Frailty Impact during and after Pulmonary Rehabilitation

The impact of frailty on clinical outcomes among individuals with COPD: a systematic review and meta-analysis

BACKGROUND

Frailty is a prevalent and robust predictor of poor outcomes for older adults and those with chronic disease. We performed a systematic review and meta-analysis of the literature to understand the association between frailty and clinical outcomes for people with COPD.

METHODS

We searched MEDLINE, EMBASE, Cochrane Central, CINAHL, and Web of Science from inception to February 2022, for observational studies evaluating the association between frailty and clinical outcomes among individuals with COPD. Included studies defined COPD by spirometry, used a validated frailty assessment tool, and compared dyspnea, symptom burden, health related quality of life, exacerbations, hospitalization, or mortality between frail and non-frail individuals. Risk of bias was assessed using the Newcastle Ottawa Scale. Mean differences or hazard ratios were calculated using inverse variance (IV) methods, odds ratios were calculated using Mantel-Haenszel methods, and homogeneity was assessed using I 2 statistics. Results were pooled using a random effects model.

RESULTS

Of 1385 identified studies, 16 studies were included with 7 studies included in the meta-analyses, representing 5903 individuals. The Fried Frailty Phenotype instrument was used in 50% of included studies. When comparing frail vs. non-frail people with COPD, pooled estimates revealed frail people with COPD had higher dyspnea scores [modified Medical Research Council (mMRC) score standardized mean difference (95% CI): 1.67 (1.40-1.92), I 2 = 24%]; higher symptom burden [COPD Assessment Test (CAT) score mean difference (95% CI): 10.24 (8.30-12.17), I 2 = 31%]; more COPD exacerbations in the prior year [mean difference (95% CI): 1.09 (0.62-1.56), I 2 = 0%), and increased odds of being hospitalized in the previous year [OR (95% CI): 2.94 (1.57-5.50); I 2 = 0%]. The largest study with longest follow up period showed increased mortality risk among frail vs. non-frail individuals with COPD, [HR (95% CI): 1.83 (1.24-2.68)].

CONCLUSIONS

People with COPD and frailty experience increased dyspnea, symptom burden, exacerbation history, and hospitalizations compared to non-frail patients with COPD. Frailty is a robust predictor of outcomes among people with COPD and should be considered a treatable trait. Additional work is needed to standardize screening methods for frailty, and to understand the optimal timing of non-pharmacologic interventions to treat frailty among people with COPD.

PROSPERO REGISTRY ID

CRD42022329893.

Physical activity and sedentary behaviour interventions for people living with both frailty and multiple long-term conditions and their informal carers: a scoping review and stakeholder consultation

INTRODUCTION

This scoping review mapped evidence on physical activity (including structured exercise) and sedentary behaviour interventions (interventions to reduce sedentary behaviour) in people living with both frailty and multiple long-term conditions (MLTCs) and their informal carers.

METHODS

Ten databases and grey literature were searched from 2000 to October 2023. Two reviewers screened studies and one extracted data. Results were shared with three stakeholder groups (n = 21) in a consultation phase.

RESULTS

After screening, 155 papers from 144 studies (1 ongoing) were retained. The majority were randomised controlled trials (86, 55%). Participants' mean age was 73 ± 12 years, and 73% were of White ethnicity. MLTC and frailty measurement varied widely. Most participants were pre-to-moderately frail. Physical health conditions predominated over mental health conditions.Interventions focused on structured exercise (83 studies, 60%) or combined interventions (55 studies, 39%). Two (1%) and one (0.7%) focused solely on habitual physical activity or sedentary behaviour. Adherence was 81% (interquartile range 62%-89%) with goal setting, monitoring and support important to adherence. Carers were only involved in 15 (11%) studies. Most interventions reported positive outcomes, primarily focusing on body functions and structures.

CONCLUSIONS

A modest volume of evidence exists on multicomponent structured exercise interventions, with less focus on habitual physical activity and sedentary behaviour. Interventions report largely positive effects, but an updated systematic review is required. The field could be advanced by more rigorous characterisation of MLTCs, socioeconomic status and ethnicity, increased informal carer involvement and further evaluation of habitual physical activity and sedentary behaviour interventions.

Frailty and Exacerbation of Chronic Obstructive Pulmonary Disease: Is There Any Association?

Purpose

This study investigated if individuals with chronic obstructive pulmonary disease (COPD) and frailty are more likely to have acute exacerbations of COPD or require hospitalization for exacerbation than those without frailty.

Patients and Methods

Data on 135 outpatients with stable COPD were analyzed with the Cox proportional hazards model to assess the risk of future events. The Kihon Checklist was administered at baseline to classify the participants as robust, pre-frail, or frail. The follow-up period was a maximum of six and a half years.

Results

In all, 76 patients (56.3%) experienced an exacerbation and 46 (34.1%) were hospitalized due to it. Multivariate Cox proportional hazards analysis that accounted for FEV1 and sex showed that the frail group was more likely to face future risks of COPD exacerbations [Hazard ratio 1.762 (95% CI 1.011-3.070), p=0.046] and hospitalizations for exacerbation [2.238 (1.073-4.667), p=0.032] than the robust group. No significant differences were observed when comparing robust patients to those who were pre-frail or pre-frail to frail either in exacerbations or hospitalizations. When comparing the C-indices for frailty and FEV1, the former index (exacerbation 0.591 and hospitalization 0.663) did not exceed the latter (0.663 and 0.769) in either analysis.

Conclusion

Frail COPD patients have a more unfavorable future risk of acute exacerbations of COPD and hospitalizations for exacerbation than robust patients. However, no significant differences were observed when comparing robust patients to those who were pre-frail or pre-frail to frail, suggesting that the future risk for COPD patients with frailty is only higher compared to those who are considered robust. Additionally, FEV1 was found to be a more reliable predictor of future events than measures of frailty.

Effects of Ninjin'yoeito on Patients with Chronic Obstructive Pulmonary Disease and Comorbid Frailty and Sarcopenia: A Preliminary Open-Label Randomized Controlled Trial

Purpose

To present the preliminarily findings regarding the effects of a herbal medicine, Ninjin'yoeito, on comorbid frailty and sarcopenia in patients with chronic obstructive pulmonary disease (COPD).

Patients and Methods

Patients with COPD (GOLD II or higher) and fatigue were randomly assigned to Group A (n = 28; no medication for 12 weeks, followed by 12-week administration) or B (n= 25; 24-week continuous administration). Visual analog scale (VAS) symptoms of fatigue, the COPD assessment test (CAT), and the modified Medical Research Council (mMRC) Dyspnea Scale were examined. Physical indices such asknee extension leg strength and walking speed, skeletal muscle mass index (SMI), and respiratory function test were also measured.

Results

VAS fatigue scales in Group B significantly improved after 4, 8, and 12 weeks compared to those in Group A (each p<0.001, respectively). Right and left knee extension leg strength in Group B significantly improved after 12 weeks compared to that in Group A (p=0.042 and p=0.037, respectively). The 1-s walking speed for continued to increase significantly over 24 weeks in Group B (p=0.016, p<0.001, p<0.001, p=0.004, p<0.001, and p<0.001 after 4, 8, 12, 16, 20, and 24 weeks, respectively); it also significantly increased after the administration of Ninjin'yoeito in Group A. In Group B, the SMI significantly increased at 12 weeks in patients with sarcopenia (p=0.025). The CAT scores in Group B significantly improved after 12 weeks compared to those in Group A (p=0.006). The mMRC scores in Group B also significantly improved after 8 and 12 weeks compared to those in Group A (p= 0.045 and p <0.001, respectively). The changes in %FEV1.0 in Group B were significantly improved at 12 and 24 weeks (p=0.039 and p=0.036, respectively).

Conclusion

Overall, Ninjin'yoeito significantly improved patients' quality of life, physical activity, muscle mass, and possibly lung function, suggesting that Ninjin'yoeito may improve frailty and sarcopenia in patients with COPD.

Impact of Frailty on Symptom Burden in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD), the sixth leading cause of death in the United States in 2022 and the third leading cause of death in England and Wales in 2022, is associated with high symptom burden, particularly dyspnoea. Frailty is a complex clinical syndrome associated with an increased vulnerability to adverse health outcomes. The aim of this review was to explore the current evidence of the influence of frailty on symptoms in patients with a confirmed diagnosis of COPD according to GOLD guidelines. Fourteen studies report a positive association between frailty and symptoms, including dyspnoea, assessed with the COPD Assessment Test (CAT) and the modified Medical Research Council (mMRC) scale. Data were analysed in a pooled a random-effects meta-analysis of mean differences (MDs). There was an association between COPD patients living with frailty and increased CAT score versus COPD patients without frailty [pooled SMD, 1.79 (95% CI 0.72-2.87); I2 = 99%]. A lower association was found between frailty and dyspnoea measured by the mMRC scale versus COPD patients without frailty [pooled SMD, 1.91 (95% CI 1.15-2.66); I2 = 98%]. The prevalence of frailty ranged from 8.8% to 82% and that of pre-frailty from 30.4% to 73.7% in people living with COPD. The available evidence supports the role of frailty in worsening symptom burden in COPD patients living with frailty. The review shows that frailty is common in patients with COPD. Future research is needed to have further details related to the data from CAT to improve our knowledge of the frailty impact in this population.

Frailty and its influence on mortality and morbidity in COPD: A Systematic Review and Meta-Analysis

Frailty increases vulnerability to adverse outcomes. Long-term conditions increase the risk of frailty. We searched PubMed, Web of Science, The Cochrane Library, EMBASE from inception to March 2022. Quality assessment was conducted using the NOS. Data was analysed in a pooled a random-effects meta-analysis. Our primary outcome was the impact of frailty on mortality in adults with Chronic Obstructive Pulmonary Disease (COPD) diagnosis according to the guidelines. Secondary outcomes were: frailty and association with readmissions, hospitalisations, exacerbation rates, and prevalence of frailty in COPD. We identified 25 studies, with 5882 participants. The median prevalence of frailty was 47% (IQR, 39.3-66.3%, range 6.4-72%). There was an association between COPD patients living with frailty and increased risk of mortality versus COPD patients without frailty (pooled OR, 4.21 (95% CI 2.99-5.93, I2 55%). A descriptive analysis of relationship between frailty and hospital readmission and all cause hospitalization showed positive associations. The relationship between frailty and the risk of exacerbation showed a pooled OR, 1.45 (95% CI 0.37-5.70, I2 80%). Frailty is significantly associated with higher mortality risk in COPD. Frailty is common in patients with COPD and its measurement should be considered in clinical practice to better characterise COPD.

Prevalence and risk factors of frailty in patients with chronic obstructive pulmonary disease: systematic review and meta-analysis

OBJECTIVE

To systematically review the prevalence and risk factors for frailty in patients with chronic obstructive pulmonary disease (COPD).

METHODS

A systematic review and meta-analysis were conducted, and a search of the PubMed, Embase and Web of Science databases was carried out to collect Chinese and English studies on frailty and COPD published up to September 5, 2022.

RESULTS

A total of 38 articles were included for the quantitative analysis after the collected literature was either included or omitted based on pertinent criteria. The results indicated that the estimated overall pooled prevalence of frailty was 36% (95% confidence interval [CI] = 31-41%), and the estimated pre-frailty was 43% (95% CI = 37-49%). A higher age (odds ratio [OR] = 1.04; 95% CI = 1.01-1.06) and higher COPD assessment test (CAT) score (OR = 1.19; 95% CI = 1.12-1.27) were associated with a significantly increased likelihood of frailty in patients with COPD. However, a higher educational attainment (OR = 0.55; 95% CI = 0.43-0.69) and higher income (OR = 0.63; 95% CI = 0.45-0.88) were associated with a significantly reduced risk of frailty in patients with COPD. A total of 17 other risk factors for frailty were identified via qualitative synthesis.

CONCLUSION

The incidence of frailty in patients with COPD is high, and there are many influencing factors.

European Respiratory Society statement on frailty in adults with chronic lung disease

Frailty is a complex, multidimensional syndrome characterised by a loss of physiological reserves that increases a person's susceptibility to adverse health outcomes. Most knowledge regarding frailty originates from geriatric medicine; however, awareness of its importance as a treatable trait for people with chronic respiratory disease (including asthma, COPD and interstitial lung disease) is emerging. A clearer understanding of frailty and its impact in chronic respiratory disease is a prerequisite to optimise clinical management in the future. This unmet need underpins the rationale for undertaking the present work. This European Respiratory Society statement synthesises current evidence and clinical insights from international experts and people affected by chronic respiratory conditions regarding frailty in adults with chronic respiratory disease. The scope includes coverage of frailty within international respiratory guidelines, prevalence and risk factors, review of clinical management options (including comprehensive geriatric care, rehabilitation, nutrition, pharmacological and psychological therapies) and identification of evidence gaps to inform future priority areas of research. Frailty is underrepresented in international respiratory guidelines, despite being common and related to increased hospitalisation and mortality. Validated screening instruments can detect frailty to prompt comprehensive assessment and personalised clinical management. Clinical trials targeting people with chronic respiratory disease and frailty are needed.

Sarcoidosis and frailty: recognizing factors that foster holistic resilience

PURPOSE OF REVIEW

Sarcoidosis is a multiorgan system disease exerting significant impact on biophysical, social, psychological and emotional well-being. Mortality and disability correlate to accessible, timely, expert care for sarcoidosis and its related complications. Across health conditions, positive healthcare interactions and interventions can rehabilitate unfavourable factors tied to concepts of 'frailty'. Here, we set out to introduce concepts related to frailty and their impact in the context of sarcoidosis.

RECENT FINDINGS

Studies examining frailty across other multiorgan and single organ-based diseases that mirror organ involvement in sarcoidosis demonstrate findings that bear relevance in sarcoidosis. Namely, factors predisposing a person to frailty are a multifactorial phenomenon which are also reflected in the lived experience of sarcoidosis; and that early diagnosis, intervention and prevention may alter a course towards more favourable health outcomes.

SUMMARY

Factors predisposing to frailty in other health conditions may also signal a risk in sarcoidosis. In turn, proactive health preservation - regardless of age - may lead to improved biopsychosocial reserve and health-related quality of life. Fortifying holistic resilience in sarcoidosis is anticipated to reduce risk of the occurrence and prolongation of health-related complications, and facilitate swifter recovery from biophysical complications as well as from psychosocial and emotional stressors.

Prevalence and clinical impact of frailty in COPD: a systematic review and meta-analysis

BACKGROUND

Frailty has been increasingly identified as a risk factor of adverse outcomes in chronic obstructive pulmonary disease (COPD). The prevalence and impact of frailty on health outcomes in people with COPD require clarification.

METHODS

PubMed, Embase, The Cochrane Library and Web of Science (January 1, 2002, to July 1, 2022) were comprehensively searched to identify studies related to frailty and COPD. Comparisons were made between people who did and did not have frailty for pulmonary function, dyspnea severity, 6-minute walking distance, activities of daily life, and mortality.

RESULTS

Twenty studies (9 cross-sectional, 10 cohort studies,1 clinical trial) from Europe (9), Asia (6), and North and South America (4), Oceania (1) involving 11, 620 participants were included. The prevalence of frailty was 32.07% (95% confidence interval (CI) 26.64-37.49) with a range of 6.43-71.70% based on the frailty tool used. People with frailty had lower predicted forced expiratory volume in the first second (mean difference - 5.06%; 95%CI -6.70 to -3.42%), shorter 6-minute walking distance (mean difference - 90.23 m; 95%CI -124.70 to -55.76), poorer activities of daily life (standardized mean difference - 0.99; 95%CI -1.35 to -0.62), higher CAT(COPD Assessment Test) score(mean difference 6.2; 95%CI 4.43 to 7.96) and mMRC (modified Medical Research Council) grade (mean difference 0.93; 95%CI 0.85 to 1.02) compared with those who did not (P < 0.001 for all). Meta-analysis showed that frailty was associated with an increased risk of long-term all-cause mortality (HR 1.68; 95% CI 1.37-2.05; I² = 0%, P < 0.001).

CONCLUSION

Frailty is prevalent in people with COPD and linked with negative clinical outcomes including pulmonary function, dyspnea severity, exercise capacity, quality of life and mortality.

Prevalence and assessment of frailty in interstitial lung disease - a systematic review and meta-analysis

BACKGROUND

Frailty is a multisystem dysregulation that challenges homeostasis and increases vulnerability towards stressors. In patients with interstitial lung diseases (ILD) frailty is associated with poorer lung function, greater physical impairment, and higher symptom burden. Our understanding of the prevalence of frailty in ILD and consequently its impact on the ILD population is limited.

OBJECTIVE AND METHODS

We aimed to systematically review frailty assessment tools and to determine frailty prevalence across different ILD cohorts. Meta-analyses were used to calculate the pooled prevalence of frailty in the ILD population.

RESULTS

We identified 26 studies (15 full-texts, 11 conference abstracts) including a total of 4614 patients with ILD. The most commonly used frailty assessment tools were the Fried Frailty Phenotype (FFP), the Short Physical Performance Battery (SPPB), and the cumulative Frailty Index (FI). Data allowed for meta-analyses of FFP and SPPB prevalence. The pooled prevalence of frailty was 35% (95% CI 25%-45%) by FFP, and 19% (95% CI 12%-28%) by SPPB.

CONCLUSIONS

Frailty is common in ILD, with considerable variability of frailty prevalence depending on the frailty assessment tool used. These findings highlight the importance of frailty in ILD and the need for a standardized approach to frailty assessment in this population.

Closing the Gap between Inpatient and Outpatient Settings: Integrating Pulmonary Rehabilitation and Technological Advances in the Comprehensive Management of Frail Patients

Pulmonary rehabilitation (PR) is a well-established intervention supported by strong evidence that is used to treat patients affected by chronic respiratory diseases. However, several barriers still affect its spreading in rehabilitation clinical practices. Although chronic respiratory diseases are common age-related disorders, there is still a gap of knowledge regarding the implementation of sustainable strategies integrating PR in the rehabilitation management of frail patients at high risk of respiratory complications. Therefore, in the present study, we characterized the effects of PR in frail patients, highlighting the evidence supporting its role in improving the complex rehabilitative management of these patients. Moreover, we propose a novel organizational model promoting PR programs for frail patients in both inpatient and outpatient settings. Our model emphasizes the role of interdisciplinary care, specifically tailored to patients and environmental characteristics. In this scenario, cutting-edge technology and telemedicine solutions might be implemented as safe and sustainable strategies filling the gap between inpatient and outpatient settings. Future research should focus on large-scale sustainable interventions to improve the quality of life and global health of frail patients. Moreover, evidence-based therapeutic paths should be promoted and taught in training courses promoting multiprofessional PR knowledge to increase awareness and better address its delivery in frail patients.