Cardiac Rehab and Frailty

Alexandra Wlazlik - Supernak

British Geriatric Society recognizes frailty as a “distinctive state of health related to the aging process in which multiple body systems gradually lose their inbuilt reserves” (Turner, 2014). Andrew Clegg and his co-workers see frailty as a poor outcome of the person’s body and mind to the stressors. If there was any cumulation of the events or stressors from the past, the minor stressor can trigger irreversible changes within health status at any stage. (Andrew Clegg, 2013). This can result in-person to become vulnerable to these changes. A serious multiple consequences may occur, such as changes in cognition, falls, lack of mobility, incontinence. These may increase care needs, risk of admission to the hospital and, or to the long-term care facility. The frailty risk factors are complex, and they are conditioned by sociodemographic, psychological, and medical/ disability circumstances.?

The British Office for National Statistics in their Bulletin presented 2 graphs showing an estimated rise in elderly population 80+ from 0.2 million in 2012 to 0.3 million in 2037. However, there is evidence that 10% of older adults aged 65 to 85, would also have symptoms of frailty. (Andrew Clegg, 2013). The figures for the incidence of frailty increase even to 50% in those aged 85 and over. David Reeves and his colleagues in their paper analysed adjustments that have been made in healthcare policies among the European countries and UK. He brings to attention the need of reviewing these policies and developing a better social service based on multidisciplinary leadership. He further concluded that the UK primary care model seems to be well constructed and prepared for increasing demand of an aging population. Multiple researchers notice that disability and frailty are linked but not always coincide.

?(Fried LP, 2001) in his paper, concluded that the main signs and symptoms of frailty are weight loss > than 5% drop in body weight in the past year and which was not induced by exercises or diet, muscle weakness, reduced speed of walking, reduced physical activity and endurance. He further stated that the above phenotype model could be used as a quick assessment tool for frailty. The person is frail if 3 criteria are met, still if the person meets one of two criteria might be considered as pre- frail.?(K.Rockwood, 2005) in his article suggested that definition of frailty should be multifactorial but the way that frailty correlates with other co-morbidities and patient’s own health perception should be considered. (Monidipa Dasgupta et al, 2009) declared that eventual post-operative medical complications could be estimated better if the patients were screened towards frailty pre-operatively.?The authors also emphasized an importance of correct identification of the group of patients that are at risk of rapid deterioration.?

The National Clinical Programme for Older Persons is a joint initiative between the HSE Clinical Strategy and Programmes Division and the Royal College of Physicians of Ireland. (Lang D, 2018). Deirdre Lang and colleagues presented an education programme on fundamentals of frailty. The aims of the programme were to help the healthcare professionals in understanding frailty. This program would also provide the healthcare workers with necessary skills to be able to identify, assess and to provide healthcare services for people with frailty. They collaborated with The Irish Longitudinal Study on Aging (TILDA), and with the Acute and Emergency Medicine Programmes. Using a "proof of concept" design for the programme. It has been enrolled and piloted in three nominated hospital groups. The authors were aiming to implement an assessment tool and then audit it. They would also work on the documentation of the referral pathways. Survey of facilitators knowledge pre- and post-TILDA as well as the Analysis of NFEP participants learning were to be performed. The expectations from the implementation and evaluation of the programme were to decrease length of hospital stay, reduction in falls and further audit of delirium management. According to NHS statistics from 2012-2013, 70% of day beds were occupied by people over 65; this is more than 51,000 beds at any one time. Stay in hospital of the 85- year-olds patients were on average eight days longer than stay of the patients aged 65-year-old. There is much research and literature available to support the fact that frail patients who were discharged from the hospital had a high risk of readmission within 30 - 60 days in comparison with the patients who were not frail. If indicated, “Comprehensive Geriatric Assessment (CGA) should be initiated as soon as possible after admission to hospital by a skilled, senior member of the multidisciplinary team, and used to identify reversible medical problems, target rehabilitation goals and plan all the components of discharge and post discharge support needs”. (Oliver et al 2014).?

The CGA is led by the geriatrician who is a member of the CGA multidisciplinary team (MDT). Other members usually include Physiotherapist, Nurse, Occupational Therapist, Pharmacist, Dietetics. Other team members may also include Speech and Language Therapist, Psychologist, Psychiatrist of old age, Social Workers, Podiatrist. The CGA includes physical, functional, psychological, and social assessment. Validated frailty assessment tools include Rockwood Clinical Frailty Scale (CFS), Timed up and Go Test (TUG), PRISMA 7 Questionnaire, Edmonton Frail Scale and The Groningen Frailty Indicator Questionnaire. (HSE, 2016)?

The British Geriatrics Society (BGS) Fit for Frailty guideline is commonly known as a best practice guidance for the management of frailty in outpatients and community settings. A score of ≥3 on the PRISMA 7, a gait speed <0.8m/s; a timed-up-and-go test >10s, can indicate frailty. The other symptoms like (sudden mobility deterioration, falls, delirium) can also be used as an indicator. (Turner G. , 2014)

As a Physiotherapist working with people after cardiac events, leading Cardiac Rehabilitation services (CR) I am aware of the importance of identifying of the risk factors for frailty and acting accordingly if frailty is suspected. In this literature review I am going to explore and discuss the evidence base for evaluation of the impact of cardiac rehabilitation practices on frailty and critically appraise the evidence.

Cardiac rehabilitation and Frailty

(Dustin S. Kehler, 2020) found in their study that the patients who have completed their cardiac rehabilitation program had improved frailty levels. Patients were invited to a 12-week group-based exercise and education cardiac rehabilitation program. They attended twice weekly. Frailty was measured with 25-item accumulation of deficits frailty index before and after completion the programme. The biggest improvement was found among the frailest patients. The prospective randomized controlled study was conducted by (Molino-Lova, 2013) to compare the long-term effects of a structured physical activity intervention with those of aerobic exercises alone, in a cohort of elderly patients who had undergone elective cardiac surgery, and who were classified as frail at the end of rehabilitation based on their Short Physical Performance Battery (SPPB) score. Before discharge 140 frail elderly patients were randomly allocated either to the intervention group (IG) or to the control group (CG). CG participants were prescribed usual aerobic exercise. The IG participants were taught additional exercises for strength, balance and coordination and flexibility and given the exercise prescription. The improvement in SPPB score in IG after 1 year was the outcome of the study. The randomization used for this study seems to be true and the baseline of these two groups was similar at the start. The outcomes were measured in the same reliable way for both groups.

(Flint, Stevens-Lapsley, & Forman, 2020) concluded in their paper that CR may be a powerful tool for frail population. However, the older patients with CVD and frailty might not be able to tolerate the conventional CR exercise training due to multidimensional physical impairments. The authors further highlight the importance of addressing the intrinsic skeletal muscle impairments of frail patients and to target deficits in strength, mobility, and balance before proceeding with aerobic training. (Lutz, Delligatti, Allsup, Afilalo, & Forman, 2020) performed a retrospective analysis of CVD patients who were divided into a ‘frail group by meeting more that 2 criteria and intermediate- frail by meeting 1 criterion. The distance (6MWD) <300 m, gait speed ≤0.65 m/sec or 0.76 m/sec, tandem stand <10 sec, Timed Up & Go (TUG) <15 sec, were the main criteria. The two groups were tested pre- and post-completion of the programme. Surprisingly, each of the group has improved in all measures except for tandem stand. The authors also found that ‘frail’ group had the biggest improvement in TUG. The participants were blind to the treatment assignment groups. All the groups were tested identically. The outcomes were measured in the same way for both groups. This study shows that comprehensive interventions, including exercise that are tailored to the patient’s needs and multidimensional patient education, implemented into a CR programme, are beneficial for patients with HF with preserved ejection fraction and HF with frailty, where few effective treatments exist. One of the positive approaches in this study was that patients with physical impairment or frailty were additionally performing functional training, such as balance training and physical therapy, to improve ADL performance.

Another group of researchers attempted to explore the effect of CR on frail patients with cardiac disease. There was a group of 89 CVD patients male and female over 65 year old referred to the 3 month programme. The patients with dialysis and unstable decompensated heart failure and exercise-induced myocardial ischemia, were excluded. This study again divided the patients into two groups. The frail non-frail group has been created based on the assessment of frailty score before CR. There was appropriate statistical analysis used. And paired t-test or Wilcoxon signed- rank test was used to compare paired variables before and after CR within each group. This study proved that appropriately designed CR could improve physical function, therefore it could improve frailty symptoms in more than 80% of the patients but the improvement in exercises capacity was only noticed in non-frail patients. The design seems to be appropriate for this study type. (Akiko Ushijima, 2020).?

?(Kentaro Kamiya, 2020) together with colleagues examined in their retrospective cohort study eventual association of participation in CR with long-term survival in patients with Heart Failure (HF). They also analysed the readmissions incidence. The patients were analysed subsequently by HF with preserved ejection fraction (below 50%), age, sex, comorbidities, and frailty. The study was performed among patients hospitalized for acute HF at 15 hospitals in Japan, 2007 to 2016. Hospitalization and vital status data were collected from medical records. Composite of all-cause mortality and HF readmissions after discharge was the primary outcome. All-cause mortality and HF readmissions was the secondary outcome. Both outcomes were analysed and compared for the patients who participated CR program versus nonparticipants. Of the 3277 patients, 26% 862 participated in outpatient CR. After the researchers looked at potential confounders, 1592 patients were included (n=796 pairs), 511 had composite outcomes 223 14% all-cause deaths and 392 25% HF rehospitalizations, median 2.4-year follow-up. The associated hazard ratios with CR participation were 0.77 (95% CI, 0.65–0.92) for composite outcome, 0.67 (95% CI, 0.51–0.87) for all-cause mortality, and 0.82 (95% CI, 0.67–0.99) for HF-related rehospitalization. The association between CR participation and prognosis across frailty status was analysed in all study patients. The researchers assessed the validity of the frailty index in their patient cohort with Kaplan-Meier curves and multivariate Cox regression which was grouped into 4 categories of frailty index. The relationship between CR participation and primary outcome for each frailty group was again consequently examined using Kaplan-Meier curves and multivariate Cox regression. The adjustment variables were sex and major HF prognostic predictors including NYHA at discharge and log-BNP. Even though this study provided a good base for further research on cardiac rehabilitation and its prognosis for frail patients with HF however there were some limitations for instance the exact frequency and intensity of the CR class were missing. The medications that patients were prescribed with, were not taken into consideration. There were differences between participants included in compared groups therefore it might form a bias to the internal validity of a study as they were not drawn from the same population. For this study appropriate statistical analysis was used but the follow up was not adequately described.?

?(Ji H, 2019) searched PubMed, Web of science, and EMBASE databases. They aimed to obtain results from 2010 to August 2018 to determine what is the effects of CR in Patients with Acute Coronary Syndrome (ACS). In the conclusion of this meta-analysis results the researchers suggested that “CR is clearly associated with reductions in cardiac mortality, recurrence of MI, repeated PCI, CABG, and restenosis” (Michelle M. Graham, 2013) did a pilot study on the Edmonton Frail Scale (EFS) and its validity among the group of 183 frail, elderly patients with ACS who were admitted to the hospital over 6 months’ time. There were 3 groups EFS 0-3, EFS 4-6, and EFS>7 established. Health care providers were blinded to the results of the study which were displayed in a form of tables. EFS scores more than 7 were associated with congestive heart failure in >33% of patients and cerebrovascular disease in 25%.?The author found that the patients that scored in general from 12 to 17 on the scale were associated with higher mortality risk.?

Another randomized controlled trial of rehabilitation after hospitalization due acute illness in frail older patients was conducted in Finland by (Timonen, 2002) and colleagues. They measured the effects of rehabilitation on strength, balance, and mobility in a frail older woman. Sixty‐eight women (mean age 83.0 ± 3.9 years) who were hospitalized due to an acute illness and their mobility was impaired at admission were randomized into training N=34 and home exercise N=34 groups after one-week post discharge. The effects of a 10‐week training program after hospitalization on lower limb muscle strength, gait speed, and balance was examined. The baseline measurements were taken 1 week before the start. A rehab nurse interviewed the patients and collected information regarding their functional capacity. Weight and details on medical status of the patients were obtained from the hospital records. Strength and physical ability tests were performed by two trained physiotherapists. Follow‐up tests were performed in the same place 1 week, and 3 and 9 months after the 10‐week intervention. Classes were provided twice a week. Time of the class 90 min. Training sessions were conducted by two Physiotherapists. Patients were provided with lunch after training session. They were transported from and to their place. There were 3–8 patients in the group every time.15 minutes warm up was provided and low weights were used. Progressive resistance training for knee flexion, extension and hip abduction was performed. Functional exercises were also implemented as a part of the programme in a form of the full body work out. 2 sets of 15 repetitions were performed in each station. The cool down part consisted of relaxation and stretches. A Physiotherapy Home Visit was arranged for the home exercises group of the patients. During the visit, a home exercise program including all the functional exercises as described above was taught and practiced. The subjects were advised to perform two sets of 15 repetitions 2–3 times a week. No further visits nor advise to exercise was given to this group. The improvements were observed in the training group compared vs home exercise group in the isometric knee extension strength 20.8% vs. 5.1%, P= 0.009, balance scale +4.4 points vs. ?1.3 points, P= 0.001 and walking speed 0.12ms?1 vs. ?0.05ms?1, P= 0.022. Effects on knee extension and hip abduction strength, balance and walking speed were observed 3 months later. Some effects on hip abduction strength 9.0% vs. ?11.8%, P= 0.004 and mobility were still present even 9 months after finishing the programme. Data in this study seems to be appropriately analysed, and the outcomes were measured the same way for all participants. All the participants were blind to the assignments. All the participants had similar mobility and functional baseline. This study provides evidence that low‐cost group exercise programs are feasible to carry out in the outpatient’s settings and are beneficial for frail older women.?

Clinical implications and relevance to CR practice

Multiple papers show the evidence and rationale for referring all eligible patients to CR, including frail patients. Those who are most frail may benefit the most. (Dustin S. Kehler, 2020). Cardiac Rehabilitation in elderly CVD patients with frailty should focus on the improvement of the physical function. This could be followed by for possible improvement of exercise capacity as a second step. (Lutz, Delligatti, Allsup, Afilalo, & Forman, 2020). In some papers CR participation was also associated with lower rates of composite outcome in frail patients with HF with preserved ejection fraction >50%. These findings support a benefit of outpatient CR in HF with preserved ejection fraction and HF with frailty. There is also possible impact on survival and HF hospitalization. Research suggests health care providers should assess and address frailty in patients undergoing a procedure like transcatheter aortic valve implantation and this could be an opportunity for Physiotherapist to expand their Cardiac Rehab services offer. (NHS, 2013) The 5 needs in Maslow’s motivational hierarchy physiological, safety, belongingness and esteem levels are in the lives of general people. (Taormina, 2013)found that family support, traditional values, and life satisfaction has positive correlations with the satisfaction of all 5 needs, and the anxiety/worry facet of neuroticism had significant negative correlations with the satisfaction of all the needs. If these needs are met, then there is a higher chance that the patient even the frailest could participate in their recovery more enthusiastically.

Conclusions:

?It may need to be further discussed if longer duration of CR would be required to achieve the improvement of exercise capacity in frail patients’ group. Edmonton Frailty Scale is a simple, valid tool and could be useful in measuring frailty in cardiac services but there is a little data on validation of the frailty assessment tools in Cardiac Rehabilitation services. Home exercises programme was applicable in some studies for frail patients, but the limitation would be a cost and time with poor outcomes overall. The effects of CR on long-term benefit of cardiovascular disease (CVD) are well known. However, the effect of CR on frail CVD patients has not been fully addressed and this needs further research in the nearest future.?

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