Mapping interventions addressing frailty and associated outcomes in people with heart failure: a scoping review

Abstract

Objectives

Frailty in people with heart failure (HF) is a multidimensional state and associated with poor outcomes. Addressing frailty in people with HF has been identified as a priority area to improve outcomes. Yet, related non-pharmacological interventions are rarely described in detail. The aim of this article is to map interventions and associated outcomes addressing frailty in people with HF across the physical-functional, clinical, psycho-cognitive and social dimensions of frailty.

Design

The scoping review is conducted according to the methodology of the Joanna Briggs Institute.

Data sources

12 electronic databases were searched in March 2024.

Eligibility criteria

Reports involving adults with HF and frailty, encompassing all HF phenotypes and all operational definitions of frailty were considered eligible. All types of sources of evidence were considered.

Data extraction and synthesis

Reviewers independently extracted data using a data extraction tool specifically developed on the template for intervention description and replication checklist and guide. Results were synthesised and structured according to three research questions.

Results

We screened 10 890 records and included 155 reports, identifying 44 unique interventions addressing one or more dimensions of frailty. 22 (50%) interventions addressed two or more dimensions of frailty. We found 32 interventions in the physical-functional dimension, which focused on exercise and training in daily living activities. 31 interventions in the clinical dimension addressed HF, comorbidities, medication review, reconciliation and handover and nutrition. Interventions in the psycho-cognitive dimension (n=13) included assessment, psycho-cognitive exercise and/or education, and referrals to specialists. Social dimension interventions (n=10) focused on the assessment, activation or enhancement of social support for people with HF and/or caregivers. Other characteristics of interventions were comprehensiveness, being individualised, using a collaborative approach, integrating digital health technologies or involving caregivers. Several outcomes were reported for physical-functional, clinical and psycho-cognitive dimensions, but none for the social dimension.

Conclusions

Interventions addressing frailty in people with HF have predominantly been published for the physical-functional and clinical dimensions while psycho-cognitive and social dimensions remain understudied. This review underscores the need for detailed description of future interventions and associated outcomes, and for developing multidimensional interventions. Developing these, thereby allowing replication, will contribute to reaching the objective of improving outcomes in frail people with HF.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Guided by the Joanna Briggs Institute methodology for scoping review.

• Search conducted in 12 databases.

• Included reports published in English, German, French and Spanish.

• Database search was restricted to reports published up to 8 March 2024.

• Restricted search for backward and forward citation.

Introduction

Frailty in heart failure (HF) is defined as a multidimensional dynamic, potentially reversible state, independent of age, which makes people with HF more vulnerable to the effects of stressors.^{1 2} Frailty has been described across four dimensions: physical-functional, clinical, psycho-cognitive and social.^{1 2} It affects 45% of people with HF,³ ranging from 37% and 66% for the psycho-cognitive and social dimensions of frailty, respectively.⁴ More than 50% of individuals present with multiple frailty dimensions, reflecting substantial overlap.^{3 4} Frailty in people with HF is associated with poor outcomes,3,7 and frailty severity strongly influences prognosis in people with HF.⁸ The European Society of Cardiology (ESC) and the American Heart Association have identified frailty in people with HF as a priority area to improve outcomes for this vulnerable population.9,12

The 2021 ESC guidelines for the diagnosis and treatment of acute and chronic HF recommend that the management of frailty should be multidimensional.¹³ Evidence exists for interventions addressing specific frailty dimensions. In the physical-functional dimension, exercise training and rehabilitation improve muscle strength, mobility, endurance and quality of life.314,18 In the clinical dimension, interventions addressing comorbidities, medication review and nutritional support have demonstrated benefits: nutritional strategies enhance physical function, while medication optimisation reduces inappropriate drug use.1114,16 18 19 In the psycho-cognitive dimension, cognitive training alone is insufficient, but when combined with physical-functional interventions, it shows promise for improving cognitive performance.^{14 16} The social dimension of frailty contributes to physical-functional decline and a decline in cognitive function.¹⁴ The presence of social isolation and the lack of caregivers’ support has been shown to negatively influence outcomes of frail people with HF.^{15 16 20} The number of studies targeting interventions for the social dimension of frailty is limited.¹⁴

Guidelines and expert statements provide rather general recommendations for multidimensional frailty interventions in people with HF.^{9 13 21 22} A comprehensive synthesis mapping the characteristics of interventions across all dimensions of frailty and outcomes is lacking. The aim of this review therefore is to map interventions and associated outcomes addressing frailty in people with HF across the physical-functional, clinical, psycho-cognitive and social dimensions. The research questions (RQ) were:

1. What physical-functional, clinical, psycho-cognitive and social interventions have been described in the literature to address frailty in people with HF?

2. What are the characteristics of interventions that address frailty in people with HF?

3. What outcomes have been reported regarding interventions that address frailty in people with HF?

Methods

We conducted a scoping review in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews.²³ We did our reporting in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA) guidelines.²⁴ The protocol was registered a priori on the Open Science Framework (Registration DOI: https://doi.org/10.17605/OSF.IO/PDFSH).

Eligibility criteria

The eligibility criteria were established according to Population, Concept and Context.²³ This review includes reports involving adult people with HF and frailty. HF phenotypes encompassed HF with reduced ejection fraction, mildly reduced ejection fraction and preserved ejection fraction.¹³ Reports using any operational definition of frailty were eligible for inclusion. Interventions were selected if they addressed frailty in one or more of the following dimensions: physical-functional, clinical, psycho-cognitive and social. Interventions related to pharmaceutical agents and medical devices were excluded. Included contexts were in- and outpatient settings, in any geographic setting. All types of study design and sources of evidence were considered, including grey literature and opinion papers, except for conference abstracts and trial registrations.

Search strategy

The search strategies were designed (by GM, FM, PSK) in collaboration with a health information specialist (ACT). A preliminary search of MEDLINE was conducted to identify relevant free-text terms in titles and abstracts. These terms were discussed within the research team and combined with index terms to develop an initial search strategy for Embase.com, which was subsequently adapted for each database. No date or language limitations were applied. Conference abstracts and trial registrations were excluded. A second health information specialist reviewed the search strategies.²⁵ The final search strategies were run on 8 March 2024 (online supplemental table 1). The information sources searched were MEDLINE ALL Ovid, Embase.com, CINAHL with Full Text EBSCO, Cochrane Library (Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials), JBI EBP Database Ovid, APA PsycInfo Ovid, Web of Science Core Collection, Pubmed Central, ProQuest Dissertation & Theses, BASE Bielefeld Academic Search Engine, and Google Scholar. We examined the included reports and identified references that reported the use of interventions. These were retrieved and considered as the backward citation search dataset.

Study selection

All records were collated and uploaded into EndNote V.21,²⁶ with duplicates removed using Deduklick (Risklick AG).²⁷ We used Rayyan for the screening process.²⁸ Reviewers (GM, FM, GCS and PSK) conducted a pilot test on 25 randomly selected records to test the applicability of eligibility criteria, achieved a high level of agreement, and resolved disagreements through group discussion. Following the pilot test, the reviewers independently screened titles and abstracts according to the eligibility criteria, and assessed eligibility based on the full text versions of the selected reports. Reviewers hold regular meetings to discuss and resolve any disagreements. The results of the search strategies and study selections are reported in accordance with the PRISMA flow diagram (figure 1).²⁹

Figure 1. Study flow diagram for search results, selection and inclusion of reports.²⁹ Note: databases refer to information sources in the text. JBI, Joanna Briggs Institute; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analyses.

Data extraction and synthesis

Five reviewers (GM, FM, VMU, GCS and PSK) independently extracted data from the reports using a data extraction tool specifically developed for this study, presenting intervention details in line with the Template for Intervention Description and Replication (TIDieR) checklist and guide.³⁰ More specifically, the extraction tool included: authors, year of publication, country, study design, participants’ characteristics, frailty assessment instruments, frailty dimension(s) addressed by the intervention. Intervention details were the description of the procedures, activities and/or processes used, physical or informational materials, category of intervention provider (expertise, professional background and specific training given), mode of delivery, involvement of caregivers, where the intervention took place, number of times and period of time the intervention was delivered (number of sessions, duration, schedule), whether the intervention was modifiable, outcomes measured and reported results. The reports were randomly assigned to reviewers. All reviewers extracted data. To ensure accuracy and completeness, 10% of reports, selected at random, were reviewed by two reviewers. Discrepancies were discussed until a consensus was reached. Regular meetings were held throughout the data extraction period. We structured the results according to the three research questions (RQs). For RQ1, we categorised the identified interventions based on frailty dimensions. We narratively summarised the characteristics of the interventions (RQ2), including activities, duration, frequency of delivery and providers involved. For RQ3, we summarised the reported outcomes across studies (RQ3). Additionally, frequencies were presented as counts and proportions and used to present the country of origin and date of publication, and the study designs for all included reports. Frequencies were also used to present the distribution of interventions across the dimensions of frailty, intervention characteristics and outcomes, for the total number of interventions reported in interventional and observational studies.

Patient and public involvement

Patients or members of the public were not involved in the design or conduct of this review. However, dissemination activities involved patients in the discussion of preliminary findings which influenced reporting.

Results

Study inclusion

The searches across all 12 databases yielded 19 820 records. After removal of duplicates, we screened 10 796 records for title and abstract, selected 811 reports for full-text eligibility assessment and included 147 reports. We additionally included eight reports via citation searching. A total of 155 reports met the eligibility criteria (figure 1).

Country of origin and date of publication

A total of 65 reports originated from Europe,1319 21 22 31,91 57 from North America,1618 20 92,145 20 from Asia14146,164 and 8 from other continents.17165,171 In five reports, the country of origin was not specified.172,176 Publication dates ranged from 2003 to 2023. The majority of reports (55%) were published between 2021 and 2023.

Study design

Study designs concerned guidelines (n=3),^{13 36 141} systematic reviews (n=3), interventional studies (n=51), observational studies (n=11), reviews (n=56) and other designs (n=31). The systematic reviews included a systematic review with a meta-analysis,¹⁵⁶ a systematic review without meta-analysis¹⁷ and a scoping review.³⁸ Interventional studies included 18 randomised clinical trials (RCTs),^{31 39 40 60 69 72 73 80 84 87 88 90 107 124 142 149 153 157} ten secondary analyses of RCTs,^{51 61 113 116 126 130 135 137 154 166} five feasibility studies or pilot RCTs,^{59 86 97 111 171} eight designs, rationales or protocols for RCTs,^{33 47 76 78 98 136 138 151} eight quasi-experimental studies,^{62 70 77 89 91 95 108 146} one protocol of a prospective before-after effectiveness study⁵⁸ and one mixed-methods process evaluation study.⁷⁹ Observational studies included five cohort studies^{32 67 145 158 160} and six other observational studies.^{44 55 66 68 152 161} Additionally, 56 non-systematic reviews were included.14,1618 19 21 34 35 43 45 46 52 Finally, 31 other reports were included: ten editorials,^{41 56 74 93 94 100 115 122 148 167} five expert consensus,^{22 48 50 99 139} four position papers,^{49 71 96 173} two commentaries^{63 170} and ten reports of studies with other designs.^{20 37 42 83 85 129 134 172 175 176}

Research question 1: what physical-functional, clinical, psycho-cognitive and social interventions have been described in the literature to address frailty in people with heart failure?

Across the four dimensions of frailty, from the 62 interventional and observational studies, there were 44 unique interventions, addressing one or more dimensions of frailty (table 1). Interventions for the physical-functional dimension were most prevalent (n=32), followed by the clinical dimension (n=31), psycho-cognitive dimension (n=13) and social dimension (n=10). 22 (50%) interventions addressed two or more dimensions of frailty. Eight (4%) interventions addressed all dimensions of frailty (figure 2).

Table 1. Interventions addressing frailty in people with heart failure in the four dimensions of frailty (n=44).

First author, year	Intervention in clinical dimension (n=31)	Intervention in physical-functional dimension (n=32)	Intervention in psycho-cognitive dimension (n=13)	Intervention in social dimension (n=10)
Adachi, 2023161		X
Arenja, 202173		X
Birke, 202259	X	X		X
Blackwood, 2020108			X
Boxer, 201398	X
Comin-Colet, 201660; Yun, 202251	X
Deschodt, 201858; Van Grootven, 202191	X	X	X	X
Dobarro, 202331		X
Essa, 202267; Essa, 202268	X		X
Fountotos, 2022136; Fountotos, 2023124	X	X	X
George, 2017111	X	X
Georges, 202266	X
Gharacholou, 2012116	X	X	X	X
Giuliano, 2020171		X
Gokalp, 201862	X	X
Hashimoto, 2022146		X
Herrero-Torrus, 202272	X	X	X	X
Hersberger, 202161; Schuetz, 201988	X
Jepma, 202184; Terbraak, 202355; Verweij, 201878; Verweij, 202179	X	X	X	X
Kamiya, 2020158	X	X
Kitzman, 2021142; Mentz, 2021137; Murray, 2022130; Pandey, 2023113; Peters, 2022126; Reeves, 2017138; Reeves, 201797; Whellan, 2022135		X
Kobulnik, 202295	X
Luger, 201687	X	X
Lutz, 2020145	X	X
Marek, 2013107	X			X
Martin-Sanchez, 201969	X	X	X	X
Mudge, 2021166		X
Nagatomi, 2022157	X	X
Nakaya, 2021149		X
Pacho, 201770; Pacho, 201939	X
Papathanasiou, 202040		X
Pavone, 201977	X
Pulignano, 201086	X
Raijmann, 202332	X	X	X	X
Tanaka, 2017151; Tanaka, 2022153; Tanaka 2022154		X
Ushijima, 2021152	X	X
van Dam van Isselt, 201889	X	X
van Leunen, 202376	X	X	X
Vigore, 202247	X	X	X	X
Wit, 201744	X	X	X
Witham, 200590		X
Witham, 201080	X
Yamashita, 2022160		X
Zelenak, 202333	X	X	X	X

Multiple authors in one cell indicate that the same intervention appears in several publications.

Figure 2. Number of interventions addressing one or more dimensions of frailty in people with heart failure: physical-functional (n=32), clinical (n=31), psycho-cognitive (n=13) and social (n=10). In total, there are 44 interventions. Reprint with permission from Oxford University Press (Licence Number 6247531040958).¹⁸³.

Research question 2: what are the characteristics of interventions to address frailty in people with heart failure?

Interventions for the physical-functional dimension

The interventions addressed aerobic and endurance exercises (n=19), resistance exercises (n=17), balance training (n=11), promotion and training in activities of daily living (ADLs) (n=7), electrical muscle stimulation of both legs (n=4), breathing exercises (n=2) and the use of digital health technologies (n=4) (table 2). Aerobic and endurance exercise included cycling on cycle-or leg-ergometer, treadmill exercises and walking.3140 44 47 89 90 97 111 113 124 126 130 135,138 142 145 149 151 Resistance exercises included weighted and unweighted exercises for the lower extremities.3140 87 89 90 97 111 113 124 126 130 135,138 142 145 149 151 Balance training included static and/or dynamic exercises.3197 111 113 124 126 130 135,138 142 145 146 149 151 153 154 158 160 166 Interventions also included the electrical muscle stimulation of both legs,^{73 151 153 154} promotion and training in ADLs^{32 44 58 72 89 91 111} and breathing exercises.^{47 90} Digital health technologies included habits and activity sensors,⁶² e-watch monitoring,¹⁵⁷ web application, progress tracking and video and chat communication,⁷⁶ or a robot with interactive games.¹⁴⁶

Table 2. Characteristics of interventions to address physical-functional dimension of frailty in people with heart failure.

Reference	Intervention components (What?)	Providers (Who?)	How much?	Where?
161	Cardiac rehabilitation* (exercise training)	NR	3 sessions per week (60 min) for 3 months	OPC
73	Electrical muscle stimulation of both legs with low-intensity or high-intensity	Nurse and/or physiotherapist	5 sessions per week (16–30 min) for 6 weeks	Hosp., home
59	Rehabilitation programme with physical activities, goal setting plan and follow-up phone calls. Paid transportation to rehabilitation and membership in a sports association	Physiotherapist, cardiac nurse, psychologist, social worker†	2 sessions per week (60 min) for 12 weeks	Hosp., home
58 91	Early physical rehabilitation. Promotion and training of self-care in activities of daily living	Physiotherapist	3 sessions per day during hospitalisation	Hosp., home
31	Individualised exercise based on Vivifrail exercise programme: resistance, balance, endurance and coordination training	NR	5 sessions per week during 6 months	Home
124 136	Exercises: encouragement to ambulate and perform chair rise exercises. If SPPB ≤9: Vivifrail programme	Graduate students in Kinesiology	2 sessions per day (20 min) during hospitalisation	Hosp.
111	Aerobic and resistance exercises involved ambulation, balance, lifting and functional independence	Physician	6 sessions per week (20 min) during 6 months	Home
116	Assessing and treatment plan of functional status*	Geriatrician, nurse, social worker†	NR	Hosp.
171	Resistance exercises: chest press, leg press, seated row, triceps pushdown, latissimus dorsi pulldown, upright row, hack squat and calf raises. Aerobic exercise	Exercise physiologist	2 sessions per week (60 min) for 8 weeks	Hosp.
62	Telemonitoring system with habits and activity sensors (motion sensor, bed sensor, chair sensor)*	Clinical nurse, GP, social worker†	NR	Home
146	Balance exercises using robot (enabling balance exercises through three interactive games targeting different movement directions) and aerobic exercises by using ergometer	NR	1 session per week for 4 months	OPC
72	Functional rehabilitation programme: physical exercise, education on improving the basic activities of daily living	NR	NR	OPC
55 78 79 84	Home cardiac rehabilitation with stepwise graded exercise approach	Physiotherapist	1–2 sessions per week, with a maximum of 9 sessions after hospital discharge	Home
158	Supervised and non-supervised cardiac rehabilitation: stretching, moderate-intensity aerobic exercise, resistance training, balance training	NR	3–5 sessions per week for 5 months	OPC
97 113 126 130 135 137 138 142	Early, transitional, tailored, progressive multidomain rehabilitation: static and dynamic balance, functional strength focused on lower extremities, mobility and endurance exercises	Study interventionist	30-minute sessions during hospitalisation. 3 sessions per week (60 min) for 12 weeks or 36 sessions	Hosp., OPC, home
87	Home-based physical training intervention with 6 muscular group strength exercises (femoral, pectoral, abdominal, ischiocrural, upper back muscles and muscles of the arms and shoulders)	Volunteer	1 session per week for 12 weeks	Home
145	Cardiac rehabilitation training incorporating aerobic exercise, strength training and balance exercises	Trained educator and/or nurse	2–3 sessions per week for 2–6 weeks after hospitalisation	NR
69	Multilevel guided discharge plan: exercise programme adjusted to the level of disability	Physician	NR	Hosp.
166	Supervised centre-based exercise training programme included aerobic, resistance and balance training	Physiotherapist	2 sessions per week for first 3 months and 1 session per week for next 3 months	Home
157	Step-by-step home exercise guidance: stretching, resistance training using weights, ergometry or walking. Exercise monitoring with e-watch.	Physiotherapist and/or cardiologist	3–5 sessions per week (aerobic exercise), 2–3 sessions per week (resistance training) (30–40 min) for 3 months	Home
149	Balance training, resistance training, cycling ergometer	Physiotherapist	5 sessions per week (20–40 min), during hospitalisation	Hosp.
40	High and moderate intensity aerobic interval training, incorporating muscle strengthening, flexibility and endurance/fitness exercise	NR	24 sessions during 12 weeks*	NR
32	Geriatric rehabilitation, mobility assessment, activities daily living dependency and care needs	Multidisciplinary team†‡	Within 48 hours of admission, during hospitalisation	Hosp.
151 153 154	Electrical muscle stimulation to all muscle groups of both legs and early rehabilitation programme with strength, balance, mobility and endurance exercises	Physiotherapist	Electrical muscle stimulation: 5 sessions per week (30–40 min) during 2 weeks Early rehabilitation: 5 sessions per week (60 min) during hospitalisation	Hosp.
152	Exercise training programme with aerobic exercise using ergometer or treadmill and resistance training	Physiotherapist	3–5 sessions per week (30–60 min) during 3 months	OPC, home
89	Training of activities daily living, endurance and strength training	Physiotherapist and/or occupational therapist	1 session physiotherapy per day (40 min), 2 sessions per week occupational therapy (30 min) for 4–6 weeks	SNF
76	Cardiac telerehabilitation with physical training and non-invasive telemonitoring (web application, goal setting, progress tracking, video and chat communication)	Physiotherapist or occupational therapists	3 sessions in-hospital (45 min) followed by 2 live-video training (45 min). 1 session per week (20 min) for 18 weeks	Hosp., home
47	Evaluation of functional status. Verify the goals of the rehabilitation programme. Sessions of cycle-ergometer or treadmill, leg ergometer and breathing exercises	Physiotherapist	2 sessions per day (30–45 min), during hospitalisation	Hosp.
44	Early mobilisation, patient encouraged to wash and dress themselves, to walk around the ward and to eat at the table	Nurse	NR	Hosp.
90	Supervised phase: warm-up, upper and lower limb exercise, slow and quicker whole body aerobic movements, wrist and ankle weights, breathing exercises, and relaxation. Home exercises with aid of a video or audio cassette demonstration and instruction, and diary of their activity	Physiotherapist	Supervised phase: 2 sessions (30 min) per week for first 3 months. Home non-supervised exercise: 2 sessions per week for next 3 months	OPC, home
160	Rehabilitation: stretch gymnastics, muscle strengthening, balance training, and endurance	NR	During hospitalisation*	Hosp.
33	Increase physical activity*	Care manager	1–2 calls per month for 9 months	Home

^*No additional information is provided.

^†No details are provided on which provider performs which intervention.

^‡Multidisciplinary team including: geriatrician, cardiologist, cardiac nurse, geriatric nurse, physiotherapist.

GP, general practitioner; home, participant’s home; hosp, hospital; NR, not reported; OPC, outpatient clinic; SNF, skilled nursing facility; SPPB, short physical performance battery.

Most interventions were delivered by physiotherapists (n=14),3247 55 58 59 73 76 78 79 84 89,91 149 151 followed by nurses (n=7),^{32 44 59 62 73 116 145} physicians (n=5),^{32 69 111 116 157} and occupational therapists (n=2).^{76 89} Interventions took place most frequently in hospitals (n=10),^{32 44 47 69 116 124 136 149 151 153 154 160 171} followed by participants’ homes (n=8),^{31 33 55 62 78 79 84 87 111 157 166} outpatient clinics (n=4),^{72 146 158 161} and skilled nursing facilities (n=1).⁸⁹ The setting was not reported in two interventions.^{40 145} Seven interventions took place in multiple settings: hospital-to-home (n=4),^{58 59 73 76 91} outpatient clinic and home (n=2)^{90 152} and hospital-to-outpatient clinic and home (n=1) (figure 3).^{97 113 126 130 135 137 138 142} Intervention frequency, delivery and duration are reported in table 2.

Figure 3. Distribution of interventions across frailty dimensions by care settings. Note: this figure does not distinguish between interventions addressing one or more dimensions of frailty.

Interventions for the clinical dimension

The interventions addressed HF and comorbidities, medication and nutrition (table 3). The interventions addressing HF and comorbidities (n=24) included monitoring signs and symptoms,^{33 44 47 51 60 66 86 98 107 157} generating and managing warning alerts related to clinical status,^{51 60 62 66} and conducting medical evaluations through assessments for residual congestion,^{39 70 95} guidance for patients on fluid balance monitoring,⁴⁴ and monitoring of vital signs,^{51 60 62 95 157} daily weights^{62 66 95 98 157} and blood tests.^{39 70 95} Some interventions provided information on cardiac disease status and symptoms for the people with HF and their caregivers.^{33 39 58 59 70 86 89 91 157} Interventions included fall risk assessment and prevention.^{32 67 68 72 116} Some interventions concerned discharge planning, including reassessment of the clinical status, structured interviews with caregivers to explain symptoms, the treatment plan and preparation for the postdischarge period.^{44 47 86} Some interventions promoted healthy behaviours and/or lifestyle instructions for supporting self-management.^{33 44 47 145} One intervention aimed to enhance communication between patients and health providers.¹⁰⁷ Interventions concerning medication (n=18) included medication review, reconciliation and handover.^{39 55 58 66 70 78 79 84 89 91 95 145} Interventions included the promotion of dose adjustments and the optimisation of medication according to protocols and guidelines.^{32 39 60 70 98} Some interventions included the rationalisation of polypharmacy burden and a review of drug-related problems,^{32 33 55 67 68 78 79 84} aiming at supporting adherence to medication.4447 67,69 107 One intervention monitored medication taking with a dispensing system or medication planner,¹⁰⁷ another supplied a pharmacological treatment sheet to improve adherence to medication.⁶⁹ Interventions addressing nutrition (n=18) included daily weight monitoring, dietary assessments, evaluation of the risk of malnutrition and the establishment of personalised nutrition goals.^{32 44 47 76 77 98 116 157} One intervention involved people with HF sharing photos of their meals as part of a dietary assessment.¹⁵⁷ Education on nutritional habits was provided through lectures and early nutritional individualised support to reach energy requirements.^{59 61 72 88 89 145} Oral and/or enteral nutritional supplementation with protein and/or micronutrients was provided.^{69 72 80 111 124 136} One intervention ensured adequate protein and energy intake through the monitoring of standard food and beverages without the use of nutritional supplements.⁸⁷ One intervention followed international evidence-based dietary practices and focused on modifying unhealthy eating habits.⁴⁷ One intervention addressed food barriers, including the correct placement of dentures to support adequate dietary intake.^{124 136}

Table 3. Characteristics of interventions to address clinical dimension of frailty in people with heart failure (HF).

Reference	Intervention (What?)	Providers (Who?)	How much?	Where?
59	Provide cardiac disease information through a book. Conduct group cardiac education sessions relevant to patients’ daily lives. Offer proactive counselling to address specific concerns and motivate participation	Cardiac nurse	During hospitalisation and follow-up at 1 and 3 months	Hosp., home
	Telephone counselling for patient supporters	Heart association
	Lecture on dietary needs	Dietician
98	Daily weights. Symptoms and activity assessment. Documentation of ejection fraction. Dietary surveillance. Medication titration. Patient and caregivers education.* Discharge instructions*	HF nurse	From admission to discharge and 7 days after discharge	SNF, home
51 60	Home Tele-HealthCare with comprehensive solution for care and monitoring with biometric data, symptoms reporting, generation and management of warning alarms. Promote diuretic dose adjustments following protocols	HF nurse	<7 days after hospital discharge for 6 months	Home
58 91	Care coordination. Bedside education.* Prevention of geriatric syndromes. Medication review. Collaborate with the cardiac care team in implementing the interdisciplinary care plan	Geriatric nurse	Visited and CGA at 24 hours of admission. Daily bedside visits and weekly interdisciplinary meeting	Hosp.
	Responsible for the management of new-onset geriatric syndromes and complications	Geriatrician
67 68	Optimisation of HF therapies, comorbidities management, falls risk assessment. Rationalisation of polypharmacy burden, medication compliance*	Multidisciplinary team†‡	NR	NR
124 136	Oral nutritional supplementation. Address food barriers. Dentures in place	Graduate students in Kinesiology	2 sessions per day (20 min) during hospitalisation	Hosp.
111	Nutritional protein supplementation	Dietician	Weekly phone call	Home
66	Follow-up and care coordination with clinical monitoring (signs and symptoms, weight monitoring, medication review)	HF nurse	1 visit before hospital discharge and 3-month follow-up*	Hosp., home
116	History and physical examination. Prevention of falls. Assessing and treatment plan of nutritional status	Nurse and/or geriatrician	Twice week meeting*	Hosp., OPC
62	Telemonitoring with clinical sensors (weight, blood pressure, pulse, oxymeter). Daily review for alerts and necessary interventions*	Nurse	Daily monitoring	Home
72	Prevention of falls. Education and intervention of nutritional status, administration of supplemental enteral nutrition	Geriatrician and/or cardiologist	First visit <10 days after discharge, other visits 3, 6 and 12 months after discharge	OPC
61 88	Early nutritional individualised support to reach energy, protein and micro-nutrient goals	Dietician	<48 hours after admission and every 24 hours or 48 hours	Hosp.
55 78 79 84	Medication handover, review of drug-related problems. Medical condition evaluation, early detection of complications	Nurse	Programme with 3 phases: in clinical, the discharge, the postdischarge phase with 4–5 home visits	Hosp., home
	Medication reconciliation	Nurse and pharmacist
158	Multidisciplinary guidance for HF management to patients and their families*	NR	3–5 times per week for 5 months	OPC
95	Monitor weight and vital signs. Home blood test	Nurse	Duration: 1-hour visit	Home
	Review patient’s clinical status. Medication review, reconciliation and prescription. Virtual physical exam for volume assessment. Advanced care planning	Cardiologist	Duration: 10–30 min Frequency: Follow-up based on initial visit
87	Nutritional intervention to ensure adequate fluid, protein and energy intake, preferably by regular foods and beverages without the use of nutritional supplements	Dietician	2 sessions per week (60 min) for 12 weeks	Home
145	Receive lifestyle, diet and/or disease-specific education	Nurse or trained educator	2–3 sessions per week for 2–6 weeks after hospitalisation	OPC
	Medication reconciliations	NR
107	Monitor medication with Medication-dispensing system. Monitor signs and symptoms. Identify goals in care and provide education to manage chronic conditions. Enhanced participant ability to communicate with health providers	Nurse	1 session every 2 weeks for 12 months	Home
	Assist nurses in creating care plans tailored to the patient’s clinical condition	APN
69	Multilevel guided discharge plan: oral and written HF education, delivery pharmacological treatment sheet, early follow-up with primary care. Verify clinical stability for discharge, clinical recommendations for comorbidities, review inappropriate prescriptions. Dietary recommendations and assess protein energy supplements	Physician	NR	Hosp.
157	Patient education for self-management of the disease state and symptoms. Referring to the pocketbook for HF patients. Patient education for self-monitoring	Nurse and/or cardiologist	Duration: 3 months	Home
	Nutritional assessment and advice (energy and protein intake goal). Patient takes and shares photos of meals.	Dietician
39 70	Postdischarge visit: exam for residual congestion, other decompensating conditions, blood sample, educational intervention for patient and caregiver.* Visits for drug adjustment, titration according to clinical guidelines	HF nurse and GP or internist or geriatrician or cardiologist	Within 7 days after discharge for 1 month	Home
77	Physical examination*	Cardiologist and cardiac surgeon	NR	OPC
	Nutritional assessment, intervention for malnutrition	Geriatrician
86	Discharge planning. Continuing education. Therapy optimisation.* Early attention to signs and symptoms. Flexible diuretic regimen	Cardiologist, nurse, primary care physician	1–2 weeks after discharge, after 1 and 3 months, and thereafter every 6 months	OPC, home
32	Nutritional status consultation.* Fall risk analysis, fall prevention measures. Treatment and impact of comorbidities: optimise treatment, patient education. Polypharmacy: systematic medication review. Sarcopenia: start or optimise treatment	Geriatrician, geriatric nurse, cardiologist, cardiac nurse, dietician†	Within 48 hours of admission*	Hosp.
152	Nutritional and medication guidance*	NR	NR	OPC
89	Nutritional status, diet advice	Dietician	After hospital discharge, for 4–6 weeks	SNF
	Pharmacologic treatment, comorbidity management*	NR
	Patient education for self-management improvement	Nurse
76	Assessment and personalised nutrition goals. Nutrition behaviour follow-up by chatbot and consultations	Dietician	2 weeks after the discharge for 18 weeks	Home
47	Promote adherence to pharmacological therapy	Nurse	During hospitalisation Assessment at admission and discharge	Hosp.
	Evaluate and monitor clinical status. Promote healthy behaviours. Optimise the pharmacological therapy. Reassess clinical status before discharge	Physician
	Evaluate the risk of malnutrition, follow evidence-based dietetics practice and modify unhealthy eating habits	Dietician
44	Screening for malnutrition, falls. Request patient to monitor fluid balance	Nurse	Daily consultation in hospital. Follow-up: 2 weeks after discharge and 3 months	Hosp., OPC
	Consultations on the management of comorbidities. Discharge interviews with family to explain symptoms, use medication, prepare the patient to undertake self-management with medication, lifestyle instructions, and consult a physician if alarming symptoms occur. Outpatient follow-up to ensure continuity of care and evaluate treatment and symptoms	APN	Frequency: daily consultation at hospital, at 2 weeks and 3 months after discharge
	Supervising the APN	Cardiologist
	Integrated in case of a malnutrition risk detected*	Dietician
80	Vitamin D supplementation	Nurse	1 dose at baseline and after 10 weeks	Home
33	Polypharmacy monitoring. Patient education on treatment and symptoms. Support in goal attainment and integration of health behaviour and self-management into patient’s daily routine for secondary prevention	Care manager	2 calls per month (first 3–4 months), and after 1 call per month for 9 months	Home
	Supervise care manager, make treatment recommendations	GP, cardiologist, and pharmacist

^*No additional information is provided.

^†No details are provided on which provider performs which intervention.

^‡Multidisciplinary team including: HF cardiologist and HF specialist nurse, nephrologist, endocrinologist, palliative care specialist, chest physician, geriatrician, pharmacist and pharmacologist.

APN, advanced practice nurse; CGA, comprehensive geriatric assessment; GP, general practitioner; home, participant’s home; hosp, hospital; NR, not reported; OPC, outpatient clinic; SNF, skilled nursing facility.

Most interventions were delivered by nurses (n=21),3239 44 47 51 55 58,60 62 66 followed by physicians (n=14),3233 39 44 47 58 67,70 72 77 86 91 95 116 157 dieticians (n=10)3244 47 59 61 76 87,89 111 157 and pharmacists (n=3).^{33 55 67 68 78 79 84} Interventions took place most frequently in participants’ homes (n=11),^{33 39 51 60 62 70 76 80 87 95 107 111 157} followed by hospitals (n=7),^{32 47 58 61 69 88 91 116 124 136} outpatient clinics (n=5),^{72 77 145 152 158} and skilled nursing facilities (n=1).⁸⁹ The setting was not reported in one intervention.^{67 68} Six interventions took place in multiple settings: hospital-to-home (n=3),^{55 59 66 78 79 84} hospital-to-outpatient clinic (n=1),⁴⁴ skilled nursing facility-to-home (n=1),⁹⁸ outpatient clinic and home (n=1) (figure 3).⁸⁶ Intervention frequency, delivery and duration are reported in table 3.

Interventions for the psycho-cognitive dimension

Interventions addressed the assessment of psycho-cognitive function (n=11),3244 55 58 67,69 76 78 79 84 91 116 124 136 psycho-cognitive exercise and/or education (n=9)^{32 33 47 55 72 76 78 79 84 108 116 124 136} and referral to specialists (n=2) (table 4).^{58 72 91} The assessment of psycho-cognitive function included assessment of depressive symptoms (n=7),^{32 55 58 69 72 76 78 79 84 91 116} screening and/or assessment of cognitive status (n=6),5558 67,69 78 79 84 91 116 124 136 and delirium assessment (n=6).^{32 44 55 58 69 72 78 79 84 91} The psycho-cognitive exercises and/or educational interventions included cognitive training through games targeting executive function (n=2),^{108 124 136} delirium prevention with reorientation and ensuring the functionality of sensory aids (hearing, vision aids) (n=1).^{124 136} Education on cognitive impairment and the management of delirium was provided (n=2).^{32 72} Psychoeducation was offered for patients, caregivers and health providers (n=1).³² Follow-up appointments were conducted to help people develop coping strategies for managing illness (n=1)⁷⁶ and skills training was provided to cope with psychological burden (n=1).³³ Promotion of changes in psychosocial and/or behavioural risk factors was provided through psychological support (n=1).⁴⁷

Table 4. Characteristics of interventions to address psycho-cognitive dimension of frailty in people with heart failure (HF).

Reference	Intervention components (What?)	Providers (Who?)	How much?	Where?
108	Computerised cognitive training: 4 games focused on specific domains of executive function (set shifting, attention, visual spatial ability, recall)	Supervised by research team member	3 sessions per week (25 min) for 6 weeks	Senior centre
58 91	Cognitive screening. Cognitive assessment, referral to specialised memory clinic. If indicated, additional assessment for delirium, depression and dementia	Geriatric nurse and/or geriatrician in collaboration with cardiac care team	Visited and CGA at 24 hours of admission. Daily bedside visits and weekly interdisciplinary meeting	Hosp.
67 68	Cognitive dysfunction assessment*	Multidisciplinary team†‡	1 meeting per month for 18 months	NR
124 136	Reorientation. Sensory aids in place (hearing, vision aids). If MMSE ≤26/30: cognitive stimulation (word games, puzzles and reading)	Graduate students in Kinesiology	2 sessions per day (20 min) during hospitalisation	Hosp.
116	Assessment and treatment plan of cognitive and affective status*	Geriatrician, nurse, social worker†	NR	Hosp.
72	Education on cognitive impairment, referral to the dementia outpatient clinic, health education on the management of delirium, non-pharmacological and pharmacological treatment of depression	Geriatrician and/or cardiologist	First visit <10 days after discharge, other visits 3, 6, and 12 months after discharge	OPC
55 78 79 84	Follow-up integrated care based on CGA for psychological issues*	Cardiac nurse and/or community nurse	Programme with three phases: in clinical, the discharge, the postdischarge phase with 4–5 home visits (3 days, 1,3,6,12 weeks)	Hosp., home
69	Multilevel guided discharge plan: assessment of cognitive impairment, acute confusional syndrome and symptoms of depression. Early visit and transmission of information to primary care and adapted information sheet for patients and caregivers	Physician	NR	Hosp.
32	Cognition, mood, delirium assessment. Medication advice, psychoeducation for patients, caregivers and health professionals. Delirium prevention measures	Geriatrician and/or geriatric nurse	NR	Hosp.
76	Cardiac telerehabilitation: assessment for anxiety and depression symptoms. Follow-up consultations to develop coping strategies to manage illness and health	Psychologist	After hospitalisation for 18 weeks. Tailoring follow-up consultations	Home
47	Optimisation of the patient’s awareness and acceptance of the disease, promotion of changes in psychosocial and/or behavioural risk factors. Provision of psychological support	Psychologist	During hospitalisation	Hosp.
44	Screening the risk for delirium	Nurse	Daily consultation in hospital. Follow-up: 2 weeks after discharge and 3 months	Hosp., OPC
33	Impart skills to cope with psychological burden	Care manager	2 calls per month (first 3–4 months), and after 1 call per month for 9 months	Home

^*No additional information is provided.

^†No details are provided on which provider performs which intervention.

^‡Multidisciplinary team including: HF cardiologist and HF specialist nurse, nephrologist, endocrinologist, palliative care specialist, chest physician, geriatrician, pharmacist and pharmacologist.

CGA, comprehensive geriatric management; home, participant’s home; hosp, hospital; MMSE, Mini–Mental State Examination ; NR, not reported; OPC, outpatient clinic; SNF, skilled nursing facility.

Most interventions were delivered by nurses (n=6),^{32 44 55 58 67 68 78 79 84 91 116} and physicians (n=6),3258 67,69 72 91 116 followed by psychologists (n=2).^{47 76} Interventions took place most frequently in hospitals (n=6),^{32 47 58 69 91 116 124 136} followed by participants’ homes (n=2),^{33 76} outpatient clinic (n=1)⁷² and senior centre (n=1).¹⁰⁸ The setting was not reported in one intervention.^{67 68} Two interventions took place in multiple settings: hospital-to-home (n=1),^{55 78 79 84} and hospital-to-outpatient clinic (n=1) (figure 3).⁴⁴ Intervention frequency, delivery and duration are reported in table 4.

Interventions for the social dimension

Interventions addressed the activation or enhancement of social support for people with HF and/or caregivers (n=8),^{32 33 47 55 59 69 72 78 79 84 107} or the assessment of the social dimension of frailty (n=5) (table 5).^{32 55 58 72 78 79 84 91 116} The activation or enhancement of social support included care coordination through social facilitation (n=1),¹⁰⁷ multilevel discharge plan that activated resources based on social needs (n=1),⁶⁹ and the mobilisation of personal, social and familial resources (n=1).⁴⁷ Additionally, information on social support services, and encouragement to participate in senior activity programmes were provided (n=2),^{32 33} as well as improved patient communication with health providers was targeted (n=1).¹⁰⁷ A support café was set up for caregivers, offering a space where to address concerns and receive advice on how to support their relatives (n=1).⁵⁹ The assessment of the social dimension of frailty included patients’ social networks, activities and related issues (n=4).^{32 55 72 78 79 84 116} Other assessments included difficult home situations (n=1),^{58 91} financial conditions (n=1)³² and caregivers’ capabilities and burden (n=2).^{32 116}

Table 5. Characteristics of interventions to address social dimension of frailty in people with heart failure.

Reference	Intervention components (What?)	Providers (Who?)	How much?	Where?
59	Support café for relatives to provide support in dealing with their worries and in supporting cardiac patients	Cardiac nurse, Psychologist, social worker*	During hospitalisation and follow-up at 1 and 3 months	Hosp., home
58 91	Problematic home situation, included social intake and assessment	Geriatric nurse and/or social worker	Visited and CGA at 24 hours of admission. Daily bedside visits and weekly interdisciplinary meeting	Hosp.
116	Evaluating the primary caregiver’s capabilities and the patient’s social situation	Geriatrician, nurse, social worker*	NR	Hosp.
72	Assessment with CGA and intervention†	Geriatrician and/or social worker	First visit <10 days after discharge, other visits 3, 6 and 12 months after discharge	OPC
55 78 79 84	Follow-up integrated care based on CGA for social issues†	Cardiac nurse and/or community nurse	Programme with 3 phases: in clinical, the discharge, the postdischarge phase with 4–5 home visits (3 days, 1, 3, 6, 12 weeks)	Hosp., home
107	Care coordination used social facilitation to support patient and enhanced patient ability to communicate with health providers	APN, registered nurse	1 session every 2 weeks for 12 months	Home
69	Multilevel guided discharge plan: activation of resources according to the social needs†	Physician	NR	Hosp.
32	Assessment of social network and activities, caregiver burden, need for social or financial support. Stimulate senior activity programmes, caregivers support, additional home care, inform about available support services	Geriatrician, geriatric nurse, cardiologist, cardiac nurse*	Within 48 hours of admission, during hospitalisation including weekly meeting between geriatric nurse and cardiac nurse	Hosp.
47	Activation of personal/socio familial resources†	Psychologist	During hospitalisation	Hosp.
33	Encourage using community resources†	Care manager	2 calls per month (first 3–4 months), and after 1 call per month for 9 months	Home

^*No details are provided on which provider performs which intervention.

^†No additional information is provided.

APN, advance practice nurse; CGA, comprehensive geriatric management; home, participant’s home; hosp, hospital; NR, not reported; OPC, outpatient clinic.

Most interventions were delivered by nurses (n=6),^{32 55 58 59 78 79 84 91 107 116} followed by physicians (n=4),^{32 69 72 116} social workers (n=4),^{58 59 72 91 116} and psychologists (n=2).^{47 59} Interventions took place most frequently in hospitals (n=5),^{32 47 58 69 91 116} followed by participants’ homes (n=2),^{33 107} and outpatient clinics (n=1).⁷² Two interventions took place in hospital-to-home settings (n=2) (figure 3).^{55 59 78 79 84} Intervention frequency, delivery and duration are reported in table 5.

Other characteristics of interventions to address frailty in people with HF

93 reports described interventions in general terms. 19 reports described their interventions in terms of using a comprehensive approach,1618 21 34 42 71 92 94 101,103 117 118 128 129 164 167 adopting an individualised strategy (n=18),^{13 35 36 41 48 65 74 81 101 104 105 110 123 131 132 134 141 150} using follow-up (n=8),^{36 43 75 100 121 148 175 176} integrating digital health technology (n=7),^{14 50 75 83 128 147 170} adopting collaborative care models (n=8),^{14 17 22 96 118 133} using the shared decision-making process (n=5),^{20 45 105 112 128} involving the caregivers in the interventions (n=8),^{20 37 45 46 50 120 121 168} and integrating palliative and end-of-life interventions (n=5).^{46 50 71 118 119} Regarding the comprehensive approach, this included comprehensive geriatric assessment,^{34 71 128 168} home-based cardiac rehabilitation,^{16 92 103 129 169} cardiac rehabilitation with coordinated care,¹⁰¹ a whole-system perspective⁹⁴ and structured interventions addressing the complex relationships of frailty dimensions.^{42 102 118 164} Regarding individualised strategy, this included tailoring the intervention to people’s abilities and preferences,^{13 17 35 41 65 81 101 105 134 141 150} individualised self-care support,³⁶ integration of intervention to behaviour and lifestyle modification,¹⁰⁴ progressive physical rehabilitation¹¹⁰ and prioritisation of therapeutic strategies.⁴⁸ Regarding the follow-up, this included early and frequent follow-up^{36 43 121 148 176} and transitional programme.^{100 175} Regarding collaborative care models, they included intervention delivery by a multidisciplinary team^{14 22 118 133} or by a cardiology and geriatric team to develop integrated care.⁹⁶ Regarding caregivers involvement, this included family meetings,³⁷ participation of patient and caregivers in discussions to determine the care plan^{20 45 168} and involvement in educational interventions provided to the patient.¹²⁰ Regarding the use of digital health technology, this included communication via smartphone applications and video calling,¹⁴ the promotion of social interactions with video calls and virtual reality¹⁴⁷ and telehealth coaching sessions with tele-rehabilitation.^{50 83} Palliative and end-of-life interventions included early incorporation in care planning⁴⁶ and involvement of multidisciplinary specialists.¹¹⁹

Research question 3: what outcomes were reported regarding interventions to address frailty in people with HF?

The 44 unique interventions reported outcomes across the frailty dimensions, as well as clinical, patient-reported and economic outcomes. Physical-functional dimension outcomes concerned physical function (n=22),3140 47 58 73 76 80 84 89 90 97 108 111 113 126 130 135,138 142 145 146 149 151 functional status (n=13),3147 58 61 69 72 73 78 84 88,91 107 116 160 muscle strength (n=8),7391 111 146 149 151,154 157 aerobic capacity (n=5),^{40 76 146 152 171} level of physical activity (n=4)^{31 59 80 166} and hospital-acquired disability (n=1).^{124 136} Clinical dimension outcomes concerned cardiac function (n=7),^{31 73 76 80 111 146 157} nutritional status (n=7),^{44 47 76 87 146 152 157} incidence of falls (n=5),^{31 32 44 58 61 91} incidence of fractures (n=1),⁶¹ adherence to medication (n=4)^{69 76 78 84 107} and polypharmacy (n=2).^{67 68 72} Psycho-cognitive dimension outcomes concerned the mood disturbance including anxiety disorders and depression symptoms (n=13),3133 47 73 76 78 84 89 90 97 107 113 124 126 130 136,138 142 145 146 cognitive function (n=8)^{47 58 72 91 97 107 108 111 113 126 130 137 138 142 151 153 154} and incidence of delirium (n=3).^{32 44 58 91} No outcome was reported for the social dimension. Clinical outcomes included mortality (n=21),3244 51 58 60 61 66 69 72 77,79 84 86 88 89 91 95 97 98 113 116 124 126 130 135 non-fatal events (n=7),^{40 51 58 60 61 77 88 91 95 157} hospital readmission (n=13),3239 44 51 58 60 61 66 70 72 78 84 88 91 97 113 124 126 130 136,138 142 151 153 154 166 hospitalisation (n=7),67,6972 86 98 158 161 emergency department visits (n=3),^{66 69 98} admission to intensive care (n=1),^{61 88} length of stay (n=5),^{32 44 58 61 88 89 91} living days out of hospital (n=1)⁶⁹ or admission to a nursing home or rehabilitation facility (n=3).^{32 58 91 98} Patient-reported outcomes concerned quality of life (n=22),3133 40 47 58,61 72 73 76 78 80 84 88 frailty (n=8),^{47 59 76 87 97 113 126 130 135 137 138 142 149 157 166} self-efficacy (n=2),^{51 60 145} HF self-management (n=1),⁹⁸ coping strategies (n=1),⁵⁹ self-care behaviour (n=1),⁷⁶ patient experiences (n=1),⁵⁹ positive and active engagement in life (n=1),⁵⁹ self-perceived health (n=1)^{58 91} and personality characteristics (n=1).⁷⁶ Economic outcomes included cost-effectiveness and/or health services utilisation (n=5).^{33 51 60 67 68 98}

Discussion

This scoping review is the first to comprehensively map interventions addressing frailty in people with HF across all dimensions of frailty. Most of the identified reports focused on interventions addressing the physical-functional or clinical dimensions; much less reports focused on the psycho-cognitive and social dimensions. This highlights an important imbalance in interventions across all dimensions of frailty: exercise programmes, medication reviews and nutritional interventions are relatively well explored, whereas strategies addressing cognitive decline, psychological distress or social isolation remain rare. This finding is consistent with previous reports^{14 16} and may reflect the influence of the phenotypic model of frailty.¹⁷⁷ Fried et al defined frailty as a biological syndrome characterised by the presence of at least three of the following physical components: unintentional weight loss, muscle weakness, slow walking speed, low physical activity and exhaustion.¹⁷⁷ Most interventions identified in this review predominantly address these components, which are embedded in the physical-functional and clinical dimensions. By contrast, the 2019 definition of frailty in people with HF recognises its multidimensional state, including physical-functional, clinical, psycho-cognitive and social dimensions.¹ The Heart Failure Frailty Score was recently developed to assess frailty in people with HF including the four dimensions of frailty.² It aims to facilitate the identification of impairment across frailty dimensions and to support clinicians for a comprehensive and multidimensional management of frailty.² To this end, further research into interventions that address the psycho-cognitive and social dimensions of frailty is needed.

Most interventions were reported with insufficient detail regarding components of the intervention, the type of health professionals involved in their delivery and the frequency and duration of intervention delivery. The lack of a detailed description was mainly identified in interventions addressing the psycho-cognitive and social dimensions. Lack of detail impairs their replication of intervention and their transferability from research studies into care contexts, which is a well-recognised issue in non-pharmacological interventions.^{178 179} The use of the TIDieR checklist and guide helped structure the results of this review and facilitated the description of those interventions which were described in sufficient detail.³⁰

Nurses were the most frequently involved healthcare providers for the clinical, psycho-cognitive and social dimensions of frailty. This finding highlights the crucial implication of nurses in frailty interventions for people with HF. Interventions carried out by nurses are recognised for being individualised and adapted to people’s needs.⁸ An individualised approach is recommended for interventions addressing frailty in people with HF.¹³ Several interventions were delivered by healthcare providers in the field of cardiology and geriatrics. Cardio-geriatric teams are crucial to define priorities in the care plan and tailor the interventions to the person’s needs and abilities.²²

In our review, hospitals, participants’ homes and multiple care settings were the most frequent care settings where interventions were delivered. In the few reports from skilled nursing facilities and senior centres, interventions in the skilled nursing facilities were delivered to address the physical-functional and clinical dimensions of frailty, while interventions in senior centres were delivered to address the psycho-cognitive dimension. The appropriate setting for interventions addressing frailty in people with HF remains a key discussion in the literature.¹⁰ People with HF who are treated in hospital or in an ambulatory setting often present distinct clinical profiles, necessitating adjustments in intervention based on individual abilities.^{10 22} Hospital-based interventions highlight the opportunity to address frailty during hospitalisation. Home-based interventions embed frailty management within the person’s daily life and align with recommendations for the management of frailty in people with HF.^{8 22} Skilled nursing facilities and senior centres are understudied care settings for delivering interventions addressing frailty in people with HF. Future research is required regarding interventions delivered in these care settings.

We did not differentiate interventions addressing frailty in people with HF according to the phenotypes of HF. Frailty has been reported to be more prevalent in people with HF with preserved ejection fraction compared with people with HF with reduced ejection fraction who are typically in older age and present a higher burden of comorbidities.¹⁸ Indeed, ESC guidelines for the diagnosis and treatment of acute and chronic HF increasingly emphasise the differentiation of treatments according to the phenotypes of HF.¹³ Future research is required regarding tailoring interventions addressing frailty according to the phenotypes of HF and their distinct characteristics.

Among the 44 unique interventions only eight addressed all four dimensions of frailty. Developing and evaluating the effectiveness of multidimensional interventions is a key priority in frailty management in people with HF.^{8 22} Future interventions should consider contextual factors, such as healthcare settings and resource availability, which influence the feasibility and implementation of interventions in clinical settings.¹⁸⁰ Multidimensional interventions are complex interventions, as they include multiple components and flexibility within the intervention.¹⁸⁰ According to the UK Medical Research Council framework for the development and evaluation of complex interventions in health, reviewing the evidence is an essential step in the development phase.¹⁸⁰ Our review provides an evidence base to inform the development of multidimensional interventions addressing frailty.

Limitations

The main limitations of this scoping review are as follows. The database search was restricted to reports published up to 8 March 2024. We did not have the capacity to perform an updated search including more recent publications. The challenge of providing the latest evidence is well known in large-scale scoping reviews.^{181 182} The backward and forward citation search as proposed in the protocol was adapted in line with the high number of reports (see methods). The critical appraisal of the included sources of evidence was not conducted. However, our research questions focused on mapping interventions. Therefore, a critical appraisal of the quality of the reports was not necessary to find answers to our research questions.²³

Conclusions

Multidimensional interventions addressing frailty in people with HF are recommended as a priority area both for healthcare and for research.^{1 2 8 11 13 22} Interventions addressing frailty in people with HF have predominantly been published for the physical-functional and clinical dimensions while psycho-cognitive and social dimensions remain understudied. Our findings highlight the need for developing multidimensional interventions to address frailty in people with HF and the requirement for more detailed descriptions of the future interventions and their associated outcomes. Systematically describing future interventions with sufficient detail will allow their replication, which will contribute to reaching the objective of improving outcomes in frail people with HF.

Data availability statement

Data are available on reasonable request.