‘Frailty’ is something many struggle to describe in words but ‘know it when they see it’, however it was only defined clinically in 2001 - as a typically geriatric condition characterised by physical decline and increased risk of adverse health outcomes.

Professor Phillip Newton and Dr Caleb Ferguson from 91����’s School of Nursing and Midwifery are investigating how frailty relates to cardiovascular diseases such as heart failure and stroke, specifically how it is measured and how it may be used as a prognostic and screening tool.

Most common frailty tests assess whether the patient conforms to Fried’s Frailty phenotype — where a patient is regarded as frail if they have three or more of the following symptoms: weak grip strength, slowed walking speed, unintentional weight loss, low physical activity and exhaustion. 

While there are many other tests for frailty, none have yet been validated for use in heart failure patients. As part of a project led by PhD candidate Julee McDonagh, Newton and Ferguson decided to have a closer look.

The team are now validating the tools used to measure these symptoms. “Some of the instruments in use tend to over- or underestimate frailty,” says Ferguson. Another of the team’s studies compared frailty measurements performed using objective tools to clinicians’ estimates. They found that clinicians often underestimated the level of frailty in patients. “The message is that you do actually have to quantitatively measure frailty,” says Newton. 

Ensuring that frailty is correctly and quantitatively measured is particularly important in heart disease, as it is increasingly recognised as a predictor of adverse outcomes such as extended hospitalisation and death.

Newton and Ferguson, along with international colleagues, analysed articles published between 1966 and 2018 for mortality and incident hospitalisation in patients with heart failure and frailty compared to non-frail patients. The team found that frailty in patients with chronic heart failure was associated with a 1.5-fold increase in the likelihood of death or hospitalisation.

In a separate study, Newton worked with an international multidisciplinary team that tested for frailty in 96 patients who had been referred for heart transplantation or to receive a ventricular assist device between 2013 and 2017. Based on cognitive assessment and the Fried Frailty phenotype, 30 of the patients were identified as frail.

There were no significant differences in age or body mass index between the frail and non-frail groups. However, more women were identified as frail than men – 42% vs 23%; and at 53% vs 26%, depression was higher in the frail group. Importantly, the team found that frailty was a predictor of death following heart transplantation, with one-year survival rate of 74% in the frail group vs 98% among those who were not frail.

Thanks to this study, patients who are referred for heart and lung transplantations in Sydney are now screened for frailty in order to better identify those who will most benefit from the procedure, says Newton. He cautions, however, that frailty alone should not preclude a patient from receiving a transplant, as the team found that, for a subgroup of patients frailty was reversible once they survived a defined period after transplantation.

With robust and quantitative measurements associated with frailty and a proper understanding of how it can be used as a predictive instrument in heart failure, “frailty can evolve from just being an interesting research variable to an important clinical instrument utilised as part of the management plan for heart failure patients,” says Ferguson. “At that point, instead of merely predicting worse outcomes, frailty assessment can help prevent them.”