Interventions for Frailty Among Older Adults With Cardiovascular Disease

JACC State-of-the-Art Review

Naila Ijaz, MD; Brian Buta, MHS; Qian-Li Xue, PHD; Denise T. Mohess, MD; Archana Bushan, MD; Henry Tran, MD; Wayne Batchelor, MD, MHS; Christopher R. deFilippi, MD; Jeremy D. Walston, MD; Karen Bandeen-Roche, PHD; Daniel E. Forman, MD; Jon R. Resar, MD; Christopher M. O'Connor, MD; Gary Gerstenblith, MD; Abdulla A. Damluji, MD, PHD


J Am Coll Cardiol. 2022;79(5):482-503. 

In This Article

Abstract and Introduction


With the aging of the world's population, a large proportion of patients seen in cardiovascular practice are older adults, but many patients also exhibit signs of physical frailty. Cardiovascular disease and frailty are interdependent and have the same physiological underpinning that predisposes to the progression of both disease processes. Frailty can be defined as a phenomenon of increased vulnerability to stressors due to decreased physiological reserves in older patients and thus leads to poor clinical outcomes after cardiovascular insults. There are various pathophysiologic mechanisms for the development of frailty: cognitive decline, physical inactivity, poor nutrition, and lack of social supports; these risk factors provide opportunity for various types of interventions that aim to prevent, improve, or reverse the development of frailty syndrome in the context of cardiovascular disease. There is no compelling study demonstrating a successful intervention to improve a global measure of frailty. Emerging data from patients admitted with heart failure indicate that interventions associated with positive outcomes on frailty and physical function are multidimensional and include tailored cardiac rehabilitation. Contemporary cardiovascular practice should actively identify patients with physical frailty who could benefit from frailty interventions and aim to deliver these therapies in a patient-centered model to optimize quality of life, particularly after cardiovascular interventions.


In the United States, as in the rest of the developed world, there is a rapidly growing older adult population, with adults 65 years or older composing 16.5% of the population in 2019.[1] This figure is projected to increase to 20.3% by 2030, when all baby boomers reach 65 years of age. By 2034, older adults will outnumber children, and nearly 1 in 4 Americans will be older than 65 years by 2060.[2] This has many implications for the practice of cardiovascular medicine because older adults are disproportionately affected by cardiovascular disease (CVD). The prevalence of CVD increases with age, and outcomes are more detrimental for those older than 75 years with coexisting geriatric syndromes.[3] Between 2015 and 2018, the prevalence of CVD was 75% to 77% in those 60 to 79 years of age and 89% to 90% in those 80 years and older.[4] Very old patients have a higher mortality rate[5] and greater risk for disability after hospitalizations.[6] They are also more likely to have longer lengths of hospital stay and are less likely to be discharged back to their original places of residence.[4] This phenomenon of increased vulnerability to stressors because of decreased physiological reserves in older adults is termed frailty, which has recently gained great interest from cardiologists because of the changing demographics of the U.S. population.[7]

Frailty syndrome has been described over a spectrum ranging from the absence of frailty, termed robust, to prefrail, and then physically frail.[8] The prefrail state increases the risk for progression to frailty, and frailty increases the risk for disability, a state that is distinct from frailty.[9] Depending on the instrument used to assess for frailty, the prevalence of frailty among community-dwelling older adults ranges from 4.0% to 59.1%, and the prevalence of prefrailty ranges from 18.7% to 53.1%,[10] but the highest estimates are observed among older patients with CVD. There is a strong bidirectional association between CVD and frailty, with a dose-dependent response seen from robust to frail. Prefrailty and frailty are independently associated with a higher risk for developing CVD.[11]

The hospital environment, with immobilization, fasting, sleep deprivation, and disorientation, can dramatically worsen physical frailty with rapid, severe loss of muscle mass and function. The result is "posthospital syndrome," with high rates of rehospitalization, mortality, and nursing home admissions; prolonged physical disability; poor quality of life; and high health care costs.[12] Thus, interventions aimed at preventing, delaying, or reversing frailty may influence cardiovascular health in older patients. In this state-of-the-art review, we discuss the various definitions of frailty, the instruments used to measure frailty in practice, and proposed interventions to prevent, reverse, or slow the progression of frailty in patients with CVD.