So there is nothing to prevent your frailty post stroke. Better plan on being in great physical shape prior to your stroke so you can live off of past glory. I'm succeeding at that right now but will need to work on core strength soon.
How frailty modifies the trajectory of recovery after stroke? 10 points that you should know.
Frailty emerged as a concept to characterize the complex interrelationship of age, multiple comorbidities, and physical or cognitive impairment, which affect patients’ independency and daily activities. The operationalization of frailty was developed over two decades ago derived from the Cardiovascular Health Study. Freid et al. defined frailty as a clinical syndrome in which three or more of the following criteria were present: i) unintentional weight loss (10 lbs in past year), ii) self-reported exhaustion, iii) weakness (grip strength), iv) slow walking speed, and v) low physical activity.1
In the present article published in IJS,2 the authors reviewed the implications of frailty for stroke medicine. Perhaps, one of the most valuable lessons is how the authors summarized evidence-based concepts to enhance the traditional “eyeballing” approach in medicine to identify sick patients (sometimes expressed as a “gut feeling”) that may not be amenable to a diagnostic or therapeutic procedure.3
A recent systematic review and meta-analysis including 18 studies (n= 48,009 participants) also provided relevant information regarding the prevalence of frailty in stroke patients. Those patients were over twofold more likely to be frail than individuals without stroke (pooled OR = 2.32, 95% CI = 2.11–2.55; I2 = 0.0%).4
Overall, the prevalence frailty in a community-dwelling population age 65 years and older range between 7-10%.1, 5 Other studies showed that nearly 50% of stroke patients fulfill the frailty criteria.4
What have we learned about the influence of frailty in the management of patients with cerebrovascular disease?. Would frailty affect our decision-making process for acute reperfusion therapies, stroke prevention or rehabilitation?
Herein, I summarize 10 practical concepts that non-expert clinicians and stroke neurologists may want to know:
1) Conceptualization of Frailty: As highlighted by the authors, the concept of frailty includes the interrelationship of several characteristics. As such, ageing, comorbidities, and functional or cognitive impairments commonly co-exist, but are not exclusive. In other words, younger individuals with absence of comorbid conditions or a physical impairment may be frail. Contrarily, a 90-year-old with hypertension, dyslipidemia, and heart failure who requires assistance for banking may not qualify for frailty.
2) Frailty is the result of accumulative deficits in different areas: The development of a clinical event (i.e.: ischemic or hemorrhagic stroke) usually adds cumulative deficits manifested by a reduction in muscle strength, poorer nutrition, lower mobility and activity levels that is reflected by higher frailty scores. In frail stroke patients, this new condition typically does not fully return to the previous baseline status.6
3) Simple measures: Non-expert geriatricians can identify the cumulative deficit to assess frailty by assessing the 5 measurable components (e.g. patients’ weight, level of exhaustion or fatigue, iii) grip strength, iv) walking speed test, and v) level of physical activity (e.g. time in bed or at home)7, 8 as described by Freid et al.1
4) Frailty scales: There are different measures of
frailty that can be used depending on the clinical setting. For example,
the cumulative frailty index and the Clinical Frailty Scale (CFS) were
used at bedside or in outpatient clinics, whereas the Hospital Frailty
Risk Score was used in health services research.1, 6,
5) The use of frailty scores for patient selection/exclusion in clinical trials: Most randomized clinical trials use the modified Ranking scale (mRS) for excluding patients with pre-existing disability as a proxy measure of frailty. However, as highlighted by the authors,2 the mRS correlates but not necessarily reflect, the frailty of a potential participant. In other words, a measure of frailty may provide a more comprehensive assessment to determine patients’ eligibility as a better proxy measure of response to critical stroke therapies (e.g. reperfusion therapies).10-12
6) Frailty and reperfusion therapies: Although some studies showed a benefit with endovascular thrombectomy (EVT) among patients initially excluded (e.g. low ASPECT score- <5) from the 5T trials (Hermes collaboration),13 pre-stroke frailty is prevalent in real-world patients eligible for EVT and is an important predictor of poor outcomes.14, 15 For example, the prevalence of frailty among participants undergoing EVT was 28% and 29.7%, respectively.14, 15 After adjustment for covariates, frailty was an independent predictor of outcome. A more important consideration relates to the contemporary intention of expanding the criteria for EVT in more complex groups (e.g. low ASPECT scores). In RESCUE-Japan, an open label trial, patients with a large vessel occlusion and large ischemic areas (determined by an ASPECTS values between 3 to 5) were randomly assigned to EVT or best medical therapy. Although the authors showed higher rates of mRS 0 to 3 at 90 days in the EVT group (31.0% vs. 12.7%; p=0.002), there was no difference between groups for the traditional mRS 0 to 2 (14% vs 6.9%; p=NS). In other words, the great majority of patients had a mRS≥3 (with ~20% mortality) at 90 days. Unfortunately, there were no metrics of frailty reported in this trial, but one can speculate a 25-30% of eligible patients fulfilling a frailty criterion. These findings illustrate that i) the addition of a frailty score may have served to exclude patients that would unlikely benefit from EVT given the larger ischemic region, and ii) an potential effect modification by frailty in RESCUE-JAPAN (meaning that frail patients enrolled in this trial may not achieve a benefit with EVT given our current evidence) downplaying the results.
7) The vicious circle of frailty: As stroke patients commonly have an increased number of vascular risk factors, which is usually associated with more severe strokes and a decreased response to treatment (or functional recovery after treatment) leading to higher incident risk of post-stroke complications, longer length of hospital stay, lower likelihood to be discharge to the same place of residence prior to the stroke index and overall poorer recovery index.4, 10, 12
8) Impact of Frailty on Stroke Outcomes: Several studies showed an association between higher stroke severity, stroke disability and mortality with lower grip strength, slow gait walk and higher frailty scores.7, 14, 16-19
9) Frailty and disposition after stroke: As illustrated by the authors, a study conducted in the USA showed that nearly 50% of frail patients are discharged to nursing homes, and contrarily non-frail patients are more likely to be discharge to a rehabilitation institution.7, 20
10)Radiological features associated with frailty: Although white matter changes and “silent” ischemic stroke may affect a vast population with poorly controlled vascular risk factors, leukoaraiosis, atrophy, and remote infarcts were associated with poorer functional and cognitive outcomes at 90 days among frail patients after stroke.21, 22
In summary, frailty is a common phenomenon among stroke patients. Given the practical implications on stroke severity, length of hospitalization, outcomes and quality of life, frailty scores should be incorporated in our clinical assessment and for patient selection in randomized stroke trials.
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