Frailty: the great confounder, the great forgotten

Roman Romero-Ortuno, Specialist Registrar in Geriatric and General (Internal) Medicine,
January 26, 2010
Corresponding author information: Name: Roman Surname: Romero-Ortuno Email: Affiliation: Department of Medicine for the Elderly, St James's Hospital, James's Street, Dublin 8, Ireland

Frailty: the great confounder, the great forgotten

To the editor: Ryan, Steen, Seifer, et al. [1] present the results of SAFE PACE-2, which are at odds with SAFE PACE-1 [2]. The authors discuss that this may be due to greater frailty in SAFE PACE-2 participants. This point is valid and merits further reflection in relation to recent frailty literature.

Frailty is a well recognised clinical syndrome, but remains difficult to define and measure. Central to the concept of frailty is the dysregulation of multiple systems (e.g. balance, muscle strength, cognition), all of which independently contribute to the high incidence of falls in frail older people [3].

If falls can be a hallmark of frailty, any research on interventions with falls as endpoint should be able to control for this confounder. Many frailty assessment tools have been (and are still being) proposed, but are rarely used to help interpret results of trials in geriatric medicine (e.g. by using frailty scales as covariates, or conducting subgroup analyses based on increasing frailty categories).

The above would help establish which types of patients are most likely to benefit from an intervention. Along these lines, Ryan, Steen, Seifer, et al. [1] argue that the main beneficiaries of pacing may be non-frail patients, who are at low risk of falls from other sources. It is reasonable to presume that frail patients will continue to fall, despite minimising the contributing effect of carotid sinus hypersensitivity.

The issue calls for a frailty-adjusted meta-analysis of all trials of pacing for carotid sinus hypersensitivity, before the intervention is regarded as lacking evidence. The point by Alboni, Dinelli, Gianfranchi L, et al. [4] remains valid, in that the treatment for recurrent vasovagal syncope âÃÆ’¢Ã‚‚¬ÃÆ’‹Ã‚Ã…“can be chosen by considering the clinical context, the risk of trauma and possible comorbidities, in addition to utilizing the little or controversial knowledge available, as well as common sense'.

Older people are very heterogeneous. We need frailty measures that serve as common language for comparing studies that, whilst asking the same questions and employing the same methodology, happened to recruit from different populations. This would contribute towards a better evidence base in Geriatric Medicine.


1 Ryan D, Steen N, Seifer C, et al. Carotid Sinus Syndrome and falls, should we pace? A multi-centre, randomised control trial (Safepace 2). Heart 2009. 2 Kenny RA, Richardson DA, Steen N, et al. Carotid sinus syndrome: a modifiable risk factor for nonaccidental falls in older adults (SAFE PACE). J Am Coll Cardiol 2001;38:1491-6. 3 Nowak A, Hubbard RE. Falls and frailty: lessons from complex systems. J R Soc Med 2009;102:98-102. 4 Alboni P, Dinelli M, Gianfranchi L, et al. Current treatment of recurrent vasovagal syncope: between evidence-based therapy and common sense. J Cardiovasc Med (Hagerstown) 2007;8:835-9.

Conflict of Interest

None declared