Using frailty measures and patient-centered outcomes to help guide clinical decision making
Imagine, for a moment, that you are a cardiologist. Across from you is an 80-year-old woman. She has been experiencing chest pain, shortness of breath, and fatigue that are impacting her daily activities. Although the pain is manageable, she is unable to keep up with her husband and grandkids and has had to give up her favorite pastime, painting, because she can no longer grip the brushes.
After listening to her heart and running tests, you determine that her aortic valve has narrowed, limiting the amount of blood flowing from her heart to the rest of the body. Your patient is among the more than one in eight people aged 75 and older who suffer from moderate or severe aortic valve stenosis.
Like many elderly individuals with cardiovascular disease, she is considered “frail,” a geriatric condition that can be demonstrated by weak grip strength, slow walking speed, self-reported low endurance and energy, unintended weight loss of 10 lbs. or more in the prior year, and low physical activity.
Valve replacement surgery is an option, but her frailty means she has a greater risk for complications such as longer hospital stay, re-hospitalization and even death.
The Complexity of Clinical Decision Making
Your mind is flooded with questions.
How much benefit will surgery have on her physical and mental health, well-being and quality of life? Do the benefits outweigh the risks? Even if the surgery goes well, does her husband or another family member have the ability to become her caretaker so that she can remain in her home for what will likely be a difficult year ahead?
Frailty Measures and Patient-Centered Outcomes as Tools to Guide Clinical Decision Making
Mayo Clinic researchers recognize the enormity and complexity of the decision to recommend valve replacement surgery for older adults with aortic valve stenosis.
Nathan LeBrasseur, Ph.D., director of the Healthy Aging and Independent Living program at Mayo Clinic Robert and Arlene Kogod Center on Aging, considers frailty measures and patient-centered outcomes useful tools to help guide clinical decision making. In a recent study, Dr. LeBrasseur and colleagues from across the institution examined the extent to which patient-centered outcomes – physical and mental health, well-being, and quality of life – compare between frail and non-frail individuals with aortic valve stenosis before and after valve replacement surgery. They found that individuals deemed frail prior to surgery demonstrated greater benefit than their non-frail peers.
In the study, published in The Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, the research team performed frailty measures in individuals between the ages of 69 and 89 who were diagnosed with severe aortic stenosis and required surgery.
Researchers also gathered and reviewed patient-reported measures of health, well-being, and quality of life before surgery and then again three months after surgery. Out of the 103 participants, 54 were deemed frail. Frail participants had lower baseline measures of physical and mental health, physical well-being, and quality of life than non-frail participants prior to surgery.
At follow-up, frail participants showed significant improvement in physical function, with functional capacity and physical health measures improving by 50 percent and 14 percent, respectively. Individuals who were not frail did not improve significantly in these same measures. Further, frail individuals showed greater improvement than non-frail individuals in mental health measures, physical well-being, and quality of life.
Future Opportunity to Minimize Risk and Optimize Surgical Outcomes for Frail Individuals
These data show that compromised physical health, well-being, and quality of life were meaningfully improved by valve replacement surgery in higher-risk older adults and that frailty criteria was a helpful tool in identifying higher-risk surgical candidates.
While this information alone is helpful in the clinical decision making process, Dr. LeBrasseur believes that there are additional opportunities to minimize the risk and optimize outcomes for frail individuals with severe aortic valve stenosis. Further research is needed, but future strategies could include “prehabilitiation” measures such as exercise, diet and drugs before surgery, as well as innovative care plans for patients to transition home.
– Megan Forliti, April 10, 2017