O7.4 Frailty in COPD

Frailty is a loss of resilience which means people affected may be physically or mentally vulnerable and less able to recover quickly after illness or a stressful event (Clegg 2013). A consequence is that frail persons have decreased function, health status and require additional health and social care (Roe 2017).

Frailty can be assessed in a number of ways including a phenotypic approach or by noting the accumulation of deficits. The phenotypic approach is defined by the presence of three or more of the following five criteria: unintentional weight loss, self-reported exhaustion, weakness, slow gait speed, and low energy expenditure (Fried 2001). Alternatively, the accumulation of deficit approach is based counting the number of symptoms, diseases, conditions, and disability, which are used to calculate a frailty index (Rockwood 2005), with higher scores indicating more frailty.

Frailty affects older people and particularly those with chronic conditions such as COPD.  Although there is no unified definition of frailty, a number of studies have demonstrated increased frailty in COPD using different measurement tools including those based on phenotypes (Lahousse 2016b) or accumulation of deficits (Gale 2018). A systematic review of frailty in COPD including 27 studies demonstrated from pooled data that 19% of patients were frail and 56% were pre-frail. Overall, patients with COPD have double the risk of becoming frail and frailty has been associated with poorer lung function and reduced health status, increased length of stay following exacerbations (Bernabeu-Mora 2017) and increased mortality (Galizia 2011). An additional meta-analysis (Hanlon 2023) [evidence level I] on frailty, again highlighted the high prevalence of frailty in people with COPD, according to a range of frailty measures, associated with a clinically significantly increased risk of adverse outcomes. Proactive identification of frailty can identify candidates for targeted intervention such as pulmonary rehabilitation, with evidence of frailty reduction in at least one study when participants completed a programme (Maddocks 2016).

A multicentre retrospective cohort study was conducted involving adult patients admitted to Australian and New Zealand ICUs with a primary diagnosis of an exacerbation of COPD. Patients were assessed for frailty using the Clinical Frailty Scale (CFS). The primary outcome was survival up to four years after the ICU admission. Of 7,126 patients included in this analysis over half (54.1%, n=3,859) were living with frailty. Those with frailty were more likely to be female, were older, had a lower BMI and increased rates of, and more severe comorbidities. Mortality in the not-frail versus frail group at one and four years was 19.8% versus 40.4%, and 56.8% versus 77.3% respectively (p<0.001). At four years the median survival was significantly shorter for those with frailty (adjusted HR 1.66; 95% CI 1.54 to 1.80). These data highlight the importance of recognising frailty in COPD and implementing treatment strategies (Donnan 2023) [evidence level III-2].

The mechanism underlying increased frailty in COPD is likely to be multifactorial. COPD affects older adults in whom other health conditions are more prevalent. In addition, COPD is associated with inflammation that affects multiple body systems (Vanfleteren 2013), increased exacerbations, as well as lifestyle factors such as smoking and reduced physical activity (Global Initiative for Chronic Obstructive Lung Disease [GOLD] 2024), all of which may increase risk of frailty.

Although frailty can be difficult to manage, there is evidence from systematic reviews that exercise can be beneficial for physical functioning, cognitive and psychological wellbeing in frail older adults (Silva 2017). In addition, in older adults with frailty, multifactorial interventions including exercise and nutritional support can minimise physical decline and can be cost effective for health care providers (Apostolo 2018). In frail patients with COPD hospitalised for an acute exacerbation, exercise resulted in improvements in strength and balance (Torres-Sanchez 2017). Frail patients with COPD have also been shown to benefit from pulmonary rehabilitation with improvements in breathlessness, exercise performance, physical activity level and health status (Maddocks 2016). However, frail patients were twice as likely to not complete pulmonary rehabilitation. Given that smoking is a predictor of frailty (Kojima 2015) and patients with frequent exacerbations have increased risk of frailty (Lahousse 2016b), smoking cessation as well as minimisation of exacerbations are additional key therapeutic targets in COPD.

In a retrospective cohort study using publicly available Health and Retirement Study data frailty prevalence measures such as BODE and Fried indices, were substantially higher in COPD than in those without COPD. Prevalence of frailty among those aged 50–64 years using the Fried index was 7.5%, and 11.0% for age ≥65.  These measures identified patients with increased risk of poor outcomes including more than doubling of mortality, as well as increased hospital admissions and nursing home placement over the following 2 years (Roberts 2022) [evidence level III]. A study of 1,162 participants with COPD and 3,465 participants without COPD by Lee et al (2022) also supported the use of a bundle of physical frailty measurements in addition to lung function and dyspnoea scores in multidimensional evaluation of COPD. The addition of frailty measures highlighted the associations with the inability to perform daily tasks and mortality [evidence level III-2].

In summary, frailty is common in COPD and associated with poorer health outcomes, hospital admissions and failure to complete pulmonary rehabilitation. Measuring frailty is useful in COPD and may identify vulnerable patients and allow earlier interventions such as comprehensive medical or geriatric review and pulmonary rehabilitation to minimise the development and impact of frailty on patients and carers as well as health and social care services.