1. Update on Frailty Assessment in Older Patients with Aortic Stenosis Dr Amy Jones ST5/Clinical Research Fellow Geriatric Medicine

2. One year ago Limited experience of frailty assessment in this patient cohort Paucity of evidence, with limited numbers in published studies. Lots of different tools, no consensus. Our thoughts….. – 1. Comprehensive Geriatric Assessment (CGA) – 2. Simple frailty tool? But which one?!

3. Fried J Gerontology 2001; 56A: M146-56.

5. Our assessment process Open referral system CGA MoCA Geriatric Depression Scale Mini Nutritional Assessment QoL Activities of Daily Living (Katz) Instrumental Activities of Daily Living (Lawton) Physical disability scale (Nagi) Clinical Frailty Scale (Rockwood) Edmonton Frail Scale Phenotypic frailty criteria (Fried)

6. Outcome of the CGA/frailty assessment process 1.Is the patient frail? If so, what grade? 2.Is aortic valve intervention likely to improve frailty? If not, what are we concerned about? 3.What areas for Geriatric Medicine intervention have been identified? e.g. medication optimisation, chronic disease management, specialty opinion, GP recommendations

7. Descriptive data Dec 2014 to present 16 patients from Cardiology (20 total: 2 RIP, 1 DNA, 1 admitted) Mean age 86 years (range 79-93), 11 female, 5 male 15 aortic stenosis, 1 LV aneurysm Mean MoCA score 20/30 (range 11-27) Mean Geriatric Depression Scale score 4/15 Mean Mini Nutritional Assessment score 12/14

8. Descriptive data cont. Mean QoL scores (RAND 36-item Health Survey) – (0 = poorest perceived health) – (100 = best perceived health) – Physical functioning 22.5 – Energy and fatigue 47.5 – Emotional wellbeing 78.3 – General health 54.1 Mean Katz ADL score 6/6 Mean Lawton IADL score 5/8 Mean Nagi physical disability score 4/7 (≥3 implies significant physical disability)

9. 3 = well with treated comorbid disease 4 = apparently vulnerable 5 = mildly frail 6 = moderately frail 81% are frail

10. 0 = not frail 1-2 = pre frail 3-5 = frail

11. Frailty data Mean Edmonton Frail Scale Score 6/17 Most are ‘Apparently vulnerable’ No validated cut-offs Data available for 11/16 patients Mean Timed Up And Go (TUAG) score = 21.9 seconds (range 9.8- 46.3) Prolonged if >10 seconds, more frail if >20 seconds Data available for 9/16 patients (5 data not collected, 2 unable) Mean gait speed 0.56m/s Cut offs ≥0.65-0.76m/s depending on gender and height Data available for 14/16 patients (2 unable)

12. Decision outcomes so far (AS) 8 patients: conservative management 7 patients: decision awaited – 1 awaiting specialist opinion on cognition – 1 awaiting GI investigation 1 RIP in conservative Mx group

13. Conclusions so far Highly selected group but your gut feeling is correct! Most patients are at least mildly frail Our input in the decision making process has been valued Low numbers, target around 50 No definitive gold standard test

14. We aim to see all patient >70 years going through the TAVI MDT Further analysis of the patient population Outcome data In whom do we need to intervene? Currently designing a frailty index to work towards testing out brief screening tools (Clerical issues)

15. Current TAVI uncertainties Are the standard frailty assessment tools valid in this severely ill and often debilitated population or should we be relying on markers of more advanced frailty and frank disability (e.g. low albumin, ADL disability) to better discriminate risk?

16. TAVI in the literature Patient selection in TAVI is a central and often challenging issue Role of frailty assessment may ultimately prove to be in identifying who is not frail and thus appropriate for conventional AVR Conversely it may help to identify who is extremely frail and/or disabled and thus appropriate for conservative Mx – typically ≥1 of cachexia, severe weakness, inability to ambulate, dementia, and ADL dependencies 1 Decision not to intervene/end of life care 1. Afilalo et al. J Am Coll Cardiol 2014; 63(8): 747-62

17. Service Development 2-3 sessions including Heart MDT Building a team – other MDT members We need specialist dementia input Future Consultant posts

18. Thank You