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

Interventions for Frailty in Heart Failure

Interventions to address frailty have included exercise training, comprehensive geriatric assessment and management services, social support systems, nutrition, and drugs; however, few intervention studies have examined frailty in heart failure [8]. Restoration of physical function through aerobic exercise and resistance training has shown benefit in frail older adults [55–57] and in persons with heart failure [58]. Maintaining and/or restoring physical function through aerobic and resistance exercise training may be the key to preventing further decline or potentially reversing frailty in older adults with heart failure.

Aerobic exercise has been shown to be beneficial for both frail older adults and frail persons with heart failure [18]. In a study of community-dwelling frail older adults aged 65 and older, a combined aerobic and resistance exercise intervention, performed over 16 weeks, demonstrated significant improvement in frailty scores during the 1-year follow-up in contrast to worsening frailty measures in the control group [57].

Older adults with heart failure experience a much lower exercise tolerance largely due to a 50% to 75% decrease in aerobic capacity in addition to the well-known alterations in peripheral musculoskeletal performance that contribute to fatigue and greater symptom severity. Aerobic exercise has been shown to be beneficial for most heart failure patients by altering the peripheral and central mechanisms, such as inflammatory cytokines, that contribute to heart failure exacerbations, worsened symptom severity, and poor clinical outcomes [59–62].Lower rates of hospitalization, improved physical function, and enhanced health-related quality of life are reported in heart failure patients who routinely exercise [59]. Resistance training has been shown to improve physical function in frail older adults [55]. Further, the use of TheraBand exercise bands in resistance training demonstrated improvement in physical function among frail older adults [56].

Exercise also appears to exert a positive effect on cognition, particularly executive functioning, and may also have a protective effect against cognitive decline with aging and among those with heart failure. The underlying mechanism for improvement in cognition remains poorly understood but is likely related to improved cardiac function, cerebral perfusion, and oxygenation, although this has not been clearly established. Larson et al (2006) evaluated the frequency of participation in a variety of physical activities (eg, walking, bicycling and swimming) over 6 years in 1740 older adults [63]. Older adults who exercised more than 3 times per week during initial assessment were 34% less likely to be diagnosed with dementia than those who exercised fewer than 3 times per week. Several meta-analyses in recent years have shown a consistent and positive relationship between aerobic exercise and cognition [64,65]. Importantly, findings from meta-analyses have shown a moderate effect size (> 0.5) from aerobic training, which was similar for normal and cognitively impaired adults [64].

Implications for Clinical Care

A systematic assessment performed periodically using physical and cognitive measures that may identify prefrailty may be the best strategy for preventing further functional loss, limitations, and disability in persons with heart failure. Persons with heart failure ideally should be evaluated annually for physical function, since a decline has been consistently shown to be a strong predictor of adverse health outcomes, disability, and death [6,66]. Cognitive function should also be assessed routinely in persons with heart failure, particularly when first diagnosed, when changes in treatment regimen occur, and with worsening disease severity, since these events have been shown to occur before changes in cognition [31]. Incorporating geriatric performance-based measures in heart failure management would allow for more treatment strategies aimed at improving physical function, cognitive outcomes, and quality of life. Further, identifying frailty in heart failure is an important component of clinical decision-making when determining if a patient can tolerate therapies such as implantable defibrillators, cardiac resynchronization therapy, or left ventricular assist device placement.