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European Journal of Heart Failure 2005 7(5):798-802; doi:10.1016/j.ejheart.2004.09.015
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© 2004 European Society of Cardiology

Sex and age differences in fragility in a heart failure population

Salvador Altimir, Josep Lupón*, Beatriz González, Montserrat Prats, Teresa Parajín, Agustín Urrutia, Ramon Coll and Vicente Valle

Unitat d'lInsuficiéncia Cardíaca, Servei de Cardiología Hospital Universitari Germans Trias i Pujol, Carretera del canyet s/n, 08916 Badalona, Spain

* Corresponding author. Tel.: +34 934978996; fax: +34 934978772. E-mail address: jlupon{at}ns.hugtip.scs.es


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Limitations
 6. Conclusions
 References
 
Background: Heart failure (HF) patients have a high degree of fragility and dependence from physical, cognitive and psychological points of view, and are a mainly geriatric population.

Aim: To detect the existence of fragility in all patients treated in a Heart Failure Unit and to evaluate age and sex differences.

Methods: All patients underwent a basic geriatric evaluation to detect possible loss of autonomy for doing basic and instrumental activities, cognitive deterioration, emotional disturbance or social risk.

Results: Three hundred sixty patients (mean age 65.2 years, 41.7% ≥70 years, 27.5% women) were evaluated. Fragility was detected in 41.7% of patients, being more prevalent in patients ≥70 years (p<0.001) and in women (p<0.001). A Barthel Index <90 was found in 22.5% of patients and an anomalous OARS Scale was found in 18.3%. Pfeiffer test's score was abnormal in 7.8% of patients. A positive depression response in abbreviate GDS was observed in 29.7%. All items analysed were more prevalent in patients ≥70 years and in women, with the unexpected exception of depression symptoms that were as prevalent in younger as in older patients.

Conclusion: Fragility is common in patients with heart failure, even in younger patients, and can be detected easily using standardised geriatric scales. Prevalence of fragility was significantly higher in older patients and in women, although the presence of depression symptoms was as prevalent in younger as in older patients.

Key Words: Heart failure • Fragility • Age • Gender • Geriatric evaluation

Received October 5, 2003; Revised September 7, 2004; Accepted September 20, 2004


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 5. Limitations
 6. Conclusions
 References
 
Heart failure (HF) is a major public health problem in industrialised countries [1,2] and will probably become an even greater problem in the next few years, given that the prevalence and incidence are growing [3] due to progressive ageing of the population and increased survival of patients with myocardial infarction and hypertension, two of the main aetiologies of HF. The prevalence of HF in the general population is 0.3–2%, but it can reach 3–8% in people older than 65 years and 8–17% in people older than 70 years [1,2]. This elderly population is characterised by having a high degree of fragility and dependence from a physical, cognitive and psychological point of view. Even younger people with HF may show a high degree of fragility and dependence [4], which makes their treatment more difficult and thus noncompliance is quite frequent. Detection of this fragility and dependence should allow identification of those patients who might benefit from a more exhaustive geriatric evaluation and a subsequent specific intervention.

The aim of this study was to detect the existence of fragility in all patients treated in a multidisciplinary HF Unit and to evaluate the differences in fragility between men and women and between younger and older patients.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 5. Limitations
 6. Conclusions
 References
 
We initiated a multidisciplinary HF Unit in a tertiary hospital in August 2001. The HF Unit is run by a specialised nurse, a cardiologist, an internist, a family physician, a geriatrician, a psychiatrist and a rehabilitation physician.

During the first visit at the HF Unit, all patients underwent a basic geriatric evaluation with the nurse to detect possible loss of autonomy for doing basic and instrumental activities, cognitive deterioration, emotional disturbance or social risk. This evaluation consisted of several tests and used standardised geriatric scales:

  • Barthel Index [5]: evaluates dependence on basic activities of daily living (range 0–100).
  • OARS Scale [6]: evaluates autonomy in daily living instrumental activities (range 0–14).
  • The Pfeiffer Test [7]: evaluates cognitive function (range 0–10).
  • To identify possible emotional problems, a Yesavage abbreviated Geriatric Depression Scale (GDS) was used [8].
  • A basic social interview.

Patients that fulfilled predefined criteria (Barthel <90; OARS score <10 in women and <6 in men; Pfeiffer Test score >3±1 depending on educational level; a positive depression response in abbreviated GDS (one positive response out of four questions); and nobody to turn to for help) were considered to have fragility for the purpose of the study, although some patients could be considered disabled rather than frail from the strict point of view. These patients were then submitted to a more exhaustive geriatric evaluation and to a subsequent specific intervention. OARS score was considered differently for men and women due to the existence of marked cultural environmental differences, as has been recommended by other authors [9], all patients that fulfilled the above-mentioned criteria were considered.

We analysed the relationship between fragility and the following clinical variables: age, sex, aetiology, the presence of anemia, diabetes or renal failure, and the number of hospitalisations last year. After analysis of the global results, we compared the test results by age (≥70 years vs. <70 years) and by sex (men vs. women). Statistical analysis was performed using SPSS 10.0 pack for Windows. Two-sided p<0.05 was required for statistical significance. The {chi}2 test was used for age and sex differences in fragility and for the analysis of their different components. The t-test was used to compare age between sexes. A logistic regression multivariate analysis was performed using fragility as the dependent variable; those variables with significance in the univariate analysis have been included and the backward method has been used. Finally, another logistic regression multivariate analysis including age, sex and also the interaction term agexsex was performed to ascertain if age and sex had a totally independent relationship with fragility.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 5. Limitations
 6. Conclusions
 References
 
Three hundred and sixty patients with a mean age of 65.2±10.9 years were evaluated, 261 men and 99 (27.5%) women. One hundred and fifty (41.7%) were ≥70 years old. Demographic characteristics of patients are summarised in Table 1. Fragility was detected in 41.7% of patients, being more prevalent in patients ≥70 years (53.3% vs. 33.3%, p<0.001) and in women (62.6% vs. 33.7%, p<0.001), as is shown in Table 2. The results obtained in the different tests/scales are shown in Tables 3 and 4. Age (Table 3) and sex (Table 4) differences are evident. A Barthel Index <90 was found in 22.5% of patients, being more prevalent in older patients (39.3% vs. 10.5%, p<0.001) and in women (35.4% vs. 17.6%, p=0.001). An anomalous OARS Scale was found in 18.3% of patients. Again patients ≥70 years (34% vs. 7.1%, p<0.001) and women (37.4% vs. 11.1%, p<0.001) showed worse results. The score in the Pfeiffer test was abnormal in 7.8% of patients, being also more frequent in older patients (14% vs. 3.3%, p<0.001) and in women (15.2% vs. 5%, p=0.003). A positive depression response in the abbreviated GDS was observed in 29.7% of patients. This positive response was more common in women than in men (47.5% vs. 23%, p<0.001). No differences were found between patients ≥70 years and <70 years (30% vs. 29.5%) in this test.


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  		Table 1 Demographic characteristics (abnormal results)

 


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  		Table 2 Prevalence of fragility

 


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  		Table 3 Differences by age in all tests/scales (abnormal results)

 


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  		Table 4 Differences by sex in all tests/scales (abnormal results)

 
As mean age in women was higher than in men (68.9±9 vs. 63.8±11.3 years, p<0.001), we looked at sex differences in the two age groups (≥70 and <70 years). In older patients, the presence of fragility (73.5% vs. 42.2%, p<0.001), of anomalous OARS Scale (56.6.3% vs. 21.6%, p<0.001), and of positive depression response in abbreviate GDS (47.1% vs. 20.6%, p=0.001) was more common in women than men. In patients <70 years, the presence of fragility (50% vs. 28.6%, p=0.008) and all items analysed showed significant gender differences with women obtaining worse results: Barthel Index <90 (21.7% vs. 7.3%, p=0.01), anomalous OARS Scale (15.2% vs. 4.8%, p=0.02), abnormal score in Pfeiffer test (8.6% vs. 1.8%, p=0.04) and positive depression response in abbreviate GDS (47.8% vs. 24.3%, p=0.003). Although these results suggest that sex differences are not totally due to age differences between men and women, when logistic regression multivariate analysis including age, sex and also the interaction term agexsex was performed, sex lost its statistical significance as independent variable, probably due to colinearity. The p-value for the interaction term agexsex was <0.001, so the "effect" of age was probably different according to the patient's sex. In any case, fragility was more prevalent in patients ≥70 years than in younger patients both in men (42.2% vs. 28.6%, p=0.03) and in women (73.5% vs. 50%, p=0.02), while a positive depression response in the abbreviated GDS were similar in the two age groups (≥70 and <70 years) both in men (20.6% vs. 24.3%, p=ns) and in women (47.1% vs. 47.8%, p=ns).

On the other hand, we found a statistical correlation between fragility and the presence of anemia (p<0.001) and diabetes (p=0.002) but not between fragility and the aetiology of HF nor the presence of renal failure. We found also a significant correlation between fragility and the number of hospitalisations last year. In the multivariate analysis, age, sex, anemia and diabetes remain significantly associated with fragility.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
5. Limitations
 6. Conclusions
 References
 
There is evidence of the benefit that results from a comprehensive geriatric evaluation of elderly patients [9]. The incorporation of a geriatric specialist in an HF Unit is based on the necessity of offering a global health problems assessment to the heart failure patients, many of whom are elderly. This would allow wide treatment strategies that not only addressed the patients cardiac pathology, but also to maintain and improve their functional, cognitive, psychological and social capacities. There are several different instruments available to detect frail patients, the most frequently used are based on postal questionnaires such as that proposed by Barber et al. [10] and the physical test "Get Up and Go" [11]. These questionnaires are mainly aimed at primary healthcare. Other instruments, such as HARP, were designed to discriminate frail and "at risk" patients after an admission to an acute care hospital [12]. As there are no specific questionnaires to detect frail patients with HF, we decided to use known and validated geriatric scales. The cut-off points are even defined by the instrument (as is in the Pfeiffer test and in the abbreviated GDS), or clearly evidenced a significant fragility in the explored area.

However, we decided to evaluate all patients and not just elderly patients, as we suspected from our preliminary results that younger patients may also suffer some degree of dependence and fragility [4]. The application of some geriatric scales in younger people (not elderly) has been evaluated before [13,14], but to our knowledge a global geriatric evaluation has not been used in the same way as we have done in young people. Based on our work, we think that we can clearly conclude that we have been able to detect fragility and dependence in younger people with HF with this standard geriatric evaluation. It is quite remarkable that a significant proportion of patients <70 years fulfilled the pre-established criteria for fragility, 33.3% showed difficulties in at least one of the explored areas. HF alone or due to its association with cardiovascular risk factors favours the emergence of health problems that usually appear later in the ageing process. The association between HF and cognitive deterioration has been extensively published previously [15–19] and it has prognostic implications [16]. It has been found to be present in up to 53% of elderly HF patients [18]. The neuropathological mechanisms are not clear, but could be associated with microemboli phenomena and to brain hypoperfusion secondary to hypotension, mainly systolic hypotension [16,20]. In our study, we found that 14% of patients ≥70 years have an abnormal Pfeiffer test, a tool used in our study to discriminate cognitive deterioration. It is possible that this test was less sensitive than the mini-mental state examinations used in other studies. In fact, different effectiveness has been observed in detecting cognitive deterioration in HF patients with different tests [19]. We cannot exclude, however, that patients included in our study could be more selected than those in other studies.

More than a third of patients ≥70 years (39.3%) showed some kind of difficulty in performing daily living activities (Barthel index <90). These results are similar to those obtained in another elderly HF population study [17].

Women showed a higher prevalence of fragility than men. Differences are evident not only in the functional area but also in the cognitive and in the emotional areas. This phenomenon has been recently suggested in another study [21] and has been found in the elderly with other diseases [22,23]. However, in our study women were significantly older that men and age influence was superior to sex influence in the presence of fragility.

The emotional area is probably directly affected by HF. Depression is quite frequent among patients with HF and has a significant impact on morbidity and mortality [24,25]. It is quite remarkable that in our study depressive symptoms were the only item evaluated that did not show significant differences between age groups. This finding suggests that depression in these patients is more related to HF itself or to HF mechanisms than to the patients general circumstances (such as age, in this case). Recently published studies suggest a possible relationship of depression in HF patients with cardiovascular mechanisms, as decrease of baroreceptors sensitivity or heart rate alterations [26], and with immunologic system alterations and cytokine production [27].


   5. Limitations
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Limitations
6. Conclusions
 References
 
Although our population is a general one attending a Heart Failure Unit, we cannot disregard the possibility of bias of patients, which may not necessarily represent the general HF population. We had no control group and we had no comparison with patients with other cardiac conditions. This would be a possible subject for new work in the future. We have no data from the general population in our hospital, only from the selected patients that have been referred to the Geriatric Department (Barthel <90 in 65.1% and Pfeiffer >3 in 28.7%). However, this population is biased with certainty, and is of no use as a control group for our study. In a recent study performed in a geriatric Spanish population (≥75 years) without neoplasm, Sitjas et al. [28] showed less than 8% of people with a Barthel index <90 (21.7% in our patients ≥70 years and 7.3% in our patients <70 years). They also found 16% of people with a Pfeiffer test >2 (24.6% in our patients ≥70 years and 7.6% in our patients <70 years). Finally, although the same nurse performed about 90% of questionnaires, it is impossible to avoid some subjective differences in data collection.


   6. Conclusions
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Limitations
 6. Conclusions
References
 
Fragility is common in patients with HF, even in younger patients. A high percentage of patients with HF suffer a decrease in autonomy for doing basic and instrumental daily life activities, cognitive problems and emotional disturbances. The presence of fragility in HF patients can be detected easily using standardised geriatric scales. In our study, the prevalence of fragility was significantly higher in older patients and in women, although the presence of depression symptoms was as prevalent in younger as in older patients.


   Acknowledgements
 
The authors would like to thank Dr. J. López-Ayerbe for his help in database management and statistical analysis.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Limitations
 6. Conclusions
 References
 

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