Frailty in systemic sclerosis increases mortality risk nearly 10 times
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Key takeaways:
- Pre-frail and frail patients with SSc showed 3.5-fold and 9.8-fold higher risks for mortality, respectively, vs. robust patients.
- Nearly a third of pre-frail patients later became robust, along with 16% of frail patients.
Frailty among patients with systemic sclerosis significantly increases the risk for mortality by nearly 10-fold, but shows the potential to improve over time, according to data published in Clinical Rheumatology.
“There has been a growing burden of evidence recently in the wider literature about the importance of frailty as a determinant of outcome in chronic disease,” Jessica L. Fairley, MBBS (Hons), FRACP, of St. Vincent’s Hospital, in Melbourne, Australia, told Healio. “We recognized in the clinic that there were lots of features of scleroderma that may predispose patients to the frailty syndrome — particularly lung and heart involvement, as well as gut involvement, which can lead to weight loss, muscle wasting and functional impairment.”
Based on these observations, Fairley and colleagues aimed to determine whether measuring the frailty of patients with scleroderma, rather than assessing the involvement of various organs, could pinpoint who is at risk for worse outcomes.
To do so, the researchers retroactively applied a modified version of the five-item FRAIL Scale questionnaire to data from the Australian Scleroderma Cohort Study. For each annual study visit, patient- and physician-reported data on fatigue, dyspnea, function, multimorbidity and weight loss were used to determine what patients’ answers to each FRAIL Scale question may have been.
Based on their responses, patients were categorized as “pre-frail,” “frail” or “robust.” The researchers analyzed factors impacting frailty using ordinal logistic regression, while a multivariable Cox hazard model was used for survival analysis.
The study included 1,703 participants (14.4% men; median age at SSc onset, 47.5 years). Approximately one-third of patients (n = 561) were considered “robust” at all study visits, while 53% and 14% at some point met criteria for “pre-frail” or “frail,” respectively.
Compared with those who were robust, patients were more likely to be frail or pre-frail if they demonstrated diffuse SSc (OR = 1.4; 95% CI, 1.1-1.8), pulmonary arterial hypertension (OR = 7.1; 95% CI, 5.1-9.9), interstitial lung disease (OR = 1.6; 95% CI, 1.3-2), proximal weakness (OR = 1.5; 95% CI, 1.2-2) or lower-tract gastrointestinal symptoms (OR = 1.5; 95% CI, 1.3-1.8).
According to the researchers, being frail or pre-frail was linked with poorer health-related quality of life and physical function, as well as significantly higher mortality. Compared with robust participants, patients deemed frail demonstrated a nearly 10-fold greater mortality risk after fulfilling the criteria (HR = 9.8; 95% CI, 6.8-14.1), while pre-frail patients had a more than three-fold higher risk (HR = 3.5; 95% CI, 2.6-4.8).
Fairley stated she was surprised by the “large magnitude” increase in mortality with frailty, even with the use of multivariable models.
“This really reinforced for me how important frailty is as a prognostic factor,” she said.
In an analysis of 1,406 participants with sequential FRAIL Scale scores, about 15% demonstrated improvement while 20% worsened. Among 411 patients who were initially pre-frail, 32% were robust in their final assessment, while 16% of the 55 initially frail patients later became robust.
“This suggests that there is an important window to intervene with simple strategies that may improve physical function and quality of life,” Fairley said. “It suggests that there is hope that interventions shown to be effective in other populations with frailty may help to improve quality of life in SSc — particularly guidance around exercise and strength training and nutritional support. We know that these holistic, multidisciplinary strategies are more likely to be implemented if we recognize that people are developing the frailty syndrome.”
For more information:
Jessica L. Fairley, MBBS (Hons), FRACP, can be reached at jessica.fairley@svha.org.au.
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