Features August 2018 Issue

As You Become Increasingly Frail, Your Heart Attack and Stroke Risk Grow

You can break the downward spiral by taking steps to regain your strength and confidence.

When you think of frailty, do you envision a bird-thin older woman who needs assistance walking or an elderly, wheelchair-bound man? While these descriptions apply to many frail elderly, there is actually no universally accepted definition of frailty and no single tool to assess it.

Nevertheless, doctors know frailty when they see it and understand that a frail patient is at increased risk for a heart attack or stroke.

“The incidence of cardiovascular disease (CVD) events in frail patients is 30 to 40 percent higher than in their non-frail peers,” says Haitham Ahmed, MD, MPH, Medical Director of Cardiac Rehabilitation and a preventive cardiologist at Cleveland Clinic. “When we see a frail patient, a red flag goesup.”

The Frailty-CVD Connection


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Neither frailty nor cardiovascular disease are inevitable.

Frailty is a downward spiral that gradually renders a person unable to carry out the activities of daily living needed to remain independent.

Dr. Ahmed recognizes frailty in a patient with increasingly fragile health and declining physical condition and sense of wellbeing. “One of the common characteristics of frailty is weight loss, especially when it is rapid, and the person is unable to maintain bone density,” he says.

Frailty is not necessarily associated with older age alone. More often than not, it’s a consequence of poor lifestyle choices that lead to deconditioning. That’s why there are 60-year-olds whose descent into frailty is preceded by years of high blood pressure, diabetes, and other cardiovascular risk factors that cause them to become increasingly sedentary and at risk for heart attack and stroke.

Modifying CV Risk

As a person becomes increasingly frail, aggressive measures to control high blood pressure, high cholesterol, high blood sugar levels and any other cardiovascular risk factor are necessary to prevent a heart attack or stroke.

But to most people’s surprise, increasing physical activity may be the most important intervention of all.

“People who become frail experience progressive loss of muscle mass that leads to decreased bone density, increased risk of falling and fear of walking. As a result, these people do less and less,” Dr. Ahmed adds. “Getting a frail patient to become active again can break that cycle.”

What Type of Activity Is Best?

“People who are prefrail or frail don’t need to join a gym, hire a trainer or invest in expensive equipment. Instead, they should focus on specific physical activities that can be routinely performed at home to increase functionality, strength and independence,” says Erik Van Iterson, PhD, Director of Cardiac Rehabilitation at Cleveland Clinic.

Such activities should be designed to improve the ability to walk without help, climb stairs with confidence, get up and down off a commode or in and out of a bathtub, and reach for and lift small items without loss of balance.

The selection of activities should be tailored to the individual with their input and capabilities in mind. To begin, the activities should be performed slowly, methodically and persistently, gradually increasing the number of repetitions and withdrawing assistance as strength and confidence increase.

Slowing the Slide Toward Frailty

A person who has begun the slide toward frailty can turn around their prognosis by increasing their activity levels in seemingly small ways.

For example, when presented with a choice between taking the stairs or elevator, an easy, but effective, compromise is to walk up or down one flight of stairs to build strength in your legs. Then take the elevator the rest of the way.

Walk around your neighborhood for 30 minutes a day at a pace that allows you to be comfortable talking. “Walking engages strength, balance and awareness of body,” says Dr. Van Iterson.

Once you become more comfortable walking, the next challenges could be to take longer walks, then to walk on a variety of surfaces, transitioning across grass, pavement, curbs, and stones.

As your strength, balance and confidence improve, you might try riding a bike 20 minutes a day or joining a water aerobics class.

“Group exercise programs are often more effective for people who need motivation to get started and remain engaged. The social component provides encouragement and gives you something to look forward to,” he says.

“It has long been known that it is easier to adhere to regular exercise if someone understands your goals and is waiting for you.”

Any move toward eliminating risk factors for CVD will be beneficial. However, being proactive in turning around frailty has additional benefits associated with retaining your independence and quality of life.

“Becoming immobile as we age is not normal,” says Dr. Van Iterson. “There are plenty of active, healthy older adults out there.”

Exercises to Fight Frailty


If you have trouble rising from a chair or commode, practice standing up using both arms of a solid chair for support. Repeat three times. As your legs become stronger, increase the number of repetitions. Eventually, use only one arm of the chair for support. Your goal should be to rise without relying on chair arms.


If you have trouble with balance or walking, walk up and down a short hallway several times a day to stimulate your leg muscles. At first, use the walls for support. Over time, you will find the walls are not needed.


If climbing stairs is difficult, start by going up and down one stair, using one or both handrails. As comfort level and strength increase, add one stair at a time. Work toward climbing stairs without using handrails.

Use small weight hand weights or look in your pantry for two cans of equal weight that are easy to hold. Practice lifting the cans overhead to help increase arm strength. Practice placing one can on a top shelf while holding on to a counter. The goal is to reach high without losing your balance.

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