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).

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) 2018), 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 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 pulmonary rehabilitation to minimise the development and impact of frailty on patients and carers as well as health and social care services.