Depression, Frailty Raise Mortality Risk Among Elderly Valve Replacement Patients

Jonathan Afilalo, MD, MS

According to newly released data, screening elderly patients for depression may be justified when they are set to undergo aortic valve replacement.

Regardless of whether patients underwent transcatheter aortic valve replacement (TAVR) or the corresponding surgical procedure (SAVR), the presence of symptoms of depression was related to a higher risk of all-cause mortality. The study, FRAILTY-AVR, was conducted by Jonathan Afilalo, MD, MS, an assistant professor of medicine in the Department of Experimental Medicine at McGill University and the Centre for Clinical Epidemiology at Jewish General Hospital, in Montréal, Quebec, Canada, and colleagues.

"I think this is informing physicians as to the high yield component of a focused geriatric assessment of their patients. It can be comprehensive, but can also be targeted to certain components that are highly prevalent and predictive," Afilalo told MD Magazine. "This is now the second paper from this study which added depression to that list of components, along with frailty. We want it to be practical and give the a high yield in terms of their patients' ability to recover from their procedures. We want to alert them to certain key geriatric domains that are of high yield."

The study examined 1035 adults (427 men [41.3%], 608 women [58.7%]) aged 70 years or older (mean age, 81.4 years [SD, 6.1]) that underwent TAVR or SAVR with or without concomitant coronary revascularization. Those admitted for emergency surgery, having multiple valve replacements, replacement of the aorta, clinical instability, or severe neuropsychiatric impairment were excluded.

Depressive symptoms were assessed with the Geriatric Depression Scale—Short Form (GDS–SF) at baseline, and at 6- and 12-month follow-up. It is a 5-item scale that obtains information on feelings of satisfaction, boredom, helplessness, anhedonia, and worthlessness, with a score of at least 2 of 5 indicative of depression.

At baseline, 326 patients (31.5%) screened positive for depression, of which 89 (8.6%) had a prior diagnosis of depression in medical records. Of patients undergoing TAVR, 222 (33.8%) scored as depressive, compared to 104 (27.5%) in the SAVR group.

At 1-month post-procedure, 24 deaths (7.4%) were observed in the group with depression compared to 21 (3.0%) in the group without, a statistically significant difference of 4.4% (unadjusted odds ratio [uOR], 2.60; 95% CI, 1.43—4.75). When compared by procedure, those undergoing TAVR had a higher rate of mortality (uOR, 2.80; 95% CI, 1.34–5.84) compared to those undergoing isolated SAVR (uOR, 1.15; 95% CI, 0.35–3.81).

Additionally, depression was linked to increased rates of physical frailty (uOR, 5.15; 95% CI, 1.83—14.50) and cognitive impairment (uOR, 2.78; 95% CI, 1.48–5.23).

"In the past 5 years, we’ve really pushed the concept of frailty," Afilalo said. "In large part, the clientele for these procedures is increasingly elderly and mutli-morbid. There is a need for tools beyond the usual cardiac tests to determine who is a good candidate for these procedures, and how we canoptimizee patient care to ensure a good outcome afterward."

Afilalo and colleagues worked on the development of an application for smartphones that includes such a tool—the aptly named Frailty Tool. It works to allow physicians to assess a patient's physical and cognitive function, and also utilizes 2 biomarkers to help determine the status of a patient, all done in under 5 minutes.

At month 12, there were 63 deaths (19.0%) in the depression group compared to 83 (11.7%) in the group without depression. The association between depression and mortality at 12 months was considered statistically significant (uOR, 1.77; 95% CI, 1.24—2.54).

In total, of the 145 deaths, they were cardiovascular in nature in 45 cases (31.0%), noncardiovascular in 57 (39.3%), and of unknown causes in 43 (29.7%). No significant difference was observed based on depression status.

After analysis, it was also shown that those with depression were shown to have higher rates of diabetes (114 [35.0%] vs. 175 [24.7%]), chronic kidney disease (154 [47.2%] vs. 271 [38.2%]), hypertension (276 [84.7%] vs 543 [76.6%]), chronic obstructive pulmonary disease (74 [22.7%] vs 108 [15.2%]), cerebrovascular disease (69 [21.2%] vs 106 [15.0%]), and higher mean Society of Thoracic Surgeons—predicted risk of mortality (5.8% [4.2%] vs 5.1% [3.7%]) than those without depression.

The authors determined that depression was “highly prevalent” among patients with aortic stenosis undergoing TAVR or SAVR, and “appears to be” linked to a higher risk of all-cause mortality. They noted that the “findings underscore the importance of screening for depression during the baseline evaluation and reevaluating changes in depression status during follow-up,” and called for psychogeriatric specialists to be utilized with depressed patients in order to optimize the outcomes for these patients.

"Both [depression and frailty] need to be assessed," Afilalo said. "Some would argue to aggregate the 2 under an umbrella and call it frailty, and others would call them different components of a geriatric assessment, but that’s semantics. The key is to assess frailty—which includes physical frailty, cognition, mood, and social factors. By deconstructing the word we can better target our interventions. When we talk about individualized care, that is key, to pinpoint the issues that could benefit from targeted intervention and promote good quality of life after procedures."

The application, Frailty Tool, is available for download on Apple and Android devices.

The study, “Association of Depression With Mortality in Older Adults Undergoing Transcatheter or Surgical Aortic Valve Replacement,” was published in JAMA Cardiology.

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