You definitely don't want to be frail after your stroke. Your doctor is responsible for ensuring you don't become frail.
YOUR DOCTOR'S RESPONSIBILITY!
Frailty and cerebrovascular disease: Concepts and clinical implications for stroke medicine
Abstract
Frailty is a distinctive health state in which the ability of older people to cope with acute stressors is compromised by an increased vulnerability brought by age-associated declines in physiological reserve and function across multiple organ systems. Although closely associated with age, multimorbidity, and disability, frailty is a discrete syndrome that is associated with poorer outcomes across a range of medical conditions. However, its role in cerebrovascular disease and stroke has received limited attention. The estimated rise in the prevalence of frailty associated with changing demographics over the coming decades makes it an important issue for stroke practitioners, cerebrovascular research, clinical service provision, and stroke survivors alike. This review will consider the concept and models of frailty, how frailty is common in cerebrovascular disease, the impact of frailty on stroke risk factors, acute treatments, and rehabilitation, and considerations for future applications in both cerebrovascular clinical and research settings.
Introduction
Frailty—the state of vulnerability characterized by the cumulative multisystem decline of physiological reserves to maintain homeostasis following a stressor event1—is associated with increased morbidity and mortality across a range of medical conditions,2 though only recently has attention been paid to its role in cerebrovascular disease. Stroke represents an archetypal stressor event, and frailty may affect stroke risk factors, disease trajectory, and outcomes (Figure 1).
Figure 1. Differing trajectories in disability following stroke events in non-frail (a) and frail (b) individuals.
Frailty is a distinct clinical syndrome discrete from—but closely related to—age, multimorbidity, and disability (Figure 2). Although these conditions frequently co-exist, an individual may be frail in the absence of significant co-morbidity and disability, and without being elderly. This distinction is important, as it may be possible to attenuate or reverse frailty trajectories in order to reduce its burden on health outcomes.3
Figure 2. Schema illustrating the relationships between frailty, disability, and multimorbidity.
The prevalence of frailty rises markedly with age.4 However, as people are living longer, and living for an extended proportion of that time with greater disability and comorbidity, there is a wide variation in the health of older people. Chronological age is insufficient to capture this variation in the ageing process. Despite advocacy of the “Compression of Morbidity” paradigm—where postponement of chronic disease outweighs any increase in life-expectancy, thereby reducing time in later life with chronic disability5—some western countries have experienced worsening health across multiple age ranges.6 Shifting demographic trends with rising numbers of older, multimorbid, frailer individuals necessitate a move away from consideration of single organ disease-specific processes to a more nuanced frailty-based consideration of how the multisystem decline in physiological reserves and consequent vulnerability modifies the natural history of stroke.
This review will consider the models of frailty and how it is evaluated, prior to considering the effect of frailty along the natural history of stroke (including effects on cardiovascular risk factors preceding stroke, its role during acute stroke presentation and treatment, and impact after stroke on rehabilitation and secondary prevention). Finally, we will consider future directions and applications for frailty in both clinical care and research.
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