Frailty negatively impacts lung function, survival in patients with IPF
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Key takeaways:
- Frailty was measured via the Survey of Health, Aging and Retirement in Europe-Frailty Instrument.
- No correlation was observed between BMI and frailty score.
Significant predictors of FVC and diffusion capacity of lung for carbon monoxide included frailty, low fat-free mass index and sarcopenia in patients with idiopathic pulmonary fibrosis, according to data published in Respiratory Research.
Additionally, the risk for mortality was significantly heightened with frailty but not with low fat-free mass index (FFMI) or sarcopenia, according to researchers.
“Frailty is multifaceted, involving physical, cognitive, social and psychosocial decline,” Meenakshi Sridhar, MBBS, assistant professor of pulmonary, allergy and critical care medicine at The University of Alabama at Birmingham, told Healio. “Frailty and sarcopenia are common in aging populations. IPF is often diagnosed in the later decades of life, putting patients at risk of both the disease and age-related frailty. These patients face increased risks of falls, hospitalization and death.
“Early identification of muscle loss, sarcopenia and frailty will provide an opportunity to implement interventions like structured exercise, nutrition consultations and gait training,” Sridhar added.
Sridhar and colleagues evaluated 70 patients (mean age, 70.4 years; 68.6% men; mean percent-predicted FVC, 66.5%; mean percent-predicted diffusion capacity of lung for carbon monoxide [DLCO], 49.6%) with IPF to uncover how FFMI is linked to lung function, exercise tolerance and survival. The link between frailty and these three factors was also investigated.
To find each of these measures, researchers used various assessments: CT chest scans, body composition, lung function test, 6-minute walk distance (6MWD), hand grip strength test, Survey of Health, Aging and Retirement in Europe-Frailty Instrument (SHARE-FI) and St. George’s Respiratory Questionnaire (SGRQ).
“A major limitation of most frailty and sarcopenia-related studies has been the differences in tools used and the lack of comprehensive evaluations that could be translated into clinical settings,” Sridhar told Healio. “This study highlights the feasibility of using CT-derived muscle mass measures, along with in-office tests like the 6-minute walk test and hand-grip strength, to identify low muscle mass, sarcopenia and frailty.
“We employed a novel technique for measuring muscle mass using existing CT scans,” Sridhar added. “While this technique has been used in other lung diseases, this is its first application in IPF.”
At baseline, patients with vs. without frailty determined via the SHARE-FI had significantly reduced lung function based on FVC (P < .001) and DLCO (P < .01), as well as exercise tolerance based on 6MWD (P < .05).
“The utilization of the SHARE-FI offers a tool that allows continuous assessment of frailty status in an aging population, as it is validated in healthy adults over the age of 75,” Sridhar said. “This is particularly useful for a disease like IPF, which commonly affects older patients.”
Within the total cohort, 18 patients (25.7%) had low FFMI. Further, nine of 70 patients (12.8%) had sarcopenia, or “low FFMI and handgrip strength,” according to the study.
Between BMI and FFMI, researchers reported correlation. In contrast, no correlation was observed between BMI and frailty score.
In an age- and gender-adjusted model, significant predictors of FVC and DLCO included frailty, low FFMI and sarcopenia.
“Frailty was also a significant predictor of patient-reported quality of life,” Sridhar told Healio. “The association showed an incremental increase with worsening frailty.
“Since frailty can impact outcomes after lung transplant (the only curative option for IPF), it is vital to restore functional status in preparation for transplant,” Sridhar added.
In terms of survival, the risk for mortality was significantly heightened with frailty (adjusted HR = 2.6; 95% CI, 1.1-6.1), whereas there was only “a trend to increased mortality” with low FFMI and sarcopenia, according to the study.
“We found a significant association between frailty and several clinical outcomes in IPF, including lung function, exercise tolerance (6MWD) and survival,” Sridhar told Healio.
“Our study identified important differences in the effects of muscle mass loss, sarcopenia and frailty in IPF,” Sridhar added. “This suggests that while these conditions have overlapping components, they lead to more global functional impairment. It also highlights the importance of early detection.”
Moving forward, Sridhar emphasized the importance of using current tools in this patient population.
“Leveraging existing tools and incorporating patient-reported outcomes enhances the impact and applicability of this study, without adding to the burden of cost or travel for testing,” Sridhar told Healio.
“Our group is expanding on this work and investigating FFMI in other ILDs,” Sridhar said. “This initial study supplements the workflow for using radiomic markers to assess musculoskeletal disease in chronic lung diseases.”
For more information:
Meenakshi Sridhar, MBBS, can be reached at msridhar@uabmc.edu.
Perspective
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Frailty represents a constellation of symptoms, including physical, social and cognitive impacts, and is prevalent in patients with several different chronic lung diseases, including pulmonary fibrosis. It is associated with increased risk for hospitalization and mortality, as well as worse quality of life.
Using a single-center cohort of patients with IPF, the authors found notable associations between baseline measures of frailty using the SHARE-FI, sarcopenia measured by FFMI and BMI on both baseline variables and outcomes. Frailty was associated with worse baseline lung function and quality of life, higher baseline oxygen requirements, FVC decline at 6 months and mortality. It was notable that while almost 13% of patients had sarcopenia, none were considered to have underweight based on BMI. Both sarcopenia and frailty were observed more often in the setting of normal BMI, but both were documented in patients with overweight as well.
Given the obesity epidemic in the U.S., a focus on attaining and maintaining a healthy weight is appropriate; however, clinicians should recognize unintentional weight loss as a worrisome sign even in patients with overweight. In IPF, weight loss can result from IPF itself (as in “pulmonary cachexia”), from side effects of antifibrotic therapy or from comorbid conditions and concomitant medications. Weight loss in IPF has been previously demonstrated to be a marker of more severe disease and associated with worse outcomes.
While weight and BMI are regularly measured in clinical practice, objective measures of frailty and muscle mass are not part of a standard assessment. The current study demonstrates that frailty is not well-correlated with BMI and reflects functional impacts of IPF beyond weight and muscle mass. Identification of frailty in IPF may prove beneficial in counseling patients and caregivers and providing supportive care. Additional study is needed to understand whether interventions directed at frailty, such as pulmonary rehabilitation, nutritional support and psychosocial support measures, may improve clinical outcomes.
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