Frailty as Tested by Gait Speed is an Independent Risk Factor for Cirrhosis Complications that Require Hospitalization

Abstract

Frailty as measured by gait speed is an independent and potentially modifiable risk factor for cirrhosis complications requiring hospitalization. The potential clinical value of frailty measurements to help define such risk merits broader evaluation.

Editorial: Advancing Adoption of Frailty to Improve the Care of Patients with Cirrhosis: Time for a Consensus on a Frailty Index

“…Even after adjustment for liver disease severity, cirrhotics classified as frail were hospitalized more frequently for liver-related complications including volume overload, gastrointestinal bleeding, and hepatic encephalopathy in both studies. 1,2 This reinforces one of the original conceptualizations of frailty as a biological syndrome of decreased physiologic reserve and increased vulnerability to adverse health outcomes in response to acute stressors. 4 To put it another way, all cirrhotics are prone to fluid retention, but a frail one is less likely to tolerate the relatively slow diuretic adjustments as an outpatient and, as a result, more likely to be hospitalized for volume overload.…”

“…3 Compared to an otherwise similar patient with cirrhosis and a gait speed of 1.0 meter/second, a cirrhotic with a gait speed of 0.5 meters/second is estimated to spend 15 additional days in the hospital at an estimated $60,000 increased cost per year. 1 In the report by Tandon et al , cirrhotics rated as “mildly frail”, “moderately frail”, or “severely frail” on the Clinical Frailty Scale (i.e., score >4 out of 9) experienced nearly double the rate of unplanned hospital admissions as compared to patients with a Clinical Frailty Scale score ≤4 (39% versus 21%; p=0.005). 2 …”

“…Through two original articles including 673 cirrhotics from two North American centers, we learn that frailty – measured by the performance-based gait speed or clinician-assessed Clinical Frailty Scale – is associated with an increased risk of hospitalizations. 1,2 Specifically, Dunn et al report that every 0.1 meter/second decrease in gait speed (i.e., slower) was associated with 22% greater inpatient days. This is an enormous effect size for a minimally significant change in gait speed.…”

“…What should we conclude of the fact that neither hand grip strength nor the Braden Scale, tools that have previously been shown to predict mortality in cirrhotics, 5,6 were not significantly associated with an increased risk of hospitalizations? 1 …”

“…The overarching conclusion from all of the studies involving frailty is that frailty is a key determinant of outcomes in cirrhotics, 1,2,5,7–9 but the heterogeneity and sheer number of frailty instruments evaluated in these studies have impeded progress toward systematic and widespread adoption of a frailty index in clinical practice. A handful of transplant centers have already incorporated frailty into their initial transplant evaluations using tests as varied as the Fried Frailty Index, grip strength, Timed Up and Go test, or the six-minute walk test (personal communication).…”