Frailty in stroke

 Is your hospital ready with protocols to get frail stroke survivors to 100% recovery or not? If not, find someplace that is competent in that!

 Frailty in stroke

Fariha Naeem, Terry Quinn

School of Cardiovascular and Medical Sciences, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow, UK Correspondence to Dr Terry Quinn, School of cardiovascular and medical sciences, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow, UK; Terry. Quinn@ glasgow. ac. uk Accepted 28 April 2024

ABSTRACT

Stroke is predominantly a condition of older age. So, it seems sensible that specialists working in stroke services should understand the primary clinical syndrome of ageing— frailty. Recent studies have highlighted the prevalence of frailty in stroke and its associated poor outcomes, yet frailty does not feature prominently in stroke research, practice or policy. Frailty- informed stroke care may differ from the interventional management that dominates contemporary practice. However, this is not therapeutic nihilism. A person-centred approach ensures that every care decision is appropriate and based on a shared understanding of the person’s goals and likely prognosis.(Even frail persons want 100% recovery!) We present a primer on frailty in stroke, describing definition(s), epidemiology and prognostic implications. We discuss the challenges surrounding assessment and management of frailty in stroke units and offer practical guidance suitable for the stroke clinician. IS FRAILTY IN STROKE THE NEXT TABOO? With changing societal demographics, the care of older adults increasingly domi- nates contemporary medical practice. 1 The increasing human lifespan is a success of modern medicine and public health, but longevity is not synonymous with healthy older age for all. Frailty, which could be considered the primary manifestation of ‘unhealthy’ ageing, frequently accom- panies advancing years and is a concept with which we all need to become more familiar.2 However, frailty has not featured prominently in stroke research, practice and policy. This relative neglect of frailty is not unique to stroke care; frailty is only now starting to receive attention in many aspects of healthcare. A unwillingness to discuss frailty is not unique to healthcare professionals. Many older adults in focus groups feel uncomfortable discussing frailty. Frailty is perhaps the new ‘F’ word, and a new taboo in stroke care. The need to challenge this taboo is evidenced by both the prevalence of frailty in stroke, and its effects on recovery. Frailty is common in acute stroke, with up to one in four people living with frailty following stroke.3 These people tend to have poorer outcomes across a range of measures, including mortality, length of stay and needing care home residency.3 Advances in imaging and therapeu- tics have given developments in acute stroke care that can be lifesaving and life changing for many. 4 However, these inter- ventions may not be suitable for all, and for people living with advanced frailty there is substantial uncertainty around their efficacy and appropriateness. For contemporary stroke services, moving to a model of frailty-informed practice is perhaps an exemplar of the doctrine of primum non nocere (first, do no harm). With increasing recognition of the importance of frailty in healthcare, many countries are developing frailty frame- works.5 Innovative, frailty-centric services have been proposed in primary care and areas of secondary care, including acute Case vignette The stroke team assess a man aged 86 years in the emergency department. He was having lunch in a day centre when staff noticed him struggling to speak. He has age- related macular degeneration, hypertension, ischaemic heart disease, hypothyroidism, mild cognitive impairment, and prostatic cancer, and takes multiple medications but no anticoagulants. He lives alone with home care four times a day and walks short distances with a wheeled walking aid. On initial assessment 3 hours after onset, he has a non-fluent dysphasia and right hemipa- resis. His NIHSS (National Institute of Health Stroke Scale) score is 18 out of 42. Initial imaging indicates early ischaemic change in the left middle cerebral artery territory asso- ciated with a hyperdense vessel, background atrophy and white matter hyperintensities. Should he be treated with intravenous thrombolysis and mechanical thrombec- tomy?

IS FRAILTY IN STROKE THE NEXT TABOO? With changing societal demographics, the care of older adults increasingly domi- nates contemporary medical practice. 1 The increasing human lifespan is a success of modern medicine and public health, but longevity is not synonymous with healthy older age for all. Frailty, which could be considered the primary manifestation of ‘unhealthy’ ageing, frequently accom- panies advancing years and is a concept with which we all need to become more familiar.2 However, frailty has not featured prominently in stroke research, practice and policy. This relative neglect of frailty is not unique to stroke care; frailty is only now starting to receive attention in many aspects of healthcare. A unwillingness to discuss frailty is not unique to healthcare professionals. Many older adults in focus groups feel uncomfortable discussing frailty. Frailty is perhaps the new ‘F’ word, and a new taboo in stroke care. The need to challenge this taboo is evidenced by both the prevalence of frailty in stroke, and its effects on recovery. Frailty is common in acute stroke, with up to one in four people living with frailty following stroke.3 These people tend to have poorer outcomes across a range of measures, including mortality, length of stay and needing care home residency.3 Advances in imaging and therapeu- tics have given developments in acute stroke care that can be lifesaving and life changing for many. 4 However, these inter- ventions may not be suitable for all, and for people living with advanced frailty there is substantial uncertainty around their efficacy and appropriateness. For contemporary stroke services, moving to a model of frailty-informed practice is perhaps an exemplar of the doctrine of primum non nocere (first, do no harm). With increasing recognition of the importance of frailty in healthcare, many countries are developing frailty frame- works.5 Innovative, frailty-centric services have been proposed in primary care and areas of secondary care, including acuteunscheduled admissions, critical care and surgery.6–8 Stroke predominantly develops in older adults, pres- ents as an emergency with high acuity and necessitates interventional procedures. So, it seems counterintui- tive that frailty has been largely ignored in planning and delivering stroke services, and does not feature in recent UK national stroke guidelines or policy. The same is also true of guidelines in frailty, where stroke is rarely or never mentioned. Because frailty is often considered the core busi- ness of geriatric medicine, stroke physicians might argue that frailty is someone else’s problem. Given the increasing numbers of older adults living with frailty, and finite geriatric medicine resources, this attitude is no longer tenable, and will lead to clinician frustra- tion and potential patient harm.3 Even in healthcare systems where geriatrics services deliver stroke care, the increasing specialisation and interventional options risk moving stroke care further away from traditional geriatric medicine. We cannot assume that all stroke clinicians are trained or comfortable with managing frailty. Every member of the multidisciplinary team— stroke physicians (regardless of their medical training background), allied healthcare professionals, nursing staff and healthcare support workers—should under- stand the needs of people living with frailty.

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