Frailty and chronic respiratory disease: the need for a multidisciplinary care model

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Emmanouil K Symvoulakis
Apostolos Kamekis
Elena Drakonaki
Semeli Mastrodemou
Christopher J. Ryerson
Katerina Antoniou


respiratory diseases, frailty, health care, quality of life


Background.  Frailty is a state of increased vulnerability to various health stressors but little information is summarized about frailty in people with specific chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and asthma.

Methods. PubMed and Cochrane Central databases were systematically reviewed for studies reporting outcomes associated with frailty in COPD, IPF, and asthma. Electronic databases were searched for relevant articles published in English from 2010 up to July 2020. Appraisal was carried out based on the Hierarchy of Evidence Rating System and the GRADE guidelines.

Results. A total of 31 articles met all inclusion criteria with 25 of them at level IV, 1 at level V, and 5 at level VI. Frailty is likely to negatively affect quality of life and to increase the risk of mortality, especially in elderly with COPD, IPF and asthma. Each disease has a particular effect on the balance between health status, respiratory impairment and frailty. A greater understanding of frailty phenotype across different ages, as well as in a range of long-term conditions, is of great necessity in both clinical and research settings. Limited conformity was observed between different methodologies and nature of chronic diseases studied, leading to a further difficulty to extract homogeneous information.

Conclusion. Literature shows that frailty is prevalent in COPD, IPF, and asthma, after adjusting for shared risk factors. Our findings suggest that frailty should be approached as an entity per se', in order to assess real mortality risk, alongside respiratory disease severity and the presence of comorbidities. Health care professionals need knowledge, skills and multidisciplinary collaboration to buffer the impact of frailty on everyday practice.



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1. Morley JE, Vellas B, Kan GA, Anker SD, Bauer JM,Bernabei R et al. Frailty Consensus: A Call to Action. J Am Med Dir Assoc. 2013; 14(6):392-397.
2. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci . 2001; 56: 146–156.
3. Hanlon P, Nicholl BI, Jani BD, Lee D, McQueenie R, Mair FS. Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: a prospective analysis of 493 737 UK Biobank participants. Lancet Public Health. 2018; 3(7) : 323-332.
4. Rockwood K, Andrew M, Mitnitski A. A comparison of two approaches to measuring frailty in elderly people. J Gerontol A Biol Sci Med Sci. 2007;62: 738–743
5. Limpawattana P, Putraveephong P, Inthasuwan P, Boonsawat W, Theerakulpisut D, Chindaprasirt J. Frailty syndrome in ambulatory patients with COPD. Int J Chron Obstruct Pulmon Dis.2017;12: 1193-1198.
6. Maddocks M, Kon SS, Canavan JL, Jones SE, Nolan CM, Labey A et al. Physical frailty and pulmonary rehabilitation in COPD: a prospective cohort study. Thorax. 2016; 71(11): 988–995.
7. Mittal N, Raj R,Islam EA, Nugent K. The frequency of frailty in ambulatory patients with chronic lung diseases. J Prim Care Community Health. 2016; 7(1): 10–15.
8. Park SK, Richardson CR, Holleman RG, Larson JL. Frailty in people with COPD, using the National Health and Nutrition Evaluation Survey dataset (2003–2006). Heart Lung. 2013; 42(3): 163–170.
9. Weiss CO. Frailty and chronic diseases in older adults. Clin Geriatr Med. 2011; 27(1) :39–52
10. Vaz Fragoso CA, Enright PL, McAvay G, Van Ness PH, Gill TM. Frailty and respiratory impairment in older persons. Am J Med. 2012; 125:79–86.
11. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017 [published correction appears in Lancet. 2019 Jun 22;393(10190):e44]. Lancet. 2018; 392 (10159):1789–1858.
12. Bousquet J,Farrell J, Crooks G, Hellings P, Bel EH, Bewick M et al Scaling up strategies of the chronic respiratory disease programme of the European innovation partnership on active and healthy ageing (action plan B3: area 5).Clin Transl Allergy.2016;6: 29
13. Marengoni A, Vetrano DL,Manes-Gravina E, Bernabei R, Onder G, Palmer K. The relationship between COPD and frailty. Chest. 2018;154: 21–40.
14. Meyer KC, Danoff SK, Lancaster LH, Nathan SD. Management of Idiopathic Pulmonary Fibrosis in the Elderly Patient: Addressing Key Questions. Chest. 2015; 148: 242–252.
15. Sheth JS, Xia M, Murray S, Martinez CH, Meldrum CA, Belloli EA et al. Frailty and geriatric conditions in older patients with idiopathic pulmonary fibrosis. Respir Med. 2019; 148: 6-12.
16. Raghu G, Collard HR, Egan JJ, Martinez FJ, Behr J, Brown KK et al. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med. 2011;183: 788–824.
17. Centre for Reviews and Dissemination. Systematic reviews: CRD’s guidance for undertaking reviews in health care. York: University of York, 2009.
18. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. PLoS Medicine. 2009; 6(7) :e1000097.
19. Oregon Health and Science University Evidence-Based Practice Course for Interprofessional Clinical Teams. [Internet].  Oregon Health and Science University library;[cited 2021 18 February]. Available from:
20. Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins. 2005: 6-10
21. Kamekis A, Rachiotis G, Markaki A, Samara V, Symvoulakis EK. Employment and suicidal rates during economic recession: A country-targeted integrative review [published online ahead of print, 2020 Nov 2]. Int J Soc Psychiatry. 2020:20764020969740.
22. Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J et al.. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011; 64(4): 401-406.
23. Aryal S, Diaz-Guzman E, Mannino DM. Influence of sex on chronic obstructive pulmonary disease risk and treatment outcomes. Int J Chron Obstruct Pulmon Dis. 2014;9:1145-1154
24. G. Kojima G, Iliffe S, Jivraj S, Liljas A, Walters K. Does current smoking predict future frailty? The English 474 longitudinal study of ageing. Age Ageing. 2018; 47:126-131.
25. Mirza S, Benzo R. Chronic Obstructive Pulmonary Disease Phenotypes: Implications for Care. Mayo Clin Proc. 2017; 92 (7):1104-1112.
26. Dziewierz A, Tokarek T, Kleczynski P, Sorysz D, Bagienski M, Rzeszutko Let al.. Impact of chronic obstructive pulmonary disease and frailty on long-term outcomes and quality of life after transcatheter aortic valve implantation. Aging Clin Exp Res. 2018; 30(9): 1033-1040.
27. Lahousse L, Ziere G, Verlinden VJ, Zillikens MC, Uitterlinden AG, Rivadeneira F et al.Risk of frailty in elderly with COPD: a population-based study. J Gerontol A Biol Sci Med Sci. 2016; 71:689–695.
28. Uchmanowicz I, Jankowska-Polanska B, Chabowski M, Uchmanowicz B, Fal AM. The influence of frailty syndrome on acceptance of illness in elderly patients with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2016;11: 2401-2407.
29. Ierodiakonou D, Kampouraki M, Poulonirakis I, Papadokostakis P, Lintovoi E, Karanassos D et al. Determinants of frailty in primary care patients with COPD: the Greek UNLOCK study. BMC Pulm Med. 2019;19:1–9.
30. Hirai K, Tanaka A, Homma T, Kaneko K, Uno T, Sato H et al.. Comparison of three frailty models and a sarcopenia model in elderly patients with chronic obstructive pulmonary disease. Geriatr Gerontol Int. 2019;19: 896–901
31. Valenza MC, Torres-Sanchez I, Cabrera-Martos I, Rodriguez-Torres J, Gonzalez-Jimenez E, Munoz-Casaubon T. Physical activity as a predictor of absence of frailty in subjects with stable COPD and COPD exacerbation. Respir Care. 2016; 61(2):212–219.
32. Kusunose M, Oga T, Nakamura S, Hasegawa Y, Nishimura K. Frailty and patient-reported outcomes in subjects with chronic obstructive pulmonary disease: are they independent entities? BMJ Open Respir Res. 2017; 4(1): e000196. .
33. . Annegarn J, Meijer K, Passos VL, Stute K, Wiechert J, Savelberg HH, et al. Problematic activities of daily life are weakly associated with clinical characteristics in COPD. J Am Med Dir Assoc. 2012;13: 284-290.
34. Galizia G, Cacciatore F, Testa G, Della-Morte D, Mazzella F, Langellotto A et al.Role of clinical frailty on long-term mortality of elderly subjects with and without chronic obstructive pulmonary disease. Aging Clin Exp Res. 2011; 23:118–125.
35. Chen PJ, Yang KY, Perng WC, Lin KC, Wang KY. Effect of dyspnea on frailty stages and related factors in Taiwanese men with COPD. Int J Chron Obstruct Pulmon Dis. 2018;13:2463-2469.
36. Kennedy CC, Novotny PJ, LeBrasseur NK, Wise RA, Sciurba FC, Benzo RP. Frailty and Clinical Outcomes in Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc. 2019;16(2):217-224.
37. Dias LS, Ferreira ACG, da Silva Junior JLR, Conte MB, Rabahi MF. Prevalence of Frailty and Evaluation of Associated Variables Among COPD Patients. Int J Chron Obstruct Pulmon Dis. 2020; 15:1349-1356
38. Milne KM, Kwan JM, Guler S,. Winstone TA, Le A, Khalil N et al. Frailty is common and strongly associated with dyspnoea severity in fibrotic interstitial lung disease. Respirology. 2017;22:728–734
39. Faverio P, Bocchino M, Caminati A, Fumagalli A, Gasbarra M, Iovino P et al.Nutrition in Patients with Idiopathic Pulmonary Fibrosis: Critical Issues Analysis and Future Research Directions. Nutrients. 2020;12(4):1131.
40. . Guler SA,Kwan JM,. Leung JM, Khalil N, Wilcox PG, Ryerson CJ. Functional aging in fibrotic interstitial lung disease: the impact of frailty on adverse health outcomes. Eur Respir J. 2019;53(3)
41. Landré B, Nadif R, Goldberg M, Gourmelen J, Zins M, Ankri J et al.. Asthma is associated with frailty among community-dwelling adults: the GAZEL cohort. BMJ Open Respir Res. 2020; 7(1):e000526.
42. Kim S, Jung HW, Won CW. What are the illnesses associated with frailty in community-dwelling older adults: the Korean Frailty and Aging Cohort Study. Korean J Intern Med. 2020:10.3904/kjim.2019.097.
43. Rincon M, Irvin CG. Role of IL-6 in asthma and other inflammatory pulmonary diseases. Int J Biol Sci. 2012;8(9):1281-1290.
44. Trevisan C, Rizzuto D, Maggi S, Sergi G, Welmer AK, Vetrano DL. Cross-Sectional and Longitudinal Associations between Peak Expiratory Flow and Frailty in Older Adults. J Clin Med. 2019;8(11):1901.
45. Smitherman AB, Anderson C, Lund JL, Bensen JT, Rosenstein DL, Nichols HB. Frailty and Comorbidities Among Survivors of Adolescent and Young Adult Cancer: A Cross-Sectional Examination of a Hospital-Based Survivorship Cohort. J Adolesc Young Adult Oncol. 2018;7(3):374-383.
46. Collard RM, Boter H,. Schoevers RA,. Oude Voshaar RC. Prevalence of frailty in communitydwelling older persons: a systematic review. J Am Geriatr Soc. 2012; 60(8): 1487-1492.
47. Brighton LJ, Evans CJ, Man WDC, Maddocks M. Improving Exercise-Based Interventions for People Living with Both COPD and Frailty: A Realist Review. Int J Chron Obstruct Pulmon Dis. 2020;15:841-855.
48. Guler SA, Ryerson CJ. Frailty in patients with interstitial lung disease. Curr Opin Pulm Med. 2020;26(5):449-456.
49. Farooqi M, O'Hoski S, Goodwin S, Makhdami N, Aziz A, Cox G et al. Prevalence and prognostic impact of physical frailty in interstitial lung disease: A prospective cohort study. Respirology. 2021;26(7):683-689.
50. Kreuter M, Ehlers-Tenenbaum S, Palmowski K, Bruhwyler J, Oltmanns U , Muley T et al.Impact of Comorbidities on Mortality in Patients with Idiopathic Pulmonary Fibrosis. PLoS One. 2016;11(3):e0151425
51. Montgomery E, Macdonald PS, Newton PJ, Chang S, Jha SR, Hannu MK et al. Frailty as a Predictor of Mortality in Patients With Interstitial Lung Disease Referred for Lung Transplantation. Transplantation. 2020;104(4):864-872.
52. King C, Nathan SD. Identification and treatment of comorbidities in idiopathic pulmonary fibrosis and other fi brotic lung diseases . Curr Opin Pulm Med .2013; 19 (5):466 – 473.
53. Antoniou K, Kamekis A, Symvoulakis EK, Kokosi M,. Swigris JJ. Burden of idiopathic pulmonary fibrosis on patients' emotional well being and quality of life: a literature review. Curr Opin Pulm Med. 2020:10.1097/MCP.0000000000000703.
54. Wuthrich B, Schmid-Grendelmeier P, Schindler C,. Imboden M, Bircher A, Zemp E et al. Prevalence of atopy and respiratory allergic diseases in the elderly SAPALDIA population. Int Arch Allergy Immunol. 2013;162:143-148.
55. Kang JY, Kim IK, Hur J, Kim SC, Lee SY, Kwon SS et al. Expression of Muscarinic Receptors and the Effect of Tiotropium Bromide in Aged Mouse Model of Chronic Asthma. Tuberc Respir Dis (Seoul). 2019;82(1):71-80
56. De Martinis M, Sirufo MM, Ginaldi L. Allergy and aging: an old/new emerging health issue. Aging Dis. 2017;8:162-175.
57. Cardona V, Guilarte M, Luengo O, Labrador-Horrillo M, Sala-Cunill A, Garriga T. Allergic diseases in the elderly. Clin Transl Allergy. 2011;1:11
58. Vignola AM, Scichilone N, Bousquet J, Bonsignore G,Bellia V. Aging and asthma: pathophysiological mechanisms. Allergy. 2003;58:165-175.
59. Tzortzaki EG, Proklou A, Siafakas NM. Asthma in the elderly: can we distinguish it from COPD? J Allergy. 2011:843543.
60. Bellia V, Pedone C, Catalano F, Zito A , Davi E, Palange S et al.. Asthma in the elderly: mortality rate and associated risk factors for mortality. Chest. 2007;132:1175-1182.
61. PG Gibson PG, McDonald VM, Marks GB. Asthma in older adults. Lancet. 2010;376:803-813.
62. Bellia V, Scichilone N, Battaglia S. Asthma in the elderly. Eur Respir Mon. 2009;43:56–76
63. Mangoni AA, Jackson SH. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol. 2004;57(1):6–14.
64. Franssen FM, Spruit MA, Wouters EF. Determinants of polypharmacy and compliance with GOLD guidelines in patients with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2011;6:493.
65. Inoue D, Watanabe R, Okazaki R. COPD and osteoporosis: links, risks, and treatment challenges. Int J Chron Obstruct Pulmon Dis. 2016;11:637-648.
66. Okazaki R, Watanabe R, Inoue D. Osteoporosis Associated with Chronic Obstructive Pulmonary Disease. J Bone Metab. 2016;23(3):111-120.
67. Lehouck A, Boonen S, Decramer M, Janssens W. COPD, bone metabolism, and osteoporosis. Chest. 2011;139(3):648-657.
68. Li G, Thabane L, Papaioannou A, Ioannidis G, Levine MA, Adachi JD. An overview of osteoporosis and frailty in the elderly. BMC Musculoskelet Disord. 2017;18(1): 46.
69. Sternberg SA, Levin R, Dkaidek S, Edelman S, Resnick T, Menczel J. Frailty and osteoporosis in older women--a prospective study. Osteoporos Int. 2014; 25(2):763-768.
70. Beltramo G, Cottenet J, Mariet AS, Marjolaine G, Lionel P, Pascale TB et al. Chronic respiratory diseases are predictors of severe outcome in COVID-19 hospitalised patients: a nationwide study. Eur Respir J. 2021;in press (
71. Ahrenfeldt LJ, Nielsen CR, Möller S, Christensen K, Lindahl-Jacobsen R. Burden and prevalence of risk factors for severe COVID-19 disease in the ageing European population - A SHARE-based analysis. Res Sq. 2020. doi:10.21203/
72. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet Lond Engl. 2020;395(10223):497‑506.
73. Wong AW, Shah AS, Johnston JC, Carlsten C, Ryerson CJ. Patient-reported outcome measures after COVID-19: a prospective cohort study. Eur Respir J. 2020;56(5):2003276.
74. Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C,Stevens JS et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27:601–615
75. Carfi A, Bernabei R, Landi F, Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent symptoms in patients after acute COVID-19. JAMA. 2020;324(6):603-605..
76. Huang C, Huang L, Wang Y, Li X, Ren L, Gu X et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. 2021; 397: 220–232.
77. She Q, Chen B, Liu W, Li M, Zhao W, Wu J. Frailty Pathogenesis, Assessment, and Management in Older Adults With COVID-19. Front Med (Lausanne). 2021;8:694367.
78. Zhavoronkov A. Geroprotective and senoremediative strategies to reduce the comorbidity, infection rates, severity, and lethality in gerophilic and gerolavic infections. Aging (Albany NY). 2020;12(8):6492-6510.
79. Torres-Sánchez I, Valenza MC, Cabrera-Martos I, López-Torres I, Benítez-Feliponi Á, Conde-Valero A. Effects of an Exercise Intervention in Frail Older Patients with Chronic Obstructive Pulmonary Disease Hospitalized due to an Exacerbation: A Randomized Controlled Trial. COPD. 2017;14(1):37-42
80. Weening-Dijksterhuis E, De Greef MH, Scherder EJ, Slaets JP, van der Schans CP. Frail institutionalized older persons: A comprehensive review on physical exercise, physical fitness, activities of daily living, and quality-of-life. Am J Phys Med Rehabil. 2011; 90(2):156–168.
81. Chou CH, Hwang CL, Wu YT. Effect of exercise on physical function, daily living activities, and quality of life in the frail older adults: a metaanalysis. Arch Phys Med Rehabil. 2012;93(2):237–244
82. Maltese G, Corsonello A, Di Rosa M, Soraci L, Vitale C, Corica Fet al Frailty and COVID-19: A Systematic Scoping Review. J Clin Med. 2020;9(7):2106.
83. Ceravolo MG, De Sire A, Andrenelli E, Negrini F, Negrini S. Systematic rapid “living” review on rehabilitation needs due to covid-19: Update to march 31st 2020. Eur J Phys Rehabil Med. 2020;56(3):347-353.
84. Anyfantakis D, Symvoulakis E K, Linardakis M, Shea S, Panagiotakos D, Lionis C. Effect of religiosity/spirituality and sense of coherence on depression within a rural population in Greece: the Spili III project. BMC psychiatry. 2015;15:173.
85. Lionis C, Petelos E, Papadakis S, Tsiligianni I, Anastasaki M, Angelaki A et al. Towards evidence-informed integration of public health and primary health care: Experiences from Crete. Public Health Panorama. 2018;4:491–735
86. Richter D, Guasti L, Walker D, Lambrinou E, Lionis C, Abreu A et al. Frailty in cardiology: definition, assessment and clinical implications for general cardiology. A consensus document of the Council for Cardiology Practice (CCP), Acute Cardiovascular Care Association (ACCA), Association of Cardiovascular Nursing and Allied Professions (ACNAP), European Association of Preventive Cardiology (EAPC), European Heart Rhythm Association (EHRA), Council on Valvular Heart Diseases (VHD), Council on Hypertension (CHT), Council of Cardio-Oncology (CCO), Working Group (WG) Aorta and Peripheral Vascular Diseases, WG e-Cardiology, WG Thrombosis, of the European Society of Cardiology, European Primary Care Cardiology Society (EPCCS) [published online ahead of print, 2021 Jul 16]. Eur J Prev Cardiol. 2021;zwaa167.

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