Clinical Review

Coexisting Frailty, Cognitive Impairment, and Heart Failure: Implications for Clinical Care

Journal of Clinical Outcomes Management. 2015 January;22(1)

Author(s):

References

1. Velagaleti RS and Vasan RS. Heart failure in the twenty-first century: is it a coronary artery disease or hypertension problem. Cardiol Clin 2007;25:487–95.

2. Vincent GK, Velkoff VA. The next four decades. The older population in the United States: 2010 to 2050. United States Census Bureau Report No: P25-1138. U.S. Department of Commerce; May 2010.

3. Butler J, Kalogeropoulos A. Worsening heart failure hospitalization epidemic we do not know how to prevent and we do not know how to treat. J Am Coll Cardiol 2008;52:435–7.

4. Gary R. Evaluation of frailty in older adults with cardiovascular disease: incorporating physical performance measures. J Cardiovasc Nurs 2012;27:120–131.

5. Shamliyan T, Talley KM, Ramakrishnan R, Kane RL. Association of frailty with survival: a systematic literature review. Age Res Rev 2013;12:719–36.

6. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Med Sci 2001; 56:M146–M156.

7. Newman AB, Gottdiener JS, Mcburnie MA, et al. Associations of subclinical cardiovascular disease with frailty. J Gerontol A Biol Sci Med Sci 2001;56:M158–66.

8. Afilalo J, Karunananthan S, Eisenberg MJ, et al. Role of frailty in patients with cardiovascular disease. Am J Cardiol 2009; 103:1616–21.

9. Cacciatore F, Abete P, Maella F, et al. Frailty predicts long-term mortality in elderly subjects with chronic heart failure. Eur J Clin Invest 2008;35:723–30.

10. Lupón J, González B, Santaeugenia S, et al. Prognostic implication of frailty and depressive symptoms in an outpatient population with heart failure. Rev Españ Cardiol 2008;61:835–42.

11. Rich MW. Heart failure in the oldest patients: the impact of comorbid conditions. Am J Geriatr Cardiol 2007;14:134–41.

12. Buck HG, Riegel B. The impact of frailty on health related quality of life in heart failure. Eur J Cardiovasc Nurs 2011;10:159–66

13. Boxer RS, Shah KB Kenny AM. Frailty and prognosis in advanced heart failure. Curr Opin Supp Pall Care 2014;8:25–9.

14. Afilalo J, Sebag IA, Chalifour LE, et al. Age-related changes in lamin A/C expression in cardiomyocytes. Am J Physiol Heart Circ Physiol 2007;293:H1451–6.

15. Walston J. Frailty—the search for underlying causes. Sci Aging Know Environ 2004;2004:e4.

16. Hubbard RE, O’Mahony MS, Savva GM, et al. Inflammation and frailty measures in older people. J Cell Mol Med 2009; 13:3103–9.

17. Hubbard RE Woodhouse KW. Frailty, inflammation and the elderly. Biogerontol 2010;11:635–41.

18. Baptista G, Dupuy A-M, Jaussent A, et al. Low-grade chronic inflammation and superoxide anion production by NADPH oxidase are the main determinants of physical frailty in older adults. Free Rad Res 2012;46:1108–14.

19. Abbate A. The heart on fire: Inflammasome and cardiomyopathy. Exper Physiol 2013;98:385.

20. Collerton J, Martin-Ruiz C, Davies K, et al. Frailty and the role of inflammation, immunosenescence and cellular ageing in the very old: Cross-sectional findings from the Newcastle 85+ Study. Mech Age Devel 2012;133:456–66.

21. Ferrucci L, Harris TB, Guralnik JM, et al. Serum IL-6 level and the development of disability in older persons. J Am Geriatr Soc 1999;47:639–46.

22. Toth MJ, Matthews DE, Tracy RP and Previs MJ. Age-related differences in skeletal muscle protein synthesis: relation to markers of immune activation. Am j Physiol Endocrin Metab 2005;288:E883–91.

23. Howard C, Ferrucci L, Sun K, et al. Oxidative protein damage is associated with poor grip strength among older women living in the community. J Appl Physiol 2007;103:17–20.

24. Muzembo BA, Nagano Y, Eitoku M, et al. A cross-sectional assessment of oxidative DNA damage and muscle strength among elderly people living in the community. Envir Health Prev Med 2014;19:21–9.

25. Wu I-C, Shiesh S-C, Kuo P-H and Lin X-Z. High oxidative stress is correlated with frailty in elderly Chinese. J Am Geriatr Soc 2009;57:1666–71.

26. Alosco ML, Spitznagel MB, Cohen R, et al. Cognitive impairment is independently associated with reduced instrumental activities of daily living in persons with heart failure. J Cardiovasc Nurs 2012;27:44–50.

27. Feola M, Rosso GL, Peano M, et al. Correlation between cognitive impairment and prognostic parameters in patients with congestive heart failure. Arch Med Res 2007;38:234–9.

28. Pressler SJ, Subramanian U, Kareken D, et al. Cognitive deficits in chronic heart failure. Nurs Res 2010;59:127–39.

29. Pressler SJ, Kim J, Riley P, et al. Memory dysfunction, psychomotor slowing, and decreased executive function predict mortality in patients with heart failure and low ejection fraction. J Cardiac Fail 2010;16:750–60.

30. Pressler SJ, Subramanian U, Kareken D, et al. Cognitive deficits and health-related quality of life in chronic heart failure. J Cardiovasc Nurs 2010;25:189–98.

31. Hajduk AM, Lemon SC, Mcmanus DD, et al. Cognitive impairment and self-care in heart failure. Clin Epidemiol 2013; 24:407–16.

32. Dardiotis E, Giamouzis G, Mastrogiannis D, et al. Cognitive impairment in heart failure. Cardiol Res Prac 2012; 2012:595821.

33. Petersen RC and O’brien J. Mild cognitive impairment should be considered for DSM-V. J Geriatr Psychiatry Neurol 2006; 19:147–54.

34. Hjelm C, Dahl A, Broström A, et al. The influence of heart failure on longitudinal changes in cognition among individuals 80 years of age and older. J Clin Nurs 2012; 21:994–1003.

35. Almeida OP, Garrido GJ, Beer C, et al. Cognitive and brain changes associated with ischaemic heart disease and heart failure. Eur Heart J 2012;33:1769–76.

36. Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–98.

37. Nasveddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005;53:695–699.

38. Cameron J, Worrall-Carter L, Page K, et al. Screening for mild cognitive impairment in patients with heart failure: Montreal cognitive assessment versus mini mental state exam. Eur J Cardiovasc Nurs 2013;12:252–60.

39. Avila-Funes JA, Amieva H, Barberger-Gateau P, et al. Cognitive impairment improves the predictive validity of the phenotype of frailty for adverse health outcomes: the three-city study. J Am Geriatr Soc 57:453–61.

40. Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. Am Geriatr Soc 2006;54:743–9.

41. Kwon S, Perera S, Pahor M, et al. What is a meaningful change in physical performance? Findings from a clinical trial in older adults (the LIFE-P study). J Nutr Health Aging 2009;13:538–44.

42. Abellan Van Kan G, Rolland Y, Houles M, et al. The assessment of frailty in older adults. Clin Geriatr Med 2010; 26:275–86.

43. Pahor M, Manini T, Cesari M. Sarcopenia: clinical evaluation, biological markers and other evaluation tools. J Nutr Health Aging 2009;13:724–8.

44. Gary R. Evaluation of frailty in older adults with cardiovascular disease. J Cardiovasc Nurs 2012;27:120–31.

45. Macklai NS, Spagnoli J, Junod J, Santos-Eggimann B. Prospective association of the SHARE-operationalized frailty phenotype with adverse health outcomes: evidence from 620+ community-dwelling Europeans living in 11 countries. BMC Geriatr 2013;13:1–9.

46. Ravinrarajah R, Lee DM, Pye SR, et al. The ability of three different models of frailty to predict all-cause mortality: Results from the European Male Aging Study (EMAS). Arch Gerontol Geriatr 2013;57:360–8.

47. Rockwood K, Andrew M and Mitnitski A. A comparison of two approaches to measuring frailty in elderly people. J Gerontol Med Sci 2007;62:738–43.

48. Morley JE, Vellas B, Van Kan GA, et al. Frailty consensus: a call to action. J Am Med Dir Assoc 2013;14:392–7.

49. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 1994;49:M85–94.

50. Guralnik JM, Ferrucci L, Simonsick EM, et al. Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability. N Engl J Med 1995;332:556–61.

51. Di Bari M, Pozzi C, Cavallini Mc, et al. The diagnosis of heart failure in the community. Comparative validation of four sets of criteria in unselected older adults: the ICARe Dicomano Study. J Am Coll Cardiol 2004;44:1601–08.

52. Chiarantini D, Volpato S, Sioulis F, et al. Lower extremity performance measures predict long-term prognosis in older patients hospitalized for heart failure. J Cardiac Failure 2010; 16:390–5.

53. Volpato S, Cavalieri M, Sioulis F, et al. Predictive value of the short physical performance battery following hospitalization in older patients. J Gerontol A Biol Sci Med Sci 2011;66:89–96.

54. Studenski S, Perera S, Wallace D, et al. Physical performance measures in the clinical setting. J Am Geriatr Soc 2003; 51:314–22.

55. Binder EF, Schechtman KB, Ehsani AA, et al. Effects of exercise training on frailty in community-dwelling older adults: results of a randomized, controlled trial. J Am Geriatr Soc 2012; 50:1921–8.

56. Brown M, Sinacore DR, Ehsani AA, et al. Low-intensity exercise as a modifier of physical frailty in older adults. Arch Phys Med Rehab 2000;81:960–5.

57. Yamada M, Arai H, Sonoda T and Aoyama T. Community-based exercise program is cost-effective by preventing care and disability in Japanese frail older adults. J Am Med Dir Assoc 2012;13:507–11.

58. Gary RA, Cress ME, Higgins MK, et al. A combined aerobic and resistance exercise program improves physical functional performance in patients with heart failure: a pilot study. J Cardiovasc Nurs 2012;27:418–30.

59. De Meirelles L, Matsuura C, Resende AD, et al. Chronic exercise leads to antiaggregant, antioxidant and anti-inflammatory effects in heart failure patients. Eur J Prev Cardiol 2014;21:1225–32.

60. Feiereisen P, Vaillant M, Gilson G, Delagardelle C. Effects of different training modalities on circulating anabolic/catabolic markers in chronic heart failure. J Cardiopulm Rehab Prev 2013;33:303–8.

61. Smart NA, Steele M. The effect of physical training on systemic proinflammatory cytokine expression in heart failure patients: a systematic review. Congest Heart Fail 2011;17:110–4.

62. Nunes RB, Alves JP, Kessler LP, Lago PD. Aerobic exercsie improves the inflammatory profile correlated with cardiac remodeling and function in chronic heart failure rats. Clin Chest Med 2013;68:876–82.

63. Larson EB, Wang L, Bowen JD, et al. Exercise is associated with reduced risk for incident dementia among persons 65 years of age and older. Ann Intern Med 2006;144:73–8.

64. Colcombe S and Kramer AF. Fitness effects on the cognitive function of older adults: a meta-analytic study. Psychol Sci 2003;14:125–30.

65. Heyn P, Abreu BC, Ottenbacher KJ. The effects of exercise training on elderly persons with cognitive impairment and dementia: a meta-analysis. Arch Phys Med Rehab 2004; 85:1694–704.

66. Bautmans I, Vanpuyvelde K, Mets T. Sarcopenia and functional decline: pathophysiology, prevention and therapy. Acta Clinica Belgica 2009;64:303–16.

67. Guralnik JM, Ferrucci L, Pieper CF, et al. Lower extremity function and subsequent disability: Consistency across studies, predictive models, and value of gait speed alone compared with the short physical performance battery. J Gerontol A Biol Sci Med Sci 2000;55A:M221–M231.

68. Kramer AF, Erickson KI. Capitalizing on cortical plasticity: influence of physical activity on cognition and brain function. Trends Cogn Sci 2007;11:342–8.

69. Harkness K, Heckman GA, Mckelvie RS. The older patient with heart failure: high risk for frailty and cognitive impairment. Expert Rev Cardiovasc Ther 2012;10:779–95.

70. Waters DL, Baumgartner RN, Garry PJ, Vellas B. Advantages of dietary, exercise-related, and therapeutic interventions to prevent and treat sarcopenia in adult patients: an update. Clin Interv Aging 2010;5:259–70.

From the Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA.

Abstract

Objective: To review some of the proposed pathways that increase frailty risk in older persons with heart failure and to discuss tools that may be used to assess for changes in physical and cognitive functioning in this population in order to assist with appropriate and timely intervention.
Methods: Review of the literature.
Results: Heart failure is the only cardiovascular disease that is increasing by epidemic proportions, largely due to an aging society and therapeutic advances in disease management. Because heart failure is largely a cardiogeriatric syndrome, age-related syndromes such as frailty and cognitive impairment are common in heart failure patients. Compared with age-matched counterparts, older adults with heart failure 4 to 6 times more likely to be frail or cognitively impaired. The reason for the high prevalence of frailty and cognitive impairment in this population is not well known but may likely reflect the synergistic effects of heart failure and aging, which may heighten vulnerability to stressors and accelerate loss of physiologic reserve. Despite the high prevalence of frailty and cognitive impairment in the heart failure population, these conditions are not routinely screened for in clinical practice settings and guidelines on optimal assessment strategies are lacking.
Conclusion: Persons with heart failure are at an increased risk for frailty, which may worsen symptoms, impair self-management, and lead to worse heart failure outcomes. Early detection of frailty and cognitive impairment may be an opportunity for intervention and a key strategy for improving clinical outcomes in older adults with heart failure.

Approximately 5.7 million persons in the United States are diagnosed with heart failure, and the number of reported new cases is expected to increase to over 700,000 cases annually by the year 2040 [1]. This rising incidence is fueled by an aging population; by the year 2030, 1 in 5 Americans will be over 65 years of age [2]. Heart failure is prevalent among those 65 years of age and older and is the most common reason for hospitalization in this age-group. High readmission rates, approaching 50% over 6 months, are a major contributor to the the escalating economic burden associated with heart failure [3].

Persons with heart failure are more likely to be frail and experience cognitive impairment than their age-matched counterparts without heart failure. The reasons for this are not well known but may be related to hemodynamic, vascular, and inflammatory changes occurring as heart failure progresses. In this paper, we review the link between frailty and cognitive impairment in heart failure, instruments that may be useful for early detection, and interventions such as exercise that may be beneficial for attenuating both conditions.

Frailty in Heart Failure

Epidemiology

Frailty is a heightened vulnerability to stressors in the presence of low physiological reserve [4]. When exposed to stressors, persons who are frail have a much higher probability for disproportionate decompensation, negative events, functional decline, disability, and mortality [5]. Among persons with heart failure, frailty may predispose them to decompensate at a lower threshold, requiring more frequent hospitalizations. Persons with heart failure are more likely to be frail than their age-matched counterparts without heart failure [6,7].