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The inclusion of frailty in the assessment and management of cardiovascular disease patients is a “no brainer, said Daniel E. Forman, MD, at the 2016 AHA Conference.
Many doctors assume that older patients with cardiovascular disease (CVD) who are frail are not good candidates for cardiac rehabilitation. “More likely the opposite is true,” said Daniel E. Forman, MD, professor of medicine for the Divisions of Geriatric Medicine and Cardiology in the University of Pittsburgh’s Department of Medicine in Pennsylvania.
“It is more common for doctors to refer relatively robust patients to cardiac rehabilitation, but to avoid it when they are frail,” said Forman during a session entitled “Tailoring Cardiac Rehabilitation to the Frail Elderly” during the 2016 American Heart Association (AHA) Scientific Sessions in a session. But he emphasized that “frail patients often derive the most benefit” and thereby are better able to “maintain impendence, physical function and quality of life despite CVD and hospitalizations.”
In his talk, Forman spoke on the importance of including physical frailty as a risk factor when assessing patients with CVD for cardiac rehabilitation. “Frailty predisposes to poor medical outcomes and loss of independence,” he said. Trained in both cardiology and geriatrics, Forman helped develop a novel cardiac rehabilitation program at the Veterans Administration Pittsburgh Healthcare System that broadens cardiac rehabilitation to include frailty.
“What we’ve done is to acknowledge that frailty is intertwined with cardiac disease in adults,” he said. “There is a robust physiological insight that shows how inflammation underlying cardiac disease overlaps with the mechanisms that also predispose to a phenotype of physical frailty.”
Forman described physical frailty as a loss of lean muscle mass as well as speed of movement, weakening, fatigability and diminished activity that are typical among many older people struggling with CVD.
The intertwining of frailty and CVD is particularly magnified, he said, in respect to patients who are hospitalized. Often these patients become more disabled while in the hospital, even if the incident CVD is treated successfully, and they either do poorly at home or go to a nursing home, and many are soon re-hospitalized for non-cardiovascular issues. “Frailty essentially exacerbates vulnerability to poor short- and long-term outcomes,” Forman said.
Forman asserted that cardiac rehabilitation can moderate frailty in these patients, and he emphasized the value of a holistic perspective of what predisposes patients to CVD risk. “When people say risk factors for cardiac rehabilitation, they often talk about ejection fraction, cholesterol or tobacco history,” he said. “We agree with that, but also with the need to address other dimensions of the patient.”
Along with the traditional precepts of cardiac rehabilitation to achieve risk factor reduction, aerobic exercise and education, Forman and his colleagues have added strength and balance as key training goals for frail patients.
In addition, Forman said they also assess for and address cognitive impairments that are sometimes associated with frailty. One critical component in their program is the development of instructions and reinforcements geared toward patients with cognitive deficits.
Although the cardiac rehabilitation program at Veterans Administration Pittsburgh Healthcare System is only one year old, Forman said that pre/post data on over 70 patients show that the patients who are frail benefit the most from the program compared to patients who are not frail with proportionately greater improvements in strength, speed and balance.
Another powerful measure of the benefit of cardiac rehabilitation in frail patients, Forman said, is the measure of confidence that patients feel in their daily activities (e.g., questions like “Do you feel safe walking up the driveway or walking to the grocery store?”). “Everyone [in cardiac rehabilitation] benefits,” said Forman, “but the benefit relative to initial impairment is greater in patients who are frail.”
Overall, Forman says that he thinks the inclusion of frailty in the assessment and management of CVD patients is a “no brainer” and anticipates that it will become a component of other cardiac rehabilitation programs.
He emphasized that cardiac rehabilitation is a vital part of overall cardiovascular care for frail adults, and it plays a key role in enabling vulnerable patients to regain capacities to manage their activities of daily living, and to reduce chances of rehospitalization.