Commentary: Frailty: I know it when I see it

Abstract

Central MessageFrailty describes both physical weakness and fragility, accounting for its association with adverse cardiac surgery outcomes. We now find it may also be associated with health-related quality of life.See Article page XXX.Cardiothoracic surgeons instinctively recognize the frail patient, even if they can't point to one defining characteristic or metric. Rather, “I know it when I see it.” Observationally, frailty embodies both physical weakness and fragility1The American Heritage Dictionary of the English Language. 5th ed. Houghton Mifflin Harcourt, 2011Google Scholar and is associated with exhaustion, low body mass index (“wasting” or cardiac cachexia), low physical activity, weak grip strength, slow walking,2Tang A. Ahmad U. Raja S. Rappaport J. Raymond D.P. Sudarshan M. et al.Looking beyond the eyeball test: a novel vitality index to predict recovery after esophagectomy.J Thorac Cardiovasc Surg. 2021; 161: 822-832Google Scholar as in the Fried Frailty Index,3Fried L.P. Tangen C.M. Walston J. Newman A.B. Hirsch C. Gottdiener J. et al.Frailty in older adults: evidence for a phenotype.J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156Google Scholar and multimorbidity.4Rockwood K. Song X. MacKnight C. Bergman H. Hogan D.B. McDowell I. et al.A global clinical measure of fitness and frailty in elderly people.CMAJ. 2005; 173: 489-495Google Scholar,5Subramaniam S. Aalberg J.J. Soriano R.P. Divino C.M. New 5-factor modified frailty index using American College of Surgeons NSQIP data.J Am Coll Surg. 2018; 226: 173-181Google Scholar Biomarkers of frailty include low albumin levels,6Rich M.W. Keller A.J. Schechtman K.B. Marshall Jr., W.G. Kouchoukos N.T. Increased complications and prolonged hospital stay in elderly cardiac surgical patients with low serum albumin.Am J Cardiol. 1989; 63: 714-718Google Scholar sarcopenia with low creatinine levels,7Nascimento C.M. Ingles M. Salvador-Pascual A. Cominetti M.R. Gomez-Cabrera M.C. Viña J. Sarcopenia, frailty and their prevention by exercise.Free Radic Biol Med. 2019; 132: 42-49Google Scholar and reduced psoas muscle size,8Kondo Y. Suzuki T. Enomoto M. Takashima N. Kinoshita T. Psoas muscle size, possible sarcopenia and frailty, and long-term survival in elderly patients after isolated surgical aortic valve replacement for aortic stenosis.Indian J Thorac Cardiovasc Surg. 2022; 38: 134-141Google Scholar with most studies including older age as well. Thus, frailty is a gestalt: a “pattern of elements so unified as a whole that its properties cannot be derived from a simple summation of its parts.”1The American Heritage Dictionary of the English Language. 5th ed. Houghton Mifflin Harcourt, 2011Google Scholar Evidences of frailty have been associated with increased morbidity, prolonged postoperative length of stay, and mortality after cardiothoracic surgery.2Tang A. Ahmad U. Raja S. Rappaport J. Raymond D.P. Sudarshan M. et al.Looking beyond the eyeball test: a novel vitality index to predict recovery after esophagectomy.J Thorac Cardiovasc Surg. 2021; 161: 822-832Google Scholar,8Kondo Y. Suzuki T. Enomoto M. Takashima N. Kinoshita T. Psoas muscle size, possible sarcopenia and frailty, and long-term survival in elderly patients after isolated surgical aortic valve replacement for aortic stenosis.Indian J Thorac Cardiovasc Surg. 2022; 38: 134-141Google Scholar,9Kojima G. Iliffe S. Walters K. Frailty index as a predictor of mortality: a systematic review and meta-analysis.Age Ageing. 2018; 47: 193-200Google ScholarIn this issue, Verwijmeren and colleagues,10Verwijmeren L. Noordzij P.G. Daeter E.J. Emmelot-Vonk M.H. Vernooij L.M. van Klei W.A. et al.Preoperative frailty and one-year functional recovery in elderly cardiac surgery patients.J Thorac Cardiovasc Surg. February 2, 2022; ([Epub ahead of print])Google Scholar primarily intensive care anesthesiologists collaborating with gerontologists and cardiac surgeons, join numerous investigators adding to an exponentially increasing literature about frailty (Figure 1). Unlike most studies, they attempt to link 11 variables they believe reflect frailty to 1-year postoperative patient-reported health-related quality of life (HRQoL) rather than to more familiar notions of weakness or fragility. To justify their approach, they pick cut points for 6 physical domain measures (that include nutrition and multipharmacy), 2 mental health measures, and 3 social domain variables to stratify patients aged 70 years and older as frail (n = 120) or nonfrail (n = 435). These groups are not very distinct (frailty domains in their Table 1 don't count), and we don't know whether patients' physicians and surgeons had a gestalt for whether those labeled frail appeared frail to them.Figure 1Exponential increase in PubMed entries for frailty publications overall (A) and in cardiac surgery (B).View Large Image Figure ViewerDownload Hi-res image Download (PPT)How well did these metrics relate to change in HRQoL from preoperative assessment to 1-year postoperatively? Multipharmacy was weakly associated with lower HRQoL. Contrary to the authors' interpretation, worse nutritional status was associated with better physical health scores, but worse mobility was associated with worse physical health, as was living dependently. The same variables were associated with self-reported mental health. Importantly, but not recognized by Verwijmeren and colleagues, EuroSCORE (European System for Cardiac Operative Risk Evaluation), a surrogate for multicomorbidity, was associated with lower (worse) HRQoL scores. Note that the only statistics provided in the main paper relate to change in HRQoL from baseline to 1 year; the authors’ Table E5 shows the full model including the main effects. This shows, for example, that the apparent anomaly of grip strength not being statistically significant in terms of postoperative change is indeed associated with lower physical HRQoL both preoperatively and at 1 year, but with no change between.Self-reported HRQoL is a more challenging end point than hard clinical end points because it, like frailty, is multidimensional. Nevertheless, Verwijmeren and colleagues have added to the definition of frailty patients’ own perception of weakness and fragility. Frailty describes both physical weakness and fragility, accounting for its association with adverse cardiac surgery outcomes. We now find it may also be associated with health-related quality of life. Frailty describes both physical weakness and fragility, accounting for its association with adverse cardiac surgery outcomes. We now find it may also be associated with health-related quality of life. See Article page XXX. See Article page XXX. Cardiothoracic surgeons instinctively recognize the frail patient, even if they can't point to one defining characteristic or metric. Rather, “I know it when I see it.” Observationally, frailty embodies both physical weakness and fragility1The American Heritage Dictionary of the English Language. 5th ed. Houghton Mifflin Harcourt, 2011Google Scholar and is associated with exhaustion, low body mass index (“wasting” or cardiac cachexia), low physical activity, weak grip strength, slow walking,2Tang A. Ahmad U. Raja S. Rappaport J. Raymond D.P. Sudarshan M. et al.Looking beyond the eyeball test: a novel vitality index to predict recovery after esophagectomy.J Thorac Cardiovasc Surg. 2021; 161: 822-832Google Scholar as in the Fried Frailty Index,3Fried L.P. Tangen C.M. Walston J. Newman A.B. Hirsch C. Gottdiener J. et al.Frailty in older adults: evidence for a phenotype.J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156Google Scholar and multimorbidity.4Rockwood K. Song X. MacKnight C. Bergman H. Hogan D.B. McDowell I. et al.A global clinical measure of fitness and frailty in elderly people.CMAJ. 2005; 173: 489-495Google Scholar,5Subramaniam S. Aalberg J.J. Soriano R.P. Divino C.M. New 5-factor modified frailty index using American College of Surgeons NSQIP data.J Am Coll Surg. 2018; 226: 173-181Google Scholar Biomarkers of frailty include low albumin levels,6Rich M.W. Keller A.J. Schechtman K.B. Marshall Jr., W.G. Kouchoukos N.T. Increased complications and prolonged hospital stay in elderly cardiac surgical patients with low serum albumin.Am J Cardiol. 1989; 63: 714-718Google Scholar sarcopenia with low creatinine levels,7Nascimento C.M. Ingles M. Salvador-Pascual A. Cominetti M.R. Gomez-Cabrera M.C. Viña J. Sarcopenia, frailty and their prevention by exercise.Free Radic Biol Med. 2019; 132: 42-49Google Scholar and reduced psoas muscle size,8Kondo Y. Suzuki T. Enomoto M. Takashima N. Kinoshita T. Psoas muscle size, possible sarcopenia and frailty, and long-term survival in elderly patients after isolated surgical aortic valve replacement for aortic stenosis.Indian J Thorac Cardiovasc Surg. 2022; 38: 134-141Google Scholar with most studies including older age as well. Thus, frailty is a gestalt: a “pattern of elements so unified as a whole that its properties cannot be derived from a simple summation of its parts.”1The American Heritage Dictionary of the English Language. 5th ed. Houghton Mifflin Harcourt, 2011Google Scholar Evidences of frailty have been associated with increased morbidity, prolonged postoperative length of stay, and mortality after cardiothoracic surgery.2Tang A. Ahmad U. Raja S. Rappaport J. Raymond D.P. Sudarshan M. et al.Looking beyond the eyeball test: a novel vitality index to predict recovery after esophagectomy.J Thorac Cardiovasc Surg. 2021; 161: 822-832Google Scholar,8Kondo Y. Suzuki T. Enomoto M. Takashima N. Kinoshita T. Psoas muscle size, possible sarcopenia and frailty, and long-term survival in elderly patients after isolated surgical aortic valve replacement for aortic stenosis.Indian J Thorac Cardiovasc Surg. 2022; 38: 134-141Google Scholar,9Kojima G. Iliffe S. Walters K. Frailty index as a predictor of mortality: a systematic review and meta-analysis.Age Ageing. 2018; 47: 193-200Google Scholar In this issue, Verwijmeren and colleagues,10Verwijmeren L. Noordzij P.G. Daeter E.J. Emmelot-Vonk M.H. Vernooij L.M. van Klei W.A. et al.Preoperative frailty and one-year functional recovery in elderly cardiac surgery patients.J Thorac Cardiovasc Surg. February 2, 2022; ([Epub ahead of print])Google Scholar primarily intensive care anesthesiologists collaborating with gerontologists and cardiac surgeons, join numerous investigators adding to an exponentially increasing literature about frailty (Figure 1). Unlike most studies, they attempt to link 11 variables they believe reflect frailty to 1-year postoperative patient-reported health-related quality of life (HRQoL) rather than to more familiar notions of weakness or fragility. To justify their approach, they pick cut points for 6 physical domain measures (that include nutrition and multipharmacy), 2 mental health measures, and 3 social domain variables to stratify patients aged 70 years and older as frail (n = 120) or nonfrail (n = 435). These groups are not very distinct (frailty domains in their Table 1 don't count), and we don't know whether patients' physicians and surgeons had a gestalt for whether those labeled frail appeared frail to them. How well did these metrics relate to change in HRQoL from preoperative assessment to 1-year postoperatively? Multipharmacy was weakly associated with lower HRQoL. Contrary to the authors' interpretation, worse nutritional status was associated with better physical health scores, but worse mobility was associated with worse physical health, as was living dependently. The same variables were associated with self-reported mental health. Importantly, but not recognized by Verwijmeren and colleagues, EuroSCORE (European System for Cardiac Operative Risk Evaluation), a surrogate for multicomorbidity, was associated with lower (worse) HRQoL scores. Note that the only statistics provided in the main paper relate to change in HRQoL from baseline to 1 year; the authors’ Table E5 shows the full model including the main effects. This shows, for example, that the apparent anomaly of grip strength not being statistically significant in terms of postoperative change is indeed associated with lower physical HRQoL both preoperatively and at 1 year, but with no change between. Self-reported HRQoL is a more challenging end point than hard clinical end points because it, like frailty, is multidimensional. Nevertheless, Verwijmeren and colleagues have added to the definition of frailty patients’ own perception of weakness and fragility. Preoperative frailty and one-year functional recovery in elderly cardiac surgery patientsThe Journal of Thoracic and Cardiovascular SurgeryPreviewFrailty increases risk for morbidity and mortality after cardiac surgery. Its influence on functional outcome is largely unknown. We studied the association of frailty with health-related quality of life and disability after cardiac surgery. Full-Text PDF