Proposal for the Appropriate Frailty Assessment in the JCS/JHFS 2025 Guideline on Diagnosis and Treatment of Heart Failure ― Reply ―
論文ID: CJ-25-0553
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論文ID: CJ-25-0553
We thank Dr. Takahiro Kobayashi and Dr. Hidenori Arai for their insightful feedback on the JCS/JHFS 2025 Guideline on diagnosis and treatment of heart failure,1,2 and their valuable proposal. We concur with their proposal and, in response, have revised Table 9 in the JCS/JHFS 2025 Guideline on diagnosis and treatment of heart failure in the Circulation Journal, and Table 41 in the Japanese version.3
Frailty Assessment Methods in Patients With Heart Failure [Revised]
| Method | Characteristics |
|---|---|
| Physical frailty | |
| CHS criteria (Fried criteria) | Five items (weight loss, muscle weakness, fatigue, slow walking speed, and low activity) were examined, and 3 or more items were classified as frail, and 1 or 2 points were classified as pre-frail. |
| Mental and psychological frailty | |
| MoCA·CDR·MMSE | The MoCA or MoCA-J (Japanese version of the MoCA) is a screening tool for MCI, comprising assessments of visuospatial and executive function, naming, memory, attention, repetition, language fluency, abstraction, delayed recall, and orientation. The MMSE consists of 11 components with a maximum score of 30, including temporal orientation, spatial orientation, immediate and delayed recall of three words, calculation, object naming, sentence repetition, a three-step verbal command, written command, sentence writing, and figure copying. A score of 27 or below suggests possible MCI, while a score of 23 or below suggests possible dementia. The Mini-Cog, which combines immediate and delayed recall of three words with a clock drawing test, is a screening tool for dementia and is not suitable as an assessment method for cognitive frailty, for which MCI serves as the diagnostic criterion. |
| Item GDS | The 30-item GDS, a shortened version of the 15-item (15-GDS), and the 5-item (5-GDS) are used to assess depressive symptoms in the elderly. PHQ-2 and PHQ-9 are assessment tools used for depression screening; however, they are not suitable for evaluating mental, or psychological frailty, which are considered preclinical stages of depression. |
| Social frailty | |
| Makizako’s 5 questions, Yamada’s questions |
Defined as living alone, frequency of going out, and social pre-frailty when two or more of the five items related to family and friends are applicable, and social frailty when one of the five items is applicable. Yamada’s questionnaire takes into account economic status, living alone, social activities, and relationships with neighbors. |
| Multidimensional frailty | |
| KCL·QMCOO | KCL is a 25-item questionnaire developed by the Ministry of Health, Labor and Welfare in Japan for care prevention. QMCOO is a health assessment questionnaire for the screening program of old-old adults aged ≥75 years. The questionnaire comprises 15 items, of which 12 address multidimensional aspects of frailty, two address general health status, and one addresses smoking habits.5,8 |
| Frailty Index (FI-CD, FI-CGA) | More than 30 elderly-specific symptoms, signs, and problems in multiple domains are considered and converted to a real number between 0 and 1 to determine frailty. |
| CFS | |
| CFS | Overall health screening, scale to assess degree of “frailty” (9 levels from very healthy to end of life). A CFS score of 4 to 6 is diagnosed as clinically significant frailty. Patients at a more advanced stage than frailty, who are unable to walk, are classified as CFS 7 or higher. |
CDR, Clinical Dementia Rating; CFS, Clinical Frailty Scale; CHS, Cardiovascular Health Study; FI-CD, Frailty Index based on Cumulative Deficits; FI-CGA, Frailty Index based on Comprehensive Geriatric Assessment; GDS, Geriatric Depression Scale; KCL, Kihon checklist; MMSE, Mini-Mental State Examination; MCI, mild cognitive impairment; MoCA, Montreal Cognitive Assessment; PHQ, Patient Health Questionnaire; QMCOO, Questionnaire for Medical Checkup of Old-Old.
In accordance with their proposal, we have updated the physical frailty assessment to exclude the J-CHS criteria (revised version), which are essentially the same as CHS criteria. Additionally, to enhance the assessment of social frailty, we have revised “Cognitive, mental and psychological frailty” to “Mental and psychological frailty”, incorporated the Questionnaire for Medical Checkup of Old-Old (QMCOO) into the tables,4,5 and excluded the “Simplified Frailty Index” from the tables. Given that the Clinical Frailty Scale (CFS) encompasses a broad measure of vulnerability that includes conditions more advanced than frailty, we have adopted the suggestion to place it in a separate, dedicated section rather than classifying it within the Multidimensional Frailty Assessment Methods.
Regarding cognitive assessment, while we acknowledge that the Mini-Cog is quickly administered and has been utilized for diagnosing cognitive impairment in clinical studies of frailty, such as the FRAGILE-HF study,6,7 we have noted its limitations for the specific diagnosis of cognitive frailty, which requires the identification of mild cognitive impairment (MCI). Therefore, we have added the Montreal Cognitive Assessment (MoCA) in the revised tables.
We also ensured that the content in Table 9 in the JCS/JHFS 2025 guideline on diagnosis and treatment of heart failure in the Circulation Journal aligns with the Japanese version, and vice versa. Specifically, due to spatial constraints, the Edmonton Frailty Scale has been removed from Table 9 in the JCS/JHFS 2025 guideline on diagnosis and treatment of heart failure. Because we also focus on frailty assessment methods in patients with heart failure, we have excluded the depression screening tools, such as PHQ-2 or -9, from the table.
We hope that these enhancements will contribute to more precise frailty assessments for patients with heart failure and, ultimately, better patient management.
