characteristics of the most commonly used frailty scales&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Changes in everyday activities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Problems going out alone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor limb coordination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Head and neck problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Impaired mobility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor coordination&#44; trunk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Facial bradykinesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Musculoskeletal problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor standing posture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Poor muscle tone in neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bradykinesia of the limbs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Irregular gait pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Problems getting dressed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor muscle tone in limbs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Falls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Problems with bathing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Impaired vibration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mood problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Problems carrying out personal grooming&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tremor at rest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Feeling sad&#44; blue&#44; depressed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urinary incontinence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postural tremor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">History of depressed mood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Toileting problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intention tremor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tiredness all the time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bulk difficulties&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">History of Parkinson&#39;s disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depression &#40;clinical impression&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rectal problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Family history of degenerative disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sleep changes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gastrointestinal problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Seizures&#44; partial complex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Restlessness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Problems cooking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Seizures&#44; generalized&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Memory changes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sucking problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Syncope or blackouts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Short-term memory impairment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Skin problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Peripheral pulses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Long-term memory impairment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Malignant disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cardiac problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Changes in general mental functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breast problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Myocardial infarction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Onset of cognitive symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abdominal problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arrhythmia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clouding or delirium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Presence of snout reflex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Congestive heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Paranoid features&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Presence of the palmomental reflex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">History relevant to cognitive impairment or loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">History of thyroid disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Respiratory problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Family history relevant to cognitive impairment or loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thyroid problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">History of diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">History of stroke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cerebrovascular problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other medical history&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">List of variables used by the Canadian Study of Health and Aging &#40;CSHA&#41; to construct the 70-item CSHA Frailty Index&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">39</span></a></p>"
        ]
      ]
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        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">5-GDS&#58; five-item Geriatric Depression Scale&#59; BADL&#58; basic activities of daily living&#59; CAF&#58; Comprehensive Assessment of Frailty score&#59; CES-D&#58; Center for Epidemiologic Studies Depression scale&#59; CFS&#58; Clinical Frailty Scale&#59; COPD&#58; chronic obstructive pulmonary disease&#59; CSHA&#58; Canadian Study of Health and Aging&#59; MMSE&#58; Mini Mental State Exam&#59; MNA&#58; Mini Nutritional Assessment&#59; MoCA&#58; Montreal Cognitive Assessment score&#59; MSSA&#58; 4-item MacArthur Study of Successful Aging frailty scale&#59; SPPB&#58; Short Physical Performance Battery&#59; TFI&#58; Tilburg Frailty Indicator&#59; TUG&#58; Timed Up and Go test&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tool&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Measurement method&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criteria for frailty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sundermann et al&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CAF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Patient is asked to get up and down from a chair 3 times and time is measured<br>&#8226; Self-reported weakness<br>&#8226; Patient is asked to climb as many stairs as they are able<br>&#8226; Two physicians &#40;one a cardiac surgeon&#41; conduct the CFS from the CSHA<br>Serum creatinine level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Results from the CAF scores are tabulated into a scale from 1 to 35 points as outlined by the supplementary CAF Test Sheet&#46; Scores between 1 and 10 are deemed not frail&#44; between 11 and 25 are deemed moderately frail&#44; and between 26 and 36 are deemed severely frail&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Green et al&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">53</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified Fried frailty criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Slow 15-m gait speed<br>&#8226; Weak dominant handgrip strength<br>&#8226; Assistance required in any of Katz Index of Independence in Activities of Daily Living criteria<br>&#8226; Serum albumin as a measurement of malnutrition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frailty defined as a score &#62;5 on a scale from 0-12 where a higher score equates to more frail<br>For gait speed&#44; grip strength&#44; and serum albumin&#44; based on which quartile a patient was in&#44; a value of 0-3 was given for each quartile in descending order&#46; For activities of daily living&#44; 0 points were given for independent and 3 for dependent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Afilalo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 scales used&#58;<br>&#8226; 5-item Modified Fried Criteria<br>&#8226; 7-item expanded Modified Fried Criteria<br>&#8226; 4-item MSSA<br>&#8226; Five-Meter Gait Speed Test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; 5-item Modified Fried Criteria&#58; gait speed&#44; handgrip strength&#44; inactivity&#44; exhaustion&#44; and weight loss<br>&#8226; 7-item Modified Fried Criteria&#58; the above as well as cognitive impairment and depressed mood<br>&#8226; 4-item MSSA used gait speed&#44; handgrip strength&#44; inactivity&#44; and cognitive impairment<br>&#8226; prolonged time for gait speed test &#40;&#62;6 s to walk 5 m&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Defined as frail if any of the 4 scales deemed patient as frail&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stortecky et al&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">31</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multidimensional<br>Geriatric Assessment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; MMSE showing cognitive impairment<br>MNA shows malnutrition<br>&#8226; TUG showing limitation of mobility<br>&#8226; BADL and instrumental activities of daily living showed an activity with limitation<br>&#8226; Preclinical mobility disability defined as decreased frequency of walking 200 m and&#47;or climbing stairs in preceding 6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Defined frailty as &#8805;3 points&#44; 2 points if MMSE &#60;21&#44; 1 point if MMSE &#8805;21 and &#60;27&#44; MNA &#60;12&#44; TUG &#8805;20 s&#44; BADL with at least 1 limited activity&#44; instrumental activities of daily living with at least 1 limited activity&#44; preclinical mobility disability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Schoenenberger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Geriatric baseline examination<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; MMSE showing cognitive impairment<br>&#8226; MNA shows malnutrition<br>&#8226; TUG showing limitation of mobility<br>&#8226; BADL and instrumental activities of daily living showed an activity with limitation<br>&#8226; Preclinical mobility disability defined as decreased frequency of walking 200 m and&#47;or climbing stairs in preceding 6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Defined frailty as &#8805;3 points&#44; 2 points if MMSE &#60;21&#44; 1 point if MMSE &#8805;21&#44; and &#60;27&#44; MNA &#60;12&#44; TUG &#8805;20 s&#44; BADL with at least 1 limited activity&#44; instrumental activities of daily living with at least 1 limited activity&#44; preclinical mobility disability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jung et al&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified Fried Frailty Criteria definition of frailty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Slowness<br>&#8211; After two trials of a 5 m walk&#44; average time &#62;6 s<br>Weakness<br>&#8211; After three grip strength measurements with each hand&#44; maximum value &#8804;30 kg if male or &#8804;20 kg if female<br>Weight loss<br>&#8211; Self-reported weight loss &#62;4&#46;5 kg &#40;10 lbs&#41; or &#62;5&#37; body weight in past 12 months<br>Exhaustion<br>&#8211; Two-item CES-D scale &#8805;1 out of 2<br>Depression<br>&#8211; 5-GDS &#8805;2 out of 5<br>Low physical activity<br>&#8211; Paffenbarger Physical Activity Index &#60;383 kcal per week if male or &#60;270 kcal per week if female<br>Cognitive impairment<br>&#8211; MoCA score &#60;26 out of 30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patient was deemed frail if at least 3 of the 7 criteria were present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35-item Frailty Index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#40;i&#41; Comorbidities<br>&#8211; Angina<br>&#8211; Arthritis<br>&#8211; Asthma<br>&#8211; Cerebrovascular disease<br>&#8211; Cognitive impairment<br>&#8211; COPD<br>&#8211; Dyslipidemia<br>&#8211; Gastrointestinal disease<br>&#8211; Hearing impairment<br>&#8211; Hypertension<br>&#8211; Myocardial infarction<br>&#8211; Pacemaker<br>&#8211; Peripheral vascular disease<br>&#8211; Pre-operative atrial flutter or fibrillation<br>&#8211; Prior angioplasty or stent<br>&#8211; Pulmonary hypertension<br>&#8211; Solid tumor<br>&#8211; Visual impairment<br>&#40;ii&#41; Physical and emotional measures<br>&#8211; Decline in food intake<br>&#8211; Depression based on the 5-GDS<br>&#8211; Exhaustion based on the two-item CES-D<br>&#8211; Falls in past year<br>&#8211; Inability to complete repeated chair stand test<br>&#8211; Low physical activity based on Paffenbarger Physical Activity Index<br>&#8211; Poor balance<br>&#8211; Self-rating of health<br>&#8211; TUG<br>&#8211; Unintentional weight loss in past 3 months<br>&#8211; Unintentional weight loss &#62;4&#46;5 kg &#40;10 lbs&#41;<br>&#8211; Weak grip<br>&#40;iii&#41; Functional measures<br>&#8211; Banking&#44; inability to perform<br>&#8211; Cleaning&#44; inability to perform<br>&#8211; Cooking&#44; inability to perform<br>&#8211; Driving&#44; inability to perform<br>&#8211; Shopping&#44; inability to perform&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frailty Index score&#61;individual&#39;s total number of deficits&#47;35<br>Deficits&#58; each counted as present or absent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SPPB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#40;i&#41; 5-m gait speed measurement<br>&#8211; After two trials&#44; average time&#58;<br>&#8804;6&#46;5 s&#58; 4 points&#59; 6&#46;6-8&#46;3 s&#58; 3 points&#59; 8&#46;4-11&#46;6 s&#58; 2 points&#59; &#8805;11&#46;7 s&#58; 1 point&#59; unable&#58; 0 points<br>&#40;ii&#41; Balance tests<br>&#8211; Side-by-side stand time<br>&#8805;10 s&#58; 1 point&#59; &#60;10 s&#58; 0 points&#59;<br>&#8211; Semi-tandem stand<br>&#8805;10 s&#58; 1 point&#59; &#60;10 s&#58; 0 points<br>&#8211; Tandem stand<br>&#8805;10 s&#58; 2 points&#59; 3-9&#46;99 s&#58; 1 point&#59; &#60;3 s&#58; 0 points<br>&#40;iii&#41; Repeated chair stand test<br>&#8211; Time to stand up from chair 5 times<br>&#8804;11&#46;19 s&#58; 4 points&#59; 11&#46;20-13&#46;69 s&#58; 3 points&#59; 13&#46;70-16&#46;69 s&#58; 2 points&#59; 16&#46;70-59&#46;99 s&#58; 1 point&#59; &#8805;60 s or unable&#58; 0 points&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patient was deemed frail if composite score &#8805;9 points&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Uchmanowicz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">50</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TFI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">First part&#58;<br>Sociodemographic characteristics of a participant&#58;<br>gender&#44; age&#44; marital status&#44; country of origin&#44; educational level&#44; and monthly income<br>Potential determinants of frailty&#46;<br>Second part&#58;<br>Components of frailty &#40;15 self-reported questions&#44; divided into three domains&#41;&#58;<br>- Physical domain &#40;0-8 points&#41;&#58; eight questions related to physical health&#44; unexplained weight loss&#44; difficulty in walking&#44; balance problems&#44; hearing problems&#44; vision problems&#44; strength in hands&#44; and physical tiredness&#46;<br>- Psychological domain &#40;0-4 points&#41;&#58; four items related to cognition&#44; depressive symptoms&#44; anxiety&#44; and coping&#46;<br>- Social domain &#40;0-3 points&#41;&#58; three questions related to living alone&#44; social relations&#44; and social support&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Eleven items from part two of the TFI have two response categories &#40;&#8220;yes&#8221; and &#8220;no&#8221;&#41;&#44; while the other items have three &#40;&#8220;yes&#8221;&#44; &#8220;no&#44;&#8221; and &#8220;sometimes&#8221;&#41;&#46;<br>&#8220;Yes&#8221; or &#8220;sometimes&#8221; responses are scored 1 point each&#44; while &#8220;no&#8221; responses are scored 0&#46;<br>The instrument&#39;s total score may range from 0 to 15&#58; the higher the score&#44; the higher one&#39;s frailty&#46;<br>Frailty is diagnosed when the total TFI score is &#62;5&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dunlay et al&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">31-item deficit index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Need help preparing meals<br>Need help feeding yourself<br>Need help dressing yourself<br>Need help using the toilet<br>Need help with housekeeping<br>Need help climbing stairs<br>Need help bathing<br>Need help walking<br>Need help using transportation<br>Need help getting in and out of bed<br>Need help managing medications<br>Depend on assistive devices &#40;walker&#44; cane&#44; etc&#46;&#41; or other people to perform activities of daily life<br>Dependent on a device for normal breathing<br>Climb 2 flights of stairs without rest<br>Myocardial infarction<br>Diabetes<br>Peripheral vascular disease<br>Cerebrovascular disease<br>COPD<br>Ulcer<br>Hemiplegia<br>Moderate&#47;severe renal insufficiency<br>History of liver disease<br>Rheumatologic disease<br>History of malignancy<br>History of dementia<br>Hypertension<br>Hyperlipidemia<br>Body mass index<br>Depression<br>Anemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br><br>Yes&#61;1&#44; No&#61;0<br>No&#44; cannot do at all&#61;1&#59; Yes&#44; with difficulty&#61;0&#46;5&#59; Yes with no difficulty&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes<span class="elsevierStyleMonospace">&#61;</span>1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Underweight or obese&#61;1&#59; overweight<span class="elsevierStyleMonospace">&#61;</span>0&#46;5&#59; normal&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Yes&#61;1&#44; No&#61;0<br>Patients were divided into tertiles of the deficit index&#58;<br>Lowest tertile&#61;not frail&#59; middle tertile&#61;intermediate frail&#59; highest tertile&#61;frail&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Afilalo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">51</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Essential Frailty Toolset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#40;i&#41; Time to stand 5 times from a seated position without using arms&#58; &#60;15 s<span class="elsevierStyleMonospace">&#61;</span>0 points&#59; &#8805;15 s<span class="elsevierStyleMonospace">&#61;</span>1 point&#59; unable to complete<span class="elsevierStyleMonospace">&#61;</span>2 points<br>&#40;ii&#41; Cognition&#58; MMSE &#8805;24&#58; 0 points&#59; MMSE &#60;24&#58; 1 point<br>&#40;iii&#41; Hemoglobin&#58; &#8805;13 g&#47;dl &#40;in men&#41; or &#8805;12 g&#47;dl &#40;in women&#41;&#58; 0 points&#59; &#60;13 g&#47;dl &#40;in men&#41; or &#60;12 g&#47;dl &#40;in women&#41;&#58; 1 point<br>&#40;iv&#41; Serum albumin&#58; &#8805;3&#46;5 g&#47;dl&#58; 0 points&#59; &#60;3&#46;5 g&#47;dl&#58; 1 point&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Composite score&#58; 0-5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Tools used to assess frailty in cardiovascular disease&#46;</p>"
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        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Frailty phenotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Frailty indices&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Performance on five variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Deficit count or proportion of potential deficits that a person has accumulated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Signs&#44; symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diseases&#44; activities of daily living&#44; results of a clinical evaluation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Possible before a clinical assessment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Doable only after a comprehensive clinical assessment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Categorical variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Continuous variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Predefined set of criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unspecified set of criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Frailty as a pre-disability syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frailty as an accumulation of deficits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Meaningful results potentially restricted to non-disabled older persons&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Meaningful results in every individual&#44; independently of functional status or age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Advantages&#58;<br>- performance-based<br>- easy to apply&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Advantages&#58;<br>- simple approach<br>- robust indicator of frailty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Disadvantages&#58;<br>- floor effect for some variables &#40;immobile patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Disadvantages&#58;<br>- cumbersome in clinical setting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Comparison of the frailty phenotype and frailty indices&#46;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">57</span></a></p>"
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      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:60 [
            0 => array:3 [
              "identificador" => "bib0310"
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              "referencia" => array:1 [
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                  "host" => array:2 [
                    0 => array:1 [
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                    ]
                    1 => array:1 [
                      "WWW" => array:1 [
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0315"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:1 [
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            2 => array:3 [
              "identificador" => "bib0320"
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                        ]
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            3 => array:3 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "L&#46; Rodr&#237;guez-Ma&#241;as"
                            1 => "C&#46; F&#233;art"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Frailty Oper Def Cons Conf Project"
                        "fecha" => "2013"
                        "volumen" => "68"
                        "paginaInicial" => "62"
                        "paginaFinal" => "67"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0330"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2018.05.016

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Year/Month	Html	Pdf	Total

2024 November	10	3	13
2024 October	64	37	101
2024 September	56	24	80
2024 August	38	20	58
2024 July	43	35	78
2024 June	29	31	60
2024 May	31	34	65
2024 April	32	31	63
2024 March	30	33	63
2024 February	30	19	49
2024 January	25	25	50
2023 December	21	25	46
2023 November	49	30	79
2023 October	39	24	63
2023 September	32	18	50
2023 August	23	13	36
2023 July	17	11	28
2023 June	19	13	32
2023 May	46	28	74
2023 April	21	7	28
2023 March	36	21	57
2023 February	32	21	53
2023 January	38	19	57
2022 December	55	26	81
2022 November	50	22	72
2022 October	34	18	52
2022 September	38	57	95
2022 August	31	24	55
2022 July	27	34	61
2022 June	23	34	57
2022 May	25	34	59
2022 April	27	15	42
2022 March	25	40	65
2022 February	23	35	58
2022 January	22	23	45
2021 December	30	27	57
2021 November	27	29	56
2021 October	33	39	72
2021 September	28	32	60
2021 August	25	31	56
2021 July	12	26	38
2021 June	40	15	55
2021 May	42	41	83
2021 April	29	48	77
2021 March	21	19	40
2021 February	26	24	50
2021 January	33	17	50
2020 December	18	4	22
2020 November	22	14	36
2020 October	21	12	33
2020 September	20	8	28
2020 August	17	9	26
2020 July	12	8	20
2020 June	16	18	34
2020 May	32	8	40
2020 April	19	13	32
2020 March	15	27	42
2020 February	48	69	117
2020 January	17	17	34
2019 December	19	15	34
2019 November	10	15	25
2019 October	9	16	25
2019 September	16	38	54
2019 August	40	18	58
2019 July	22	9	31
2019 June	40	27	67
2019 May	35	15	50
2019 April	23	23	46

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