The Cardiovascular Health Study and the First Clinical Classification of Older Individuals

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The first classification of older individuals into groups of different risks of mortality, hospitalisa-

Relation to life-expectancy, functional dependence and tolerance of stress

Relation to life-expectancy and tolerance of stress

Relation to life-expectancy and dependence

Relation to survival; may indicate motivation to receive treatment

Reversible condition; possible relationship to survival Risk of drug interactions

Relationship to survival Functional dependence tion, functional dependence, and disability was validated in the Cardiovascular Health Study (CHS) [12] on the basis of five simple assessments (Table 2). More than 5000 individuals age 65 and older were followed for several years to study the risk factors of cardiovascular diseases in the elderly. At the time of enrollment, all subjects underwent a complex geriatric assessment that included the tests described in Table 2. After 3 and 7 years, it was clear that three groups of patients of different mortality and risk of functional dependence, hospitalisation, and disability could be recognised: those without abnormal tests (fit); those who had one or two abnormal parameters (pre-frail), and those with three or more abnormal parameters (frail). At a recent consensus conference on frailty, it was agreed to embrace this classification as a frame of reference for future studies in older individuals. It appears reasonable that this user-friendly cost-effective assessment be adopted both in clinical practice and clinical research involving older individuals with cancer.

While the CHS classification represents a major step toward a common language, several of its limitations should be addressed:

Table 2. Assessment of older individuals in the Cardiovascular Health Study (CHS)

Assessment

Tests

Involuntary weight loss Grip strength

Slow walk

Self-reported exhaustion

Low energy levels

>10 lbs during the previous year

By hand dynamometer: decreased grip strength is considered a value within the lowest quintile for persons of the same body mass index (BMI), age and gender

Time necessary to walk 15 feet; slow walk is considered a time within the highest quintile for persons of the same gender and height

Score of the answer to the following questions:

- I feel without energy

- I cannot get going

How often have you felt this way in the last 2 weeks:

3 = most of the times

A score of 2 or 3 denotes self-reported exhaustion

Present if a person has not performed any of the following activities during the past 2 weeks: walking, mowing the lawn, raking, gardening, hiking, jogging, biking, exercise cycling, dancing, aerobics, bowling, golf, single and double tennis, racquetball, callisthenics, swimming

- The definition of frailty involves a wide array of functional status, from fully independent to fully dependent. This wide scope limits use of the CHS in clinical practice. Previous studies have demonstrated that dependence in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), as well as comorbidity scores and geriatric syndromes are predictive of mortality and of chemotherapy-related toxicity [13-14]. In clinical decisions, these parameters should be maintained to identify patients for whom symptom management only is preferred. A subclassification of frailty into subgroups of different life-expectancy and functional reserve is an urgent research project (Fig. 1).

Fig. 1. Algorithm for the evaluation of the elderly person prior to chemotherapy

- The CHS did not address the reversibility of frailty and pre-frailty, an extremely important issue that should be examined in future studies.

- The CHS classification does not address the influence of comorbidity, malnutrition, and socio-economic situations on the management of older cancer patients.

In conclusion, the CHS assessment represents a minimal common denominator that should be integrated with other measures, according to clinical circumstances; in particular, the diagnosis of frailty and pre-frailty should be seen as a red flag for a more in-depth assessment.

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