Research has shown that COPD is a disease with extra-pulmonary and systemic manifestations, including prominent muscle wasting, explains Tze Pin Ng, MD. “There is a growing recognition that the prognostic evaluation of future disability and mortality outcomes of COPD, which is based on traditional measures such as FEV1 or dyspnea, is inadequate, and that more complete prognostic information can be provided by a multi-dimensional functional evaluation,” Dr. Ng says. “Physical frailty has emerged as a diagnosable geriatric syndrome with powerful impact across multiple chronic diseases. However, the assessment of frailty in standard COPD evaluation and pulmonary rehabilitation is not well established. Therefore, there is a need to examine if the presence of frailty in patients with COPD is more than just coincidental, and if it provides useful prognostic information to guide disease management and improve outcomes.”

For a paper published in CHEST, Dr. Ng and colleagues aimed to explore the comorbid associations of physical frailty with COPD. They conducted a prospective cohort study of community-dwelling adults aged 55 and older. At baseline, they identified 1,162 participants with COPD and 3,465 without COPD, who were assessed on their level of FEV1 and dyspnea, as well as physical frailty. “We evaluated whether the baseline prevalent COPD was associated with higher prevalence of pre-frailty or frailty and whether increasing severity level of COPD measured by the level of FEV1 or dyspnea was associated with greater prevalence of pre-frailty or frailty,” Dr. Ng says. “We also evaluated whether there was a cross-sectional association between the presence or level of FEV1, dyspnea, or frailty with greater prevalence of disability in activities of daily living.”  The cohort was followed for incident disability at 3 to 5 years after baseline assessment and all-cause mortality for up to 11 years.

Most Patients With COPD Are Frail or Pre-Frail

The researchers report that the study’s key finding was that that most patients with COPD are frail (10%-20%) or pre-frail (50%-60%). “This prevalence of frailty in persons with COPD is significantly higher than in those without COPD,” Dr. Ng notes. “Frailty is a diagnosable syndrome and comorbidity in COPD that predicts worse prognosis in terms of functional disability and survival, on top of traditional indicators such as FEV1 or dyspnea. Moreover, we found that patients who have low FEV1 and frailty, or are dyspneic and frail, are most likely to become disabled or die earlier.”

The study team observed that the prevalence of frailty is even higher among persons with more severe COPD, measured by their FEV1 or the presence of dyspnea (Table). “The higher prevalence of frailty or pre-frailty is not just coincidentally due to the shared presence of factors common in both COPD and frailty, such as age, sex, ethnicity, smoking, socioeconomic status, asthma history, and comorbidity count,” Dr. Ng says. “Hence, independent of these other factors, the co-occurrence of frailty with COPD reflects a direct comorbid relationship. Frailty, characterized by loss of muscle mass, weakness, slowness, fatigue, and physical inactivity, should, therefore, be viewed as an extra-pulmonary and systemic manifestation of COPD.”

Frailty Is a Reversible Condition

There are important implications of the study team’s investigation, according to Dr. Ng. “One is that the assessment of frailty provides useful information about COPD prognosis in relation to subsequent disability and survival,” he says. “Another is that many recent interventional studies have shown that frailty is a reversible condition that can be improved or ameliorated with physical strength training and nutritional modifications. Therefore, these findings can be incorporated into existing practices by screening and risk stratification of patients with pre-frailty or frailty for targeted interventions in pulmonary rehabilitation.”

Dr. Ng and colleagues would like to see future clinical interventional studies demonstrate whether frailty screening and risk stratification for targeted interventions in pulmonary rehabilitation can improve outcomes in halting or delaying the onset of disability, hospitalization, institutionalization, and mortality among patients with COPD. “To incorporate frailty evaluation into standard COPD treatment and pulmonary rehabilitation programs, simpler brief frailty questionnaire tools may be desirable in some clinical settings,” he says. “There are an existing number of such questionnaire-based tools available, but their applications in COPD pulmonary rehabilitation need to be properly evaluated.”