Frailty and cerebrovascular disease: Concepts and clinical implications for stroke medicine

The impact of palliative care on the frailty-stroke continuum: from theoretical concepts to practical aspects

With a constant increase in prevalence and incidence worldwide, stroke remains a public health issue in the 21st century. Additionally, population aging inevitably leads to increased vulnerability in the general population, a clinical state known as frailty. While there are adequate guidelines on the treatment of stroke in the acute setting, there are a lot of gaps regarding the chronic management of stroke patients, particularly the frail ones. From the therapeutic point of view, palliative care could be the key to offering complex and individualized treatment to these frail chronic stroke patients. In the context of the heterogeneous data and incomplete therapeutic guidelines, this article provides a new and original perspective on the topic, aiming to increase awareness and understanding and improve palliative care management in stroke patients. Based on current knowledge, the authors describe a new concept called the frailty-stroke continuum and offer a detailed explanation of the intricate stroke-frailty connection in the first part. After understanding the role of palliative care in managing this kind of patients, the authors discuss the most relevant practical aspects aiming to offer an individualized framework for daily clinical practice. The novel approach consists of developing a four-step scale for characterizing frail stroke patients, with the final aim of providing personalized treatment and correctly evaluating prognosis. By pointing out the limitations of current guidelines and the challenges of new research directions, this article opens the pathway for the better evaluation of frail stroke patients, offering a better perception of patients' prognosis.

The impact of frailty on short-term prognosis in discharged adult stroke patients: A multicenter prospective cohort study

BACKGROUND

Frailty is commonly observed in stroke patients and it is associated with adverse outcomes. However, there remains a gap in longitudinal studies investigating the causal relationship between baseline frailty and short-term prognosis in discharged adult stroke patients.

OBJECTIVE

To examine the causal impact of frailty on non-elective readmission and major adverse cardiac and cerebral events, and investigate its associations with cognitive impairment and post-stroke disability.

DESIGN

A multicenter prospective cohort study.

SETTING

Two tertiary hospitals in Central and Northwest China.

PARTICIPANTS

667 adult stroke patients in stroke units were included from January 2022 to June 2022.

METHODS

Baseline frailty was assessed by the Frailty Scale. Custom-designed questions were utilized to assess non-elective readmission and major adverse cardiac and cerebral events as primary outcomes. Cognitive impairment, assessed using the Mini-Mental State Examination Scale (MMSE), and post-stroke disability, measured with the Modified Rankin Scale (mRS), were considered secondary outcomes at a 3-month follow-up. The impact of baseline frailty on non-elective readmission and major adverse cardiac and cerebral events was examined using bivariate and multiple Cox regression analyses. Furthermore, associations between baseline frailty and cognitive impairment, or post-stroke disability, were investigated through generalized linear models.

RESULTS

A total of 5 participants died, 12 had major adverse cardiac and cerebral events, and 57 had non-selective readmission among 667 adult stroke patients. Frailty was an independent risk factor for non-selective readmission (hazard ratio [HR]: 2.71, 95 % confidence interval [CI]: 1.59, 4.62) and major adverse cardiac and cerebral events (HR: 3.77, 95 % CI: 1.07, 13.22) for stroke patients. Baseline frailty was correlated with cognitive impairment (regression coefficient [β]: -2.68, 95 % CI: -3.78, -1.58) adjusting for socio-demographic and clinical factors and follow-up interval. However, the relationship between frailty and cognitive impairment did not reach statistical significance when further adjusting for baseline MMSE (β: -0.39, 95 % CI: -1.43, 0.64). Moreover, baseline frailty was associated with post-stroke disability (β: 0.36, 95 % CI: 0.08, 0.65) adjusting for socio-demographic and clinical variables, follow-up interval, and baseline mRS.

CONCLUSIONS

The finding highlights the importance of assessing baseline frailty in discharged adult stroke patients, as it is significantly associated with non-elective readmission, major adverse cardiac and cerebral events, and post-stroke disability at 3 months. These results highlight the crucial role of screening and evaluating frailty status in improving short-term prognosis for adult stroke patients. Interventions should be developed to address baseline frailty and mitigate the short-term prognosis of stroke.

TWEETABLE ABSTRACT

Baseline frailty predicts non-elective readmission, major adverse cardiac and cerebral events, and post-stroke disability in adult stroke patients. @haiyanhexyyy.

Functional outcome improvement from 3 to 12 months after intracerebral hemorrhage

INTRODUCTION

Most intracerebral hemorrhage (ICH) trials assessed outcome at 3 months but the recovery trajectory of ICH survivors may continue up to 1 year after the index event. We aimed to describe the predictors of functional outcome improvement from 3 to 12 months after ICH.

MATERIALS AND METHODS

Retrospective analysis of patients admitted to six European Stroke Centers for supratentorial ICH. Functional outcome was measured with the modified Rankin Scale (mRS) at 3 and 12 months. Predictors of functional outcome improvement were explored with binary logistic regression.

RESULTS

We included 703 patients, of whom 245 (34.9%) died within 3 months. Among survivors, 131 (28.6%) had an mRS improvement, 78 (17.0%) had a worse mRS and 249 (54.4%) had a stable functional status at 12 months. Older age and the presence of baseline disability (defined as pre-stroke mRS > 1), were associated with lower odds of functional outcome improvement (Odds Ratio (OR) 0.98 per year increase, 95% Confidence Interval (CI) 0.96-1.00, p = 0.017 and OR 0.45, 95% CI 0.25-0.81, p = 0.008 respectively). Conversely, deep ICH location increased the probability of long term mRS improvement (OR 1.67, 95% CI, 1.07-2.61, p = 0.023). Patients with mild-moderate disability at 3 months (mRS 2-3) had the highest odds of improvement at 12 months (OR 8.76, 95% CI 3.68-20.86, p < 0.001).

DISCUSSION AND CONCLUSION

Long term recovery is common after ICH and associated with age, baseline functional status, mRS at 3 months and hematoma location. Our findings might inform future trials and improve long-term prognostication in clinical practice.

Imaging Assessments and Clinical Significance of Brain Frailty in Moyamoya Disease

BACKGROUND AND PURPOSE

Imaging assessment of brain frailty in ischemic stroke has been extensively studied, while the correlation between brain frailty and Moyamoya disease remains obscure. This study aimed to investigate the imaging characteristics of brain frailty and its clinical applications in Moyamoya disease.

MATERIALS AND METHODS

This study included 60 patients with Moyamoya disease (107 hemispheres). All patients were divided into stroke and nonstroke groups based on clinical symptoms and imaging findings. The modified brain frailty score was adapted to consider 4 imaging signs: white matter hyperintensity, enlargement of perivascular space, old vascular lesions, and cerebral microbleed. The relative CBF of the MCA territory was quantified using pseudocontinuous arterial-spin labeling. Surgical outcome after revascularization surgery was defined by the Matsushima grade.

RESULTS

The relative CBF of the MCA territory decreased as the modified brain frailty score and periventricular white matter hyperintensity grades increased (ρ = -0.22, P = .02; ρ = -0.27, P = .005). Clinically, the modified brain frailty score could identify patients with Moyamoya disease with stroke (OR = 2.00, P = .02). Although the modified brain frailty score showed no predictive value for surgical outcome, basal ganglia enlargement of the perivascular space had a significant correlation with the postoperative Matsushima grade (OR = 1.29, P = .03).

CONCLUSIONS

The modified brain frailty score could reflect a cerebral perfusion deficit and clinical symptoms of Moyamoya disease, and its component basal ganglia enlargement of perivascular space may be a promising marker to predict surgical outcome and thus aid future clinical decision-making.

Stroke and frailty index: a two-sample Mendelian randomisation study

INTRODUCTION

Previous observational studies have found an increased risk of frailty in patients with stroke. However, evidence of a causal relationship between stroke and frailty is scarce. The aim of this study was to investigate the potential causal relationship between stroke and frailty index (FI).

METHODS

Pooled data on stroke and debility were obtained from genome-wide association studies (GWAS).The MEGASTROKE Consortium provided data on stroke (N = 40,585), ischemic stroke (IS,N = 34,217), large-vessel atherosclerotic stroke (LAS,N = 4373), and cardioembolic stroke (CES,N = 7 193).Summary statistics for the FI were obtained from the most recent GWAS meta-analysis of UK BioBank participants and Swedish TwinGene participants of European ancestry (N = 175,226).Two-sample Mendelian randomization (MR) analyses were performed by inverse variance weighting (IVW), weighted median, MR-Egger regression, Simple mode, and Weighted mode, and heterogeneity and horizontal multiplicity of results were assessed using Cochran's Q test and MR-Egger regression intercept term test.

RESULTS

The results of the current MR study showed a significant correlation between stroke gene prediction and FI (odds ratio 1.104, 95% confidence interval 1.064 - 1.144, P < 0.001). In terms of stroke subtypes, IS (odds ratio 1.081, 95% confidence interval 1.044 - 1.120, P < 0.001) and LAS (odds ratio 1.037, 95% confidence interval 1.012 - 1.062, P = 0.005). There was no causal relationship between gene-predicted CES and FI. Horizontal multidimensionality was not found in the intercept test for MR Egger regression (P > 0.05), nor in the heterogeneity test (P > 0.05).

CONCLUSIONS

This study provides evidence for a causal relationship between stroke and FI and offers new insights into the genetic study of FI.

The added value of frailty assessment as the premorbid stroke status on activities of daily living in patients with acute stroke, stratified by stroke severity

BACKGROUND

The modified Rankin scale (mRS) is extensively used for premorbid evaluation in patients with stroke; however, its limited capacity to assess functional status highlights the need for additional indicators such as frailty.

AIMS

This study aimed to assess the impact of the premorbid mRS score and frailty on daily living (ADL) activities at hospital discharge, focusing on varying stroke severities.

METHODS

This single-centre, prospective cohort study included patients with acute stroke aged ≥60 years. Key metrics included the frailty index for frailty assessment or mRS for functional status premorbid and the functional independence measure of the motor domain (FIM-M) at discharge for ADL outcomes. The patients were categorized into mild (0-4), moderate (5-15), and severe (16-42) groups based on the National Institute of Health Stroke Scale. Multiple hierarchical linear regression analyses were performed for each group to evaluate the influence of mRS and frailty on FIM-M scores.

RESULTS

In the mild stroke group, significant associations were observed with premorbid mRS3 (β = -0.183, p = 0.004), mRS4 (β = -0.234, p < 0.001), and frailty status (β = -0.227, p = 0.005) and FIM-M scores. Premorbid frailty did not show a significant association with the FIM-M scores in the moderate or severe stroke group. Frailty status notably contributed to changes in R², particularly in the mild stroke group (R² change = 0.031, p = 0.002). However, such changes were not evident in the other stroke severity groups.

CONCLUSION

This study emphasizes the importance of incorporating frailty assessments into premorbid evaluations, particularly when considering ADL outcomes in patients with mild stroke. Conversely, the significance of frailty in moderate-to-severe stroke was less evident.

Assessment and Management of Atrial Fibrillation in Older Adults with Frailty

Atrial fibrillation (AF) is a major driver of morbidity and mortality among older adults with frailty. Moreover, frailty is highly prevalent in older adults with AF. Understanding and addressing the needs of frail older adults with AF is imperative to guide clinicians caring for older adults. In this review, we summarize current evidence to support the assessment and management of older adults with AF and frailty, incorporating numerous recent landmark trials and studies in the context of the 2023 US AF guideline.

Psychosocial stressors associated with frailty in community-dwelling older adults in the United States

BACKGROUND

Frailty is multifactorial; however, psychosocial stressors contributing to frailty are poorly understood. This study aimed to examine whether gender, race/ ethnicity, and education are associated with differential exposure to psychosocial stressors, determine psychosocial stressors contributing to frailty, and explore the mediating psychosocial stressors pathway.

METHODS

This cross-sectional study involved 7679 community-dwelling older adults (≥65) from the Health and Retirement Study (2006 and 2008 waves). Psychosocial stressors such as loneliness, low subjective social status, financial strain, poor neighborhood cohesion, everyday discrimination, and traumatic life events were measured. Frailty was defined by the Fried phenotype measure. Multivariable logistic regressions were used to examine the association of gender, race/ethnicity, and education with psychosocial stressors, psychosocial stressors associated with frailty, and the mediating psychosocial stressors pathway.

RESULTS

Females experienced greater financial strain but lower discrimination (both p < 0.05). Older adults who identified as Hispanic, Black, and racially or ethnically minoritized experienced low subjective social status, high financial strain, low neighborhood cohesion, and high discrimination than their White counterparts (all p < 0.05). Those with lower education experienced high loneliness, low subjective social status, high financial strain, low neighborhood cohesion but lower traumatic life events (all p < 0.05). Psychosocial stressors: High loneliness, low subjective social status, high financial strain, and low neighborhood cohesion (all p < 0.05) independently increased the odds of frailty. The mediating pathway of psychosocial stressors was not significant.  CONCLUSION: Disparities exist in exposure to psychosocial stressors associated with frailty. Multilevel interventions are needed to reduce the influence of psychosocial stressors on frailty.

Physical frailty trajectories in older stroke survivors: Findings from a national cohort study

BACKGROUND

Physical frailty (PF) is highly prevalent and associated with undesirable outcomes in stroke survivors aged 65 years or older. However, the long-term trajectories of PF are understudied in those older stroke survivors.

AIMS

To identify PF trajectories and relative predictors associated with the PF trajectories in older stroke survivors.

DESIGN

This is a secondary analysis of a population-based cohort study in the United States.

METHODS

Six hundred and sixty-three older stroke survivors from the National Health and Ageing Trends Study from 2015 to 2021 were included. PF was operationally assessed based on the Fried Frailty Phenotype. Trajectories were identified by group-based trajectory modelling. The associations between sociodemographic characteristics, clinical factors, symptoms, cognitive factors and PF trajectories were examined using the design-based logistic regression method.

RESULTS

Most older stroke survivors were 75 and older (63.32%), female (53.99%), white (80.54%) and partnered (50.64%). Two PF trajectory groups were identified (Group 1: low risk, robust; 49.47%; Group 2: high risk, deteriorating; 50.53%). Individuals were at a higher risk to be assigned to Group 2 if they were 75-84 years (adjusted odds ratio [aOR]: 2.16, 95% CI: 1.23-3.80) or 85+ years (aOR: 2.77, 95% CI: 1.52-5.04), had fair self-reported health (aOR: 2.78, 95% CI: 1.53-5.07) or poor self-reported health (aOR: 3.37, 95% CI: 1.51-7.52), had comorbidities (aOR: 8.44, 95% CI: 1.31-54.42), had breathing problems (aOR: 2.18, 95% CI: 1.18-4.02) and had balance problems (aOR: 1.70, 95% CI: 1.06-2.73).

CONCLUSION

PF trajectories in older stroke survivors were heterogeneous and were associated with age, self-rated health status, comorbidities, breathing problems and balance problems.

IMPLICATION TO CLINICAL PRACTICE

Early, routine, dynamic screening for stroke-related physical frailty (PF) and relative predictors might be beneficial for identifying the most vulnerable individuals. Our findings might help develop strategies to manage PF progression.

REPORTING METHOD

The reporting followed the STROBE guideline.

Association of multimorbidity with mortality after stroke stratified by age, severity, etiology, and prior disability

BACKGROUND

Multimorbidity is common in patients with stroke and is associated with increased medium- to long-term mortality, but its value for clinical decision-making and case-mix adjustment will depend on other factors, such as age, stroke severity, etiological subtype, prior disability, and vascular risk factors.

AIMS

In the absence of previous studies, we related multimorbidity to long-term post-stroke mortality with stratification by these factors.

METHODS

In patients ascertained in a population-based stroke incidence study (Oxford Vascular Study; 2002-2017), we related pre-stroke multimorbidity (weighted/unweighted Charlson comorbidity index (CCI)) to all-cause/vascular/non-vascular mortality (1/5/10 years) using regression models adjusted/stratified by age, sex, predicted early outcome (THRIVE score), stroke severity (NIH stroke scale (NIHSS)), etiology (Trial of Org 10172 in Acute Stroke Treatment (TOAST)), premorbid disability (modified Rankin Scale (mRS)), and non-CCI risk factors (hypertension, hyperlipidemia, atrial fibrillation, smoking, deprivation, anxiety/depression).

RESULTS

Among 2454 stroke patients (M/SD age: 74.1/13.9 years; 48.9% male; M/SD NIHSS: 5.7/7.0), 1375/56.0% had ⩾ 1 CCI comorbidity and 685/27.9% had ⩾ 2. After age/sex adjustment, multimorbidity (unweighted CCI ⩾ 2 vs 0) predicted (all ps < 0.001) mortality at 1 year (aHR = 1.57, 95% CI = 1.38-1.78), 5 years (aHR = 1.73, 95% CI = 1.53-1.96), and 10 years (aHR = 1.79, 95% CI = 1.58-2.03). Although multimorbidity was independently associated with premorbid disability (mRS > 2: aOR = 2.76, 2.13-3.60) and non-CCI risk factors (hypertension: 1.56, 1.25-1.95; hyperlipidemia: 2.58, 2.03-3.28; atrial fibrillation: 2.31; 1.78-2.98; smoking: 1.37, 1.01-1.86), it predicted death after adjustment for all measured confounders (10-year-aHR = 1.56, 1.37-1.78, p < 0.001), driven mainly by non-vascular death (aHR = 1.89, 1.55-2.29). Predictive value for 10-year all-cause death was greatest in patients with lower expected early mortality: lower THRIVE score (pint < 0.001), age < 75 years (aHR = 2.27, 1.71-3.00), NIHSS < 5 (1.84, 1.53-2.21), and lacunar stroke (3.56, 2.14-5.91). Results were similar using the weighted CCI.

CONCLUSION

Pre-stroke multimorbidity is highly prevalent and is an independent predictor of death after stroke, supporting its inclusion in case-mix adjustment models and in informing decision-making by patients, families, and carers. Prediction in younger patients and after minor stroke, particularly for non-vascular death, suggests potential clinical utility in targeting interventions that require survival for 5-10 years to achieve a favorable risk/benefit ratio.

DATA ACCESS STATEMENT

Data requests will be considered by the Oxford Vascular Study (OXVASC) Study Director (P.M.R.-peter.rothwell@ndcn.ox.ac.uk).

Prevalence of Arm Weakness, Pre-Stroke Outcomes and Other Post-Stroke Impairments Using Routinely Collected Clinical Data on an Acute Stroke Unit

INTRODUCTION

The prevalence of upper limb motor weakness early post-stroke may be changing, which can have clinical and research implications. Our primary aim was to describe the prevalence of upper limb motor weakness early post-stroke, with a secondary aim to contextualize this prevalence by describing pre-stroke outcomes, other post-stroke impairments, functional activities, and discharge destination.

METHODS

This cross-sectional observational study extracted clinical data from confirmed stroke patients admitted to a metropolitan stroke unit over 15-months. The primary upper limb weakness measure was Shoulder Abduction and Finger Extension (SAFE) score. Demographics (eg, age), clinical characteristics (eg, stroke severity), pre-stroke outcomes (eg, clinical frailty), other post-stroke impairments (eg, command following), functional activities (eg, ambulation), and discharge destination were also extracted.

RESULTS

A total of 463 participants had a confirmed stroke and SAFE score. One-third of patients received ≥1 acute medical intervention(s). Nearly one-quarter of patients were classified as frail pre-stroke. Upper limb weakness (SAFE≤8) was present in 35% [95% CI: 30%-39%] at a median of 1-day post-stroke, with 22% presenting with mild-moderate weakness (SAFE5-8). The most common other impairments were upper limb coordination (46%), delayed recall (41%), and upper limb sensation (26%). After a median 3-day acute stroke stay, 52% of the sample were discharged home.

CONCLUSION

Upper limb weakness was present in just over a third (35%) of the sample early post-stroke. Data on pre-stroke outcomes and the prevalence of other post-stroke impairments highlights the complexity and heterogeneity of stroke recovery. Further research is required to tease out meaningful recovery phenotypes and their implications.

The volume and the distribution of premorbid white matter hyperintensities: Impact on post-stroke aphasia

White matter hyperintensities (WMH) are a radiological manifestation of progressive white matter integrity loss. The total volume and distribution of WMH within the corpus callosum have been associated with pathological cognitive ageing processes but have not been considered in relation to post-stroke aphasia outcomes. We investigated the contribution of both the total volume of WMH, and the extent of WMH lesion load in the corpus callosum to the recovery of language after first-ever stroke. Behavioural and neuroimaging data from individuals (N = 37) with a left-hemisphere stroke were included at the early subacute stage of recovery. Spoken language comprehension and production abilities were assessed using word and sentence-level tasks. Neuroimaging data was used to derive stroke lesion variables (volume and lesion load to language critical regions) and WMH variables (WMH volume and lesion load to three callosal segments). WMH volume did not predict variance in language measures, when considered together with stroke lesion and demographic variables. However, WMH lesion load in the forceps minor segment of the corpus callosum explained variance in early subacute comprehension abilities (t = -2.59, p = .01) together with corrected stroke lesion volume and socio-demographic variables. Premorbid WMH lesions in the forceps minor were negatively associated with early subacute language comprehension after aphasic stroke. This negative impact of callosal WMH on language is consistent with converging evidence from pathological ageing suggesting that callosal WMH disrupt the neural networks supporting a range of cognitive functions.

Genetic liability to frailty in relation to functional outcome after ischemic stroke

BACKGROUND

Frailty appears to be associated with unfavorable prognosis after stroke in observational studies, but the causality remains largely unknown.

AIMS

The aim of this study is to investigate the potential causal effect of frailty on functional outcome at 3 months after ischemic stroke using the Mendelian randomization (MR) framework.

METHODS

Genetic instruments for frailty index were identified in a genome-wide association study meta-analysis including 175,226 individuals of European descent. Corresponding genetic association estimates for functional outcome after ischemic stroke at 90 days were taken from the Genetic of Ischemic Stroke Functional Outcome (GISCOME) network of 6021 patients. We performed inverse-variance weighted MR as the main analyses, followed by several alternate methods and sensitivity analyses.

RESULTS

In univariable MR, we found evidence that genetically predicted higher frailty index (odds ratio (OR) = 5.12; 95% confidence interval (CI) = 1.31-20.09; p = 0.019) was associated with worse functional outcome (modified Rankin Scale score ⩾3) after ischemic stroke. In further multivariable MR adjusting for potential confounding traits including body mass index, C-reactive protein, inflammatory bowel disease, and smoking initiation, the overall patterns between genetic liability to frailty and poor functional outcome status remained. Sensitivity analyses with complementary methods and with model unadjusted for baseline stroke severity (OR = 4.19; 95% CI = 1.26-13.90; p = 0.019) yielded broadly concordant results.

CONCLUSIONS

The present MR study suggested a possible causal effect of frailty on poor functional outcome after ischemic stroke. Frailty might represent a potential target for intervention to improve recovery after ischemic stroke.

Cardiometabolic Disorders Are Important Correlates of Vulnerability in Hospitalized Older Adults

With an increasingly aging population worldwide, the concept of multimorbidity has attracted growing interest over recent years, especially in terms of frailty, which leads to progressive multisystem decline and increased adverse clinical outcomes. The relative contribution of multiple disorders to overall frailty index in older populations has not been established so far. This study aimed to assess the association between the vulnerable elders survey-13 (VES-13) score, which is acknowledged to be one of the most widely used measures of frailty, and the most common accompanying diseases amongst hospitalized adults aged 60 years old and more. A total of 2860 participants with an average age of 83 years were included in this study. Multiple logistic regression with adjustment for age and nutritional status was used to assess the independent impact of every particular disease on vulnerability. Diabetes mellitus type 2, coronary artery disease, atrial fibrillation, heart failure, chronic kidney disease, osteoarthritis, fractures, eyes disorders, depression, dementia, pressure ulcers, and urinary incontinence were associated with higher scores of VES-13. Hospital admission of older subjects with those conditions should primarily draw attention to the risk of functional decline, especially while qualifying older patients for further treatment in surgery and oncology. At the same time, lipid disorders, gastrointestinal diseases, higher body mass index, and albumins level were related to a lower risk of being vulnerable, which may be attributed to a younger age and better nutritional status of those patients.

Liver Enzymes and the Risk of Stroke among the General Japanese Population: A Prospective Cohort Study

INTRODUCTION

Stroke is a major cause of morbidity and mortality. Liver enzymes, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transpeptidase (GGT), are markers of liver diseases with potential cardiovascular implications. This study aimed to investigate the prospective association between liver enzymes and stroke risk.

METHODS

We analyzed data from 3,379 men and 4,007 women without cardiovascular disease and registered in the Suita Study, a Japanese population-based prospective cohort study. The hazard ratios (HRs) and 95% confidence intervals (95% CIs) of stroke risk were estimated per quintiles of ALT, AST, and GGT in men and women.

RESULTS

Within a median follow-up period of 16.7 years, 438 incident stroke events were diagnosed. In men, compared to the second quintiles, the fifth (highest) quintiles of liver enzymes showed increased stroke risks: HRs (95% CIs) = 2.07 (1.35, 3.18) in ALT, 1.66 (1.10, 2.53) in AST, and 1.76 (1.11, 2.81) in GGT. The associations did not change with cerebral infarction risk: HRs (95% CIs) = 2.09 (1.24, 3.50) in ALT, 1.84 (1.11, 3.06) in AST, and 1.74 (1.00, 3.04) in GGT. The lowest ALT, AST, and GGT quintiles tended to show increased stroke and cerebral infarction risks, yet these associations were statistically insignificant. No such associations were shown in women.

CONCLUSION

Elevated ALT, AST, and GGT levels were associated with increased stroke and cerebral infarction risks among Japanese men.

Mechanical thrombectomy for treatment of acute ischemic stroke in frail patients: a systematic review of the literature

BACKGROUND

The overall safety and efficacy of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) in frail patients is not well delineated. This systematic review aims to summarize and compare outcomes in frail and non-frail patients who underwent MT for AIS.

METHODS

A systematic review of the literature was performed using PubMed, Ovid Medline, and Web of Science to identify studies with outcomes-related data for frail patients with MT-treated AIS. The recanalization rate, procedural complications, and clinical outcome at 90-day follow-up were collected.

RESULTS

In the four included studies there were 642 frail patients and 499 non-frail patients. Frail patients had reduced rates of good functional outcomes (29% vs 42%; χ²=22, p<0.01) and increased 90-day mortality (51% vs 25%; χ²=38, p<0.01) compared with non-frail patients.

CONCLUSION

MT for treatment of AIS in frail patients may be associated with worse rates of morbidity and mortality along with reduced efficacy. Given that no studies to date directly compare conservative measures with endovascular management for AIS in frail patients, more studies are required to further evaluate and identify characteristics that may improve outcomes in these patients.

Higher Hospital Frailty Risk Score Is Associated With Increased Risk of Stroke: Observational and Genetic Analyses

BACKGROUND

Frailty is a prevalent state associated with several aging-related traits and conditions. The relationship between frailty and stroke remains understudied. Here we aim to investigate whether the hospital frailty risk score (HFRS) is associated with the risk of stroke and determine whether a significant association between genetically determined frailty and stroke exists.

DESIGN

Observational study using data from All of Us research program and Mendelian Randomization analyses.

METHODS

Participants from All of Us with available electronic health records were selected for analysis. All of Us began national enrollment in 2018 and is expected to continue for at least 10 years. All of Us is recruiting members of groups that have traditionally been underrepresented in research. All participants provided informed consent at the time of enrollment, and the date of consent was recorded for each participant. Incident stroke was defined as stroke event happening on or after the date of consent to the All of Us study HFRS was measured with a 3-year look-back period before the date of consent for stroke risk. The HFRS was stratified into 4 categories: no-frailty (HFRS=0), low (HFRS ≥1 and <5), intermediate (≥5 and <15), and high (HFRS ≥15). Last, we implemented Mendelian Randomization analyses to evaluate whether genetically determined frailty is associated with stroke risk.

RESULTS

Two hundred fifty-three thousand two hundred twenty-six participants were at risk of stroke. In multivariable analyses, frailty status was significantly associated with risk of any (ischemic or hemorrhagic) stroke following a dose-response way: not-frail versus low HFRS (HR, 4.9 [CI, 3.5-6.8]; P<0.001), not-frail versus intermediate HFRS (HR, 11.4 [CI, 8.3-15.7]; P<0.001) and not-frail versus high HFRS (HR, 42.8 [CI, 31.2-58.6]; P<0.001). We found similar associations when evaluating ischemic and hemorrhagic stroke separately (P value for all comparisons <0.05). Mendelian Randomization confirmed this association by indicating that genetically determined frailty was independently associated with risk of any stroke (OR, 1.45 [95% CI, 1.15-1.84]; P=0.002).

CONCLUSIONS

Frailty, based on the HFRS was associated with higher risk of any stroke. Mendelian Randomization analyses confirmed this association providing evidence to support a causal relationship.

[The concept and practical management of frailty in neurology]

Frailty is a clinical situation of decreased homeostatic reserve that, after a minor trigger (acute illness, fall, taking a drug...) increases the risk of an adverse event such as hospital admission, institutionalization, functional and/or cognitive decline, death, etc. Frailty can be understood as physical frailty, Fried's phenotype, a true geriatric syndrome that can be reversible by avoiding its progression to more advanced stages of irreversibility and dependence, and Rockwood's frailty due to accumulation of deficits, as a continuum of health or classification typology of the elderly along the frailty spectrum (healthy, robust, vulnerable, mild-moderate-severe and extreme frailty or end of life). The diagnosis of physical frailty is part of the comprehensive geriatric assessment, recommending the use of a performance test such as gait speed (<0,8m/s), Timed Up and Go (>12 s) or Short Physical Performance Battery (<10). Physical frailty is reversible by a multidisciplinary management based on three fundamental pillars: multicomponent physical exercise and resistance training, adequate protein and micronutrient intake (leucine, vitamin D, etc.) and appropriate pharmacological prescription, management of comorbidity and geriatric syndromes. Frailty is a risk factor for neurological disease progression and increased risk of adverse events in neurodegenerative diseases such as mild cognitive impairment, dementia, Parkinson's disease and cerebrovascular disease. Frailty based on the Clinical Frailty Scale or VIG-Frail shows patient typologies in relation to a greater or lesser state of fragility, being a basic prognostic tool of great utility in making diagnostic and therapeutic management decisions. It opens up a new opportunity for improvement in the management of neurological disease in the diagnosis and treatment of frailty.

Association of pre-stroke frailty and health-related factors with post-stroke functional independence among community-dwelling Chinese older adults

OBJECTIVES

Frailty is associated with a range of poor post-stroke outcomes. There is still a lack of comprehensive understanding of the temporal relationship between pre-stroke frailty status and other related factors with functional recovery after stroke. This study aims to evaluate pre-stroke frailty status and health-related factors associated with functional independence among community-dwelling Chinese older adults.

MATERIALS AND METHODS

The dataset based on the China Health and Retirement Longitudinal Study (CHARLS) conducted in 28 provinces across China was used. The pre-stroke frailty status was assessed using the Physical Frailty Phenotype (PFP) scale with the 2015 wave data. The PFP scale consisted of five criteria with a total score of 5, and categorized into non-frail (0 point), prefrail (1 and 2 points), and frail (3 or more points). Covariates included demographic factors (age, sex, marital status, residence, and education level) and health-related variables (comorbidities, self-reported health status and cognition). Activities of daily living (ADL) and instrumental activities of daily living (IADL) were assessed as the functional outcomes, with difficulties in at least one of the 6 ADL items and 5 IADL items defined as ADL/IADL limitation respectively. A logistic regression model was used to estimate the associations.

RESULTS

A total of 666 participants who were newly diagnosed with stroke during the 2018 wave were included. 234 (35.1%) participants were classified as non-frail, 380 (57.1%) participants were classified as prefrail, and 52 (7.8%) participants were classified as frail. Pre-stroke frailty was significantly associated with ADL and IADL limitations post stroke. Additional significant variables with ADL limitation were age, female and more comorbidities. Additional significant variables with IADL limitation were age, female, married or cohabitating, more comorbidities and pre-stroke lower global cognitive score.

CONCLUSION

Frailty status was associated with ADL and IADL limitations after stroke. A more comprehensive assessment of frailty in older people may help to identify those with most significant risk for declining functional capacities after stroke and to develop appropriate intervention strategies.

Predicting poststroke dyskinesia with resting-state functional connectivity in the motor network

SIGNIFICANCE

Motor function evaluation is essential for poststroke dyskinesia rehabilitation. Neuroimaging techniques combined with machine learning help decode a patient's functional status. However, more research is needed to investigate how individual brain function information predicts the dyskinesia degree of stroke patients.

AIM

We investigated stroke patients' motor network reorganization and proposed a machine learning-based method to predict the patients' motor dysfunction.

APPROACH

Near-infrared spectroscopy (NIRS) was used to measure hemodynamic signals of the motor cortex in the resting state (RS) from 11 healthy subjects and 31 stroke patients, 15 with mild dyskinesia (Mild), and 16 with moderate-to-severe dyskinesia (MtS). The graph theory was used to analyze the motor network characteristics.

RESULTS

The small-world properties of the motor network were significantly different between groups: (1) clustering coefficient, local efficiency, and transitivity: MtS > Mild > Healthy and (2) global efficiency: MtS < Mild < Healthy. These four properties linearly correlated with patients' Fugl-Meyer Assessment scores. Using the small-world properties as features, we constructed support vector machine (SVM) models that classified the three groups of subjects with an accuracy of 85.7%.

CONCLUSIONS

Our results show that NIRS, RS functional connectivity, and SVM together constitute an effective method for assessing the poststroke dyskinesia degree at the individual level.

Prevalence, measurement, and implications of frailty in stroke survivors: An analysis of three global aging cohorts

BACKGROUND

Our understanding of the relationship between frailty and stroke, beyond the acute phase of stroke, is limited. We aimed to estimate the prevalence of frailty in stroke survivors using differing methods of assessment and describe relationships with stroke outcomes.

METHODS

We used data from three international population surveys (American Health and Retirement Survey/English Longitudinal Study of Ageing/Survey for Health and Retirement in Europe) of aging. Frailty status was assessed using the Fried frailty phenotype, a 40-item frailty index (FI) and the clinical frailty scale (CFS). We created estimates of frailty prevalence and assessed association of frailty with outcomes of mortality/hospital admission/recurrent stroke at 2 years follow-up using logistic regression models adjusted for age/sex. Additional analyses explored effects of adding cognitive measures to frailty assessments and of missing grip strength data.

FINDINGS

Across 9617 stroke survivors, using the frailty phenotype, 23.8% (n = 2094) identified as frail; with CFS, 30.1% (n = 2906) were moderately or severely frail; using FI, 22.7% (n = 2147) had moderate frailty and 31.9% (n = 3021) had severe frailty. Frailty was associated with increased risk of mortality/hospitalization/recurrent stroke using all three measures. Adding cognitive variables to the FI produced minimal difference in prevalence of frailty. People with physical frailty (phenotype or CFS) plus cognitive impairment had a greater risk of mortality than people with an equivalent level of frailty but no cognitive impairment. Excluding people unable to provide grip strength underestimated frailty prevalence.

INTERPRETATION

Frailty is common in stroke and associated with poor outcomes, regardless of measure used. Adding cognitive variables to frailty phenotype/CFS measures identified those at greater risk of poor outcomes. Physical and cognitive impairments in stroke survivors do not preclude frailty assessment.

Automated quantification of atrophy and acute ischemic volume for outcome prediction in endovascular thrombectomy

Background

Short- and long-term outcomes from endovascular thrombectomy (EVT) for large vessel occlusion stroke remain variable. Numerous relevant predictors have been identified, including severity of neurological deficits, age, and imaging features. The latter is typically defined as acute changes (most commonly Alberta Stroke Programme Early CT Score, ASPECTS, at presentation), but there is little information on the impact of imaging assessment of premorbid brain health as a determinant of outcome.

Aims

To examine the impact of automated measures of stroke severity and underlying brain frailty on short- and long-term outcomes in acute stroke treated with EVT.

Methods

In 215 patients with anterior circulation stroke, who subsequently underwent EVT, automated analysis of presenting non-contrast CT scans was used to determine acute ischemic volume (AIV) and e-ASPECTS as markers of stroke severity, and cerebral atrophy as a marker of brain frailty. Univariate and multivariate logistic regression were used to identify significant predictors of NIHSS improvement, modified Rankin scale (mRS) at 90 and 30 days, mortality at 90 days and symptomatic intracranial hemorrhage (sICH) following successful EVT.

Results

For long-term outcome, atrophy and presenting NIHSS were significant predictors of mRS 0-2 and death at 90 days, whereas age did not reach significance in multivariate analysis. Conversely, for short-term NIHSS improvement, AIV and age were significant predictors, unlike presenting NIHSS. The interaction between age and NIHSS was similar to the interaction of AIV and atrophy for mRS 0-2 at 90 days.

Conclusion

Combinations of automated software-based imaging analysis and clinical data can be useful for predicting short-term neurological outcome and may improve long-term prognostication in EVT. These results provide a basis for future development of predictive tools built into decision-aiding software in stroke.

Frailty and hearing loss: From association to causation

Background

Observational studies suggest that frailty is associated with hearing loss (HL) but with inconsistent results. This study aims to examine such association and to assess its causality.

Materials and methods

The cross-sectional data from the National Health and Nutrition Examination Survey (NHANES). Multivariate logistic regression models were used to assess the association between HL and frailty index (FI). Genetic variants associated with the FI and HL were obtained from a large genome-wide association study (GWAS) meta-analysis and UK Biobank GWAS. The inverse variance weighting (IVW) method was used to estimate causal effects. Sensitivity analyses were performed to further validate the robustness of results.

Results

In this cross-sectional analysis, results support the possibility that frailty may be associated with a higher risk of developing HL, with self-reported [odds ratio (OR) = 2.813; 95% CI, 2.386, 3.317; p &lt; 0.001], speech frequency HL (OR = 1.975; 95% CI, 1.679–2.323; p &lt; 0.001), and high frequency HL (OR = 1.748; 95% CI, 1.459–2.094; p &lt; 0.001). In the adjusted model, frail participants remained at high risk of HL. Mendelian randomization (MR) studies showed a bidirectional causal association between genetically predicted FI and risk of HL (FI for exposure: OR = 1.051; 95% CI, 1.020–1.083; p = 0.001; HL for exposure: OR = 1.527; 95% CI, 1.227–1.901; p &lt; 0.001).

Conclusion

Our observational study found that inter-individual differences in frailty were associated with the risk of developing HL. Genetic evidence suggests a potential bidirectional causal association between FI and HL. Furthermore, the potential mechanisms of this association require investigation.

Association of Pre-stroke Frailty With Prognosis of Elderly Patients With Acute Cerebral Infarction: A Cohort Study

Background

Frailty is a state of cumulative degradation of physiological functions that leads to adverse outcomes such as disability or mortality. Currently, there is still little understanding of the prognosis of pre-stroke frailty status with acute cerebral infarction in the elderly.

Objective

We investigated the association between pre-stroke frailty status, 28-day and 1-year survival outcomes, and functional recovery after acute cerebral infarction.

Methods

Clinical data were collected from 314 patients with acute cerebral infarction aged 65–99 years. A total of 261 patients completed follow-up in the survival cohort analysis and 215 patients in the functional recovery cohort analysis. Pre-stroke frailty status was assessed using the FRAIL score, the prognosis was assessed using the modified Rankin Scale (mRS), and disease severity using the National Institutes of Health Stroke Scale (NIHSS).

Results

Frailty was independently associated with 28-day mortality in the survival analysis cohort [hazard ratio (HR) = 4.30, 95% CI 1.35–13.67, p = 0.014]. However, frailty had no independent effect on 1-year mortality (HR = 1.47, 95% CI 0.78–2.79, p = 0.237), but it was independently associated with advanced age, the severity of cerebral infarction, and combined infection during hospitalization. Logistic regression analysis after adjusting for potential confounders in the functional recovery cohort revealed frailty, and the NIHSS score was significantly associated with post-stroke severe disability (mRS > 2) at 28 days [pre-frailty adjusted odds ratio (aOR): 8.86, 95% CI 3.07–25.58, p < 0.001; frailty aOR: 7.68, 95% CI 2.03–29.12, p = 0.002] or 1 year (pre-frailty aOR: 8.86, 95% CI 3.07–25.58, p < 0.001; frailty aOR: 7.68, 95% CI 2.03–29.12, p = 0.003).

Conclusions

Pre-stroke frailty is an independent risk factor for 28-day mortality and 28-day or 1-year severe disability. Age, the NIHSS score, and co-infection are likewise independent risk factors for 1-year mortality.

Prevalence and implications of frailty in acute stroke: systematic review & meta-analysis

BACKGROUND

frailty is common in older adults and associated with poor outcomes following illness. Although stroke is predominantly a disease of older people, our knowledge of frailty in stroke is limited. We aimed to collate the literature on acute stroke and frailty to estimate the prevalence of pre-stroke frailty and its associations with outcomes.

METHODS

paired researchers searched multidisciplinary electronic databases for papers describing frailty and acute stroke. We assessed risk of bias using Newcastle-Ottawa tools appropriate to study design. We created summary estimates of pre-stroke frailty using random effects models. We collated whether studies reported significant positive associations between frailty and clinical outcomes in adjusted models.

RESULTS

we included 14 studies (n = 27,210 participants). Seven studies (n = 8,840) used a frailty index approach, four studies (n = 14,924) used Hospital Frailty Risk Scores. Pooled prevalence of pre-stroke frailty was 24.6% (95% confidence interval, CI: 16.2-33.1%; low quality evidence, downgraded due to heterogeneity, bias). Combining frailty and pre-frailty (nine studies, n = 23,827), prevalence of any frailty syndrome was 66.8% (95%CI: 49.9-83.7%). Seven studies were at risk of bias, from participant selection or method of frailty assessment. Pre-stroke frailty was associated with all adverse outcomes assessed, including longer-term mortality (positive association in 6 of 6 studies reporting this outcome; odds ratio: 3.75 [95%CI: 2.41-5.70]), length of admission (3 of 4 studies) and disability (4 of 6 studies).

CONCLUSIONS

despite substantial heterogeneity, whichever way it is measured, frailty is common in patients presenting with acute stroke and associated with poor outcomes. This has implications for the design of stroke services and pathways.

Is Frailty Index a better predictor than pre-stroke modified Rankin Scale for neurocognitive outcomes 3-months post-stroke?

Background

The prognostic value of frailty measures for post-stroke neurocognitive disorder (NCD) remains to be evaluated.

Aims

The aim of this study was to compare the predictive value of pre-stroke FI with pre-stroke modified Rankin Scale (mRS) for post-stroke cognitive impairment. Further, we explored the added value of including FI in prediction models for cognitive prognosis post-stroke.

Methods

We generated a 36-item Frailty Index (FI), based on the Rockwood FI, to measure frailty based on pre-stroke medical conditions recorded in the Nor-COAST multicentre prospective study baseline assessments. Consecutive participants with a FI score and completed cognitive test battery at three months were included. We generated Odds Ratio (OR) with NCD as the dependent variable. The predictors of primary interest were pre-stroke frailty and mRS. We also measured the predictive values of mRS and FI by the area (AUC) under the receiver operating characteristic curve.

Results

598 participants (43.0% women, mean/SD age = 71.6/11.9, mean/SD education = 12.5/3.8, mean/SD pre-stroke mRS = 0.8/1.0, mean/SD GDS pre-stroke = 1.4/0.8, mean/SD NIHSS day 1 3/4), had a FI mean/SD score = 0.14/0.10. The logistic regression analyses showed that FI (OR 3.09), as well as the mRS (OR 2.21), were strong predictors of major NCD. When FI and mRS were entered as predictors simultaneously, the OR for mRS decreased relatively more than that for FI. AUC for NCD post-stroke was higher for FI than for mRS, both for major NCD (0.762 vs 0.677) and for any NCD (0.681 vs 0.638).

Conclusions

FI is a stronger predictor of post-stroke NCD than pre-stroke mRS and could be a part of the prediction models for cognitive prognosis post-stroke.

Trial Registration

ClinicalTrials.gov Identifier: NCT02650531.

Frailty and stroke thrombectomy outcomes-an observational cohort study

INTRODUCTION

Mechanical thrombectomy (MT) can improve outcomes following ischaemic stroke. Patient selection for MT is predominantly based on physiological and imaging parameters. We assessed whether people living with pre-stroke frailty had differing outcomes following MT.

METHODS

We included consecutive patients undergoing MT at a UK comprehensive stroke centre. We calculated a cumulative deficits frailty index to identify pre-stroke frailty in those patients presenting directly to the centre. Frailty was defined as an index score ≥ 0.24. We assessed univariable and multivariable association between pre-stroke frailty and stroke outcomes. Our primary outcomes were modified Rankin Scale (mRS) and mortality at 90 days.

RESULTS

Of 175 patients who underwent MT (2014-2018), we identified frailty in 49 (28%). Frail and non-frail patients had similar rates of thrombolysis administration, successful recanalization and onset to recanalization times. Those with pre-stroke frailty had higher 24 hour National Institutes of Health Stroke Scale (12(IQR: 8-17) versus 3(IQR: 2-13); P = 0.001); were less likely to be independent (mRS 0-2: 18% versus 61%; P < 0.001) and more likely to die (47% versus 14%; P < 0.001) within 90 days. Adjusting for age, baseline NIHSS and thrombolysis, frailty remained a strong, independent predictor of poor clinical outcome at 90 days (Death OR: 3.12 (95% CI: 1.32-7.4); dependency OR: 3.04 (95%CI: 1.10-8.44). Age was no longer a predictor of outcome when adjusted for frailty.

CONCLUSION

Pre-stroke frailty is prevalent in real-world patients eligible for MT and is an important predictor of poor outcomes. Routine assessment of pre-stroke frailty could help decision-making around patient selection for MT.