Frailty Syndromes in Persons With Cerebrovascular Disease: A Systematic Review and Meta-Analysis

The prevalence of frailty among older adults with maintenance hemodialysis: a systematic

BACKGROUND

To evaluate the epidemiological data on the prevalence of frailty and prefrailty in individuals aged 60 years or older on MHD patients.

METHODS

PubMed, Web of Science, Embase, CNKI, WanFang, CBM, and VIP were searched from inception to February 2023 using combinations of subject words and free words. The methodological quality of all the selected studies was assessed using the Joanna Briggs Institute Critical Appraisal of Epidemiological Studies Checklist and Newcastle‒Ottawa Cohort Quality Assessment Scale. Random effects meta-analysis was used to pool estimates from different studies. Subgroup analysis and meta-regression were performed to explore potential sources of heterogeneity.

RESULTS

Of the 4,190 documents retrieved, 16 observational studies involving 2,446 participants from 8 countries were included in this systematic review. Among older adults receiving MHD, the overall prevalence of frailty and prefrailty was 41% (95% CI = 34-49%) and 37% (95% CI = 26-48%), respectively, with considerable heterogeneity. The pooled prevalence of frailty was greater among individuals aged > 70 years (45%) than among those aged ≤ 70 years (37%). However, subgroup analyses indicated that the confidence intervals for the age group overlap substantially.

CONCLUSION

Our research showed that the prevalence of frailty and prefrailty in older patients with MHD are high.

TRIAL REGISTRATION

The PROSPERO registration number for this study was CRD42023442569.

Development and Validation of a Nomogram for Predicting Frailty Risk Among Older Patients With Ischaemic Stroke

AIM

To investigate the risk factors associated with frailty in older patients with ischaemic stroke, develop a nomogram and apply it clinically.

DESIGN

A cross-sectional study.

METHODS

Altogether, 567 patients who experienced ischaemic strokes between March and December 2023 were temporally divided into training (n = 452) and validation (n = 115) sets and dichotomised into frail and non-frail groups using the Tilburg Frailty Indicator scale. In the training set, feature selection was performed using least absolute shrinkage and selection operator regression and random forest recursive feature elimination, followed by nomogram construction using binary logistic regression. Internal validation was performed through bootstrap re-sampling and the validation set was used to assess model generalisability. The receiver operating characteristic curve, Hosmer-Lemeshow test, Brier score, calibration curve, decision curve analysis and clinical impact curve were used to evaluate nomogram performance.

RESULTS

The prevalence of frailty was 58.6%. Marital status, smoking, history of falls (in the preceding year), physical exercise, polypharmacy, albumin levels, activities of daily living, dysphagia and cognitive impairment were predictors in the nomogram. Receiver operating characteristic curve analysis indicated outstanding discrimination of the nomogram. The Hosmer-Lemeshow test, calibration curve and Brier score results confirmed good model consistency and predictive accuracy. The clinical decision and impact curve demonstrated notable clinical utility. This free, dynamic nomogram, created for interactive use and promotion, is available at: https://dongdongshen.shinyapps.io/DynNomapp/.

CONCLUSION

This nomogram may serve as an effective tool for assessing frailty risk in older patients with ischaemic stroke.

RELEVANCE TO CLINICAL PRACTICE

The nomogram in this study may assist healthcare professionals in identifying high-risk patients with frailty and understanding related factors, thereby providing more personalised risk management.

REPORTING METHOD

TRIPOD checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Progress in lung cancer study coupled with cognitive frailty in elderly individuals

Cognitive frailty is increasingly prevalent among elderly patients, heightening the risks of dementia, disability, and mortality. This demographic also faces a rising incidence of lung cancer, and cognitive frailty complicates rehabilitation efforts. Research on cognitive frailty in elderly lung cancer patients is still emerging. This review examines the definition and assessment of cognitive frailty, its the current prevalence in this population, and nursing management strategies. While tools for assessing cognitive frailty are not standardized, the incidence remains high, leading to adverse health outcomes. Comprehensive interventions for elderly lung cancer patients with cognitive frailty are insufficient, highlighting the need for more effective strategies to mitigate this issue. The goal is to enhance both research and clinical practices in identifying and diagnosing cognitive frailty in this vulnerable population.

The effect of frailty on mortality and functional outcomes in spontaneous intracerebral haemorrhage

INTRODUCTION

Limited data in patients with spontaneous intracerebral haemorrhage (SICH) showed that frailty was associated with mortality; however, there was insufficient data on functional outcomes. This study aimed to investigate the effect of frailty on overall mortality and 90-day functional outcomes in SICH.

MATERIALS AND METHODS

We conducted a retrospective study of 1223 patients diagnosed with SICH from January 2014 to December 2020. Frailty was defined as a clinical frailty scale (CFS) score of 4-9. Binary cut-offs were defined using receiver operating curve analysis. 90-day poor functional outcomes (PFO) were defined as modified Rankin Scale (mRS) ≥3, and utility-weighted mRS (UW-mRS) were based on previous validated studies respectively. Regression analyses were conducted to investigate the association between frailty and outcomes. Confounders adjusted for included demographics, cardiovascular risk factors and haematoma characteristics.

RESULTS

1091 patients met the inclusion criterion. 167 (15.3 %) had 30-day mortality and 730 (66.9 %) had 90-day PFO. Frailty was significantly associated with lower overall survival (HR: 1.54; 95 % CI: 1.11-2.14, p=0.010), 90-day PFO (OR: 1.90; 95 % CI: 1.32-2.74; p<0.001) and poorer UW-mRS (β: -0.06; 95 % CI: (-0.08 to -0.04); p<0.001) even after adjusting for confounders.

CONCLUSIONS

Frailty was significantly associated with greater mortality and PFO after incident SICH, even after adjusting for a priori confounders. Frail male individuals may be predisposed to poorer outcomes from higher prevalence of cortical atrophy. The use of CFS in younger individuals may aid management by predicting outcomes after incident SICH. Identifying frail individuals with incident SICH could aid in decision-making and the surgical management of SICH.

A comparative analysis of three frailty assessment tools for hospitalized patients with stroke

OBJECTIVE

The aim of this study is to assess the effectiveness of three frailty assessment tools in determining frailty risk among hospitalized patients with stroke and to offer a reference framework for selecting appropriate clinical frailty assessment tools in stroke management.

METHODS

A group of 203 hospitalized patients who had stroke were selected through convenience sampling and assessed for frailty using the Frailty Index, Fried Frailty Phenotype, FRAIL Scale, and Tilburg Frailty Scale. The efficacy of the three frailty assessment tools in assessing frailty risk in hospitalized patients with stroke was compared via Bayes discrimination and ROC curve analysis by using the Frailty Index as the diagnostic criterion for stroke-related frailty.

RESULTS

The incidence of frailty among patients with stroke ranged from 21.2 % to 23.6 %. The Kappa values indicating the agreement between the Frailty Index and Fried's Frailty Phenotype, FRAIL Scale, and Tilburg Frailty Scale were 0.826, 0.928, and 0.707, respectively (all P < 0.01). The cross-validation accuracy for frailty risk prediction in patients with stroke was 94.1 %, 97.5 %, and 89.7 %, respectively. The areas under the ROC curves for these tools were 0.884, 0.955, and 0.896, respectively.

CONCLUSION

The effectiveness of the three assessment tools in assessing frailty risk in patients with stroke ranked from highest to lowest, was as follows: FRAIL Scale, Fried Frailty Phenotype, and Tilburg Frailty Scale. Considering both assessment efficacy and convenience, the FRAIL Scale is recommended for widespread use in frailty screening among hospitalized patients with stroke.

Frailty among stroke patients and its effects on hospital outcomes

BACKGROUND

Although assessment of frailty is increasingly being included in routine practice, its effects on hospital outcomes is not well studied. In this study, we used a national database to estimate the effects of frailty on hospital outcomes among stroke patients.

METHODS

This study was a retrospective analysis of data from Nationwide Inpatient Sample (NIS) database collected during the years 2016 to 2019. Adult patients 45 years and older with a primary diagnosis of stroke were included for the analysis. Primary outcome was frequency of frailty among stroke patients. Secondary outcomes were in-hospital mortality, prolonged length of stay, mechanical ventilation, and acute renal failure. Frailty levels were assessed by using the Hospital Frailty Risk Score (HFRS).

RESULTS

Among 2,031,085 stroke hospitalizations, 362,140 (17.8 %) were non-frail, 1,333,000 (65.6 %) were pre-frail, and 335,945 (16.6 %) were frail. Regression analysis showed that the odds of mortality were significantly higher among frail (aOR, 2.82, 95 % CI: 2.63-3.04) and pre-frail (aOR, 1.62, 95 % CI: 1.53-1.73) patients, compared to non-frail patients. Similarly, the odds of mechanical ventilation were significantly higher among frail (aOR, 9.72, 95 % CI: 8.84-10.69) and pre-frail (aOR, 3.41, 95 % CI: 3.12-3.73) patients. The odds of acute renal failure were significantly higher among frail (aOR, 6.96, 95 % CI: 6.62-7.33) and pre-frail (aOR, 2.94, 95 % CI: 2.80-3.08) patients.

CONCLUSION

Collaborative efforts by neurologists, neurosurgeons, and physiatrists towards identifying frailty and incorporating it in risk estimation measures could help improve management strategies, resource utilization, and optimization of patient outcomes among frail stroke patients.

Assessment of frailty status in patients with acute cerebral infarction and their relationship with serum markers

OBJECTIVE

Frailty status is closely related to cerebral infarction, but there is a lack of objective biomarkers to determine frailty status in cerebral infarction patients. This study explores frailty status and frailty-related serum markers in patients with acute cerebral infarction and determines their diagnostic value for frailty.

METHODS

A total of 146 patients with acute cerebral infarction admitted to Hangzhou Third people's Hospital from January 2021 to December 2023 were enrolled prospectively. The Edmonton scale was used to evaluate the patients in the frailty and non-frailty groups. The clinical frailty scale (CFS) was used to divide frailty patients into mild, moderate, and severe frailty groups, comparing clinical data and levels of serum markers among different groups, and analyzing the risk factors for frailty in cerebral infarction.

RESULTS

Among the 146 patients, 70 cases (47.9%) were in the frailty group, and 76 cases (52.1%) in the non-frailty group. Compared with patients in the non-frailty group, patients in the frailty group had significantly lower levels of hemoglobin, triglycerides, low-density lipoprotein, and albumin (P<0.05 or 0.01), while levels of C-reactive protein (CRP), D-dimer, and homocysteine (Hcy) were significantly increased (P<0.05 or 0.01). Logistic regression analysis found that the levels of hemoglobin and Hcy were independent risk factors for frailty in acute cerebral infarction patients, with the ROC curve areas of 0.707 and 0.751, respectively. The ROC curve area for predicting frailty by combining hemoglobin and Hcy levels was 0.799.

CONCLUSION

The incidence of frailty in patients with acute cerebral infarction is high, and serum markers of hemoglobin and Hcy have certain value in determining frailty in patients with acute cerebral infarction.

Impact of Pre-Stroke Frailty on Outcome Three Years after Acute Stroke: The Nor-COAST Study

INTRODUCTION

We aimed to explore the predictive value of pre-stroke frailty index (FI) on functional dependency and mortality 3 years after stroke.

METHODS

Based on the Rockwood 36-item FI score, we calculated the pre-stroke FI from medical conditions recorded at baseline in the multicenter prospective Nor-COAST study 2015-2017. Participants with a FI score and a modified Rankin scale (mRS) 0-6 3 years post-stroke were included in this study. We used logistic regression analysis with unfavorable mRS (over 2 vs. 0-2) at 3 years, or dead within 3 years, as dependent variable, and frailty and pre-stroke mRS, one at a time, and simultaneously, as predictors. The analyses were carried out unadjusted and adjusted for the following variables one at a time: Age, sex, years of education, stroke severity at admission, infections treated with antibiotics and stroke progression. We report odds ratio (OR) per 0.10 increase in FI.

RESULTS

At baseline, the 609 included patients had mean age 72.8 (standard deviation [SD] 11.8), 261 (43%) were females, and had a FI mean score of 0.16 (SD 0.12), range 0-0.69. During 3 years, 138 (23%) had died. Both the FI, and pre-stroke mRS, were strong predictors for unfavorable mRS (OR 4.1 and 2.7) and dead within 3 years (OR 2.2 and 1.7). Only adjusting for age affected the result. The OR for pre-stroke mRS decreased relatively more than the OR for FI when entered as predictors simultaneously.

CONCLUSIONS

FI is a stronger predictor than premorbid mRS for prognostication after stroke.

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.

Prevalence and outcome of pre-onset frailty in patients with acute stroke

BACKGROUND

Frailty in older individuals is an underappreciated condition that affects the incidence and/or prognosis of stroke.

OBJECTIVES

We evaluated the prevalence of pre-onset frailty in patients with acute first-onset and recurrent strokes and association between pre-onset frailty and functional disability at hospital discharge.

METHODS

This prospective cohort study included 210 acute stroke patients admitted to the Stroke Unit of Nippon Medical School Hospital during November 2021-June 2022. The mean participant age was 79.2 ± 7.4 years. Age, sex, pre-onset frailty, body mass index (BMI), stroke type, medical history, and National Institutes of Health Stroke Scale (NIHSS) score at admission were evaluated. Frailty was defined as a clinical frailty scale (CFS) score ≥ 5. Frailty prevalence was calculated for all patients, and scores of functional disabilities at discharge were evaluated using modified Rankin scale.

RESULTS

Overall frailty prevalence was 31% in all stroke patients, with 24% and 47% of first-onset and recurrent strokes, respectively. Pre-onset frailty, NIHSS score at admission, age, stroke type, previous stroke, sex, BMI, dyslipidemia, and atrial fibrillation were significantly associated with functional disability at discharge. Logistic regression analysis revealed that CFS score, NIHSS score at admission, and previous stroke were independent predictors of functional disability at discharge.

CONCLUSIONS

Approximately one-fourth of patients with first-onset stroke had pre-onset frailty; the rate doubled in recurrent stroke; these rates appear to be much larger than rate in healthy individuals. Pre-onset frailty, a negative independent factor affecting functional disability at discharge, is important for pre-onset frailty evaluation and rehabilitation intervention in acute stroke patients.

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.

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.

White matter hyperintensities mediate the association between frailty and cognitive impairment in moyamoya disease

OBJECTIVES

The relationship between cognitive function and frailty in moyamoya disease (MMD) remains unclear, and the underlying mechanism is poorly understood. This study aims to investigate whether white matter hyperintensities (WMHs) mediate the association between frailty and cognitive impairment in MMD.

METHODS

Patients with MMD were consecutively enrolled in our study from January 2021 to May 2023. Pre-admission frailty and cognition were assessed using the Clinical Frailty Scale (CFS) and cognitive tests, respectively. Regional deep WMH (DWMH) and periventricular WMH (PWMH) volumes were calculated using the Brain Anatomical Analysis using Diffeomorphic deformation toolbox based on SPM 12 software. Multivariate logistic regression analysis was conducted to evaluate the association between frailty and cognitive function in MMD. Mediation analysis was performed to assess whether WMHs explained the association between frailty and cognition.

RESULTS

A total of 85 patients with MMD were enrolled in this study. On the basis of the CFS scores, 24 patients were classified as frail, 38 as pre-frail, and 23 as robust. Significant differences were observed in learning, memory, processing speed, executive functions, and semantic memory among the three groups (p < 0.001). Frailty was independently associated with memory and executive functions (p < 0.05); even after controlling for WMH. Mediation analysis indicated that the associations of frailty with memory and executive functions were partially mediated by WMH, DWMH, and PWMH (p < 0.05).

CONCLUSION

Frailty is significantly correlated with a higher risk of cognitive impairment in MMD, even after adjusting for other covariates. WMHs partially mediate the association between frailty and cognitive impairment.

Association of multidimensional frailty and quality of life in middle-aged and older people with stroke: A cross-sectional study

OBJECTIVES

The aims of this study were to (i) compare the prevalence of multidimensional frailty in middle-aged and older people with stroke and to (ii) explore the relationship between multidimensional frailty and quality of life (QoL) in this patient population.

BACKGROUND

In recent years, stroke patients have become increasingly younger. As an important risk factor for stroke patients, frailty has gradually drawn research attention because of its multidimensional nature.

DESIGN

This study used a cross-sectional design.

METHODS

The study included 234 stroke patients aged 45 and older. Multidimensional frailty was defined as a holistic condition in which a person experiences losses in one or more domains of human functioning (physical, psychological and social) based on the Tilburg Frailty Indicator, and QoL was based on the short version of the Stroke-Specific Quality of Life Scale. Hierarchical regression was used to analyse the correlation factors of QoL. STROBE checklist guides the reporting of the manuscript.

RESULTS

A total of 128 (54.7%) participants had multidimensional frailty, 48 (44.5%) were middle aged and 80 (63.5%) were older adults. The overall QoL mean score of the participants was 47.86 ± 9.04. Multidimensional frailty was negatively correlated with QoL. Hierarchical regression analysis showed that multidimensional frailty could independently explain 14.6% of the variation in QoL in stroke patients.

CONCLUSIONS

Multidimensional frailty was prevalent in middle-aged and older people with stroke, and it was a significant factor associated with QoL in stroke patients.

RELEVANCE TO CLINICAL PRACTICE

This study emphasises the importance of the early identification of multidimensional frailty. And targeted interventions should be studied to prevent the occurrence of multidimensional frailty and thereby improve the QoL of patients.

PATIENT OR PUBLIC CONTRIBUTION/S

There are no patient or public contributions to this study.

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.

The measurement properties and feasibility of FRAIL scale in older adults: A systematic review and meta-analysis

Frailty is a prevalent condition amongst older adults, significantly affecting their quality of life. The FRAIL tool has been purposefully designed for clinical application by assisting healthcare professionals in identifying and managing frailty-related issues in older adults, making it a preferred choice for assessing frailty across diverse older populations. This review aimed to synthesize the measurement properties and feasibility of FRAIL. Guided by COSMIN guidelines, seven databases were searched from inception to 31 Mar 2023. The measurement properties were extracted for quality appraisal of the populations in the studied samples. Where possible, random-effects meta-analysis and meta-regression were used for quantitative synthesis. Eighteen articles containing 273 tests were drawn from 14 different populations. We found that populations testing for criterion validity had high-quality ratings, while construct validity ratings varied based on health status and geographical region. Test-retest reliability had sufficient quality ratings, while scale agreement had sufficient ratings in only four out of 14 populations tested. Responsiveness ratings were insufficient in seven out of eight populations, with inconsistent ratings in one population. Our analysis of missing data across three articles showed a 16.3% rate, indicating good feasibility of the FRAIL. FRAIL is a feasible tool for assessing frailty of older adults in community settings, with good criterion validity and test-retest reliability. However, more research is needed on construct validity and responsiveness.

Structural determinants and cardiometabolic typologies related to frailty in community-dwelling older adults

Frailty is a geriatric syndrome linked to adverse outcomes. Co-occurring cardiometabolic factors increase frailty risk; however, their distinct combinations (typologies) associated with frailty are unclear. We aimed to identify subgroups of older adults with distinct cardiometabolic typologies and characterize their relationship with structural determinants and frailty to inform tailored approaches to prevent and delay frailty. This study was cross-sectional design and included 7984 community-dwelling older adults (65+ years) enrolled in the Health and Retirement Study (2006 and 2008). Latent class analysis was performed using seven cardiometabolic indicators (abdominal obesity, obesity, low high-density lipoprotein; and elevated blood pressure, blood sugar, total cholesterol, C-reactive protein). Frailty was indicated by ≥3 features (weakness, slowness, fatigue, low physical activity, unintentional weight loss). Logistic regression was used to examine the relationship between structural determinants (gender, race/ethnicity, and education), cardiometabolic typologies, and frailty. Three cardiometabolic subgroups were identified: insulin-resistant (n = 3547), hypertensive dyslipidemia (n = 1246), and hypertensive (n = 3191). Insulin-resistant subgroup members were more likely to be female, non-Hispanic Black, and college non-graduates; hypertensive dyslipidemia subgroup members were more likely to be non-Hispanic Others and report high school education; and hypertensive subgroup members were more likely to be male and college educated (p≤.05). Frailty risk was higher for females, Hispanic or Non-Hispanic Black older adults, and those with lower education (p≤.001). Frailty risk was greater in the insulin-resistant compared to the other subgroups (both aOR=2.0, both p<.001). Findings highlight a need to design tailored interventions targeting cardiometabolic typologies to prevent and delay frailty.

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.

Cognitive testing following transient ischaemic attack: A systematic review of clinical assessment tools

Cognitive deficits are prevalent after transient ischaemic attack (TIA) and result in loss of function, poorer quality of life and increased risks of dependency and mortality. This systematic review aimed to synthesise the available evidence on cognitive assessment in TIA patients to determine the prevalence of cognitive deficits, and the optimal tests for cognitive assessment. Medline, Embase, PsychINFO and CINAHL databases were searched for relevant articles. Articles were screened by title and abstract. Full-text analysis and quality assessment was performed using the National Institute of Health Tool. Data were extracted on study characteristics, prevalence of TIA deficits, and key study findings. Due to significant heterogeneity, meta-analysis was not possible. Twenty-five full-text articles met the review inclusion criteria. There was significant heterogeneity in terms of cognitive tests used, definitions of cognitive impairment and TIA, time points post-event, and analysis methods. The majority of studies used the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) (n = 23). Prevalence of cognitive impairment ranged from 2% to 100%, depending on the time-point and cognitive domain studied. The MoCA was more sensitive than the MMSE for identifying cognitive deficits. Deficits were common in executive function, attention, and language. No studies assessed diagnostic test accuracy against a reference standard diagnosis of cognitive impairment. Recommendations on cognitive testing after TIA are hampered by significant heterogeneity between studies, as well as a lack of diagnostic test accuracy studies. Future research should focus on harmonising tools, definitions, and time-points, and validating tools specifically for the TIA population.

Associations between modifiable risk factors and frailty: a Mendelian randomisation study

BACKGROUND

Early identification of modifiable risk factors is essential for the prevention of frailty. This study aimed to explore the causal relationships between a spectrum of genetically predicted risk factors and frailty.

METHODS

Univariable and multivariable Mendelian randomisation (MR) analyses were performed to explore the relationships between 22 potential risk factors and frailty, using summary genome-wide association statistics. Frailty was accessed by the frailty index.

RESULTS

Genetic liability to coronary artery disease (CAD), type 2 diabetes mellitus (T2DM), ischaemic stroke, atrial fibrillation and regular smoking history, as well as genetically predicted 1-SD increase in body mass index, systolic blood pressure, diastolic blood pressure, low-density lipoprotein cholesterol, triglycerides, alcohol intake frequency and sleeplessness were significantly associated with increased risk of frailty (all p<0.001). In addition, there was a significant inverse association between genetically predicted college or university degree with risk of frailty (beta -0.474; 95% CI (-0.561 to -0.388); p<0.001), and a suggestive inverse association between high-density lipoprotein cholesterol level with risk of frailty (beta -0.032; 95% CI (-0.055 to -0.010); p=0.004). However, no significant causal associations were observed between coffee consumption, tea consumption, serum level of total testosterone, oestradiol, 25-hydroxyvitamin D, C reactive protein or moderate to vigorous physical activity level with frailty (all p>0.05). Results of the reverse directional MR suggested bidirectional causal associations between T2DM and CAD with frailty.

CONCLUSIONS

This study provided genetic evidence for the causal associations between several modifiable risk factors with lifetime frailty risk. A multidimensional approach targeting these factors may hold a promising prospect for prevention frailty.

Chrono-Gerontology: Integrating Circadian Rhythms and Aging in Stroke Research

Stroke is a significant public health concern for elderly individuals. However, the majority of pre-clinical studies utilize young and healthy rodents, which may result in failure of candidate therapies in clinical trials. In this brief review/perspective, the complex link between circadian rhythms, aging, innate immunity, and the gut microbiome to ischemic injury onset, progression, and recovery is discussed. Short-chain fatty acids and nicotinamide adenine dinucleotide+ (NAD+ ) production by the gut microbiome are highlighted as key mechanisms with profound rhythmic behavior, and it is suggested to boost them as prophylactic/therapeutic approaches. Integrating aging, its associated comorbidities, and circadian regulation of physiological processes into stroke research may increase the translational value of pre-clinical studies and help to schedule the optimal time window for existing practices to improve stroke outcome and recovery.

Multimorbidity Pattern and Risk for Mortality Among Patients With Dementia: A Nationwide Cohort Study Using Latent Class Analysis

OBJECTIVE

Individuals with dementia are at a substantially elevated risk for mortality; however, few studies have examined multimorbidity patterns and determined the inter-relationship between these comorbidities in predicting mortality risk.

METHODS

This is a prospective cohort study. Data from 6,556 patients who were diagnosed with dementia between 1997 and 2012 using the Taiwan National Health Insurance Research Database were analyzed. Latent class analysis was performed using 16 common chronic conditions to identify mortality risk among potentially different latent classes. Logistic regression was performed to determine the adjusted association of the determined latent classes with the 5-year mortality rate.

RESULTS

With adjustment for age, a three-class model was identified, with 42.7% of participants classified as "low comorbidity class (cluster 1)", 44.2% as "cardiometabolic multimorbidity class (cluster 2)", and 13.1% as "FRINGED class (cluster 3, characterized by FRacture, Infection, NasoGastric feeding, and bleEDing over upper gastrointestinal tract)." The incidence of 5-year mortality was 17.6% in cluster 1, 26.7% in cluster 2, and 59.6% in cluster 3. Compared with cluster 1, the odds ratio for mortality was 9.828 (95% confidence interval [CI]=6.708-14.401; p<0.001) in cluster 2 and 1.582 (95% CI=1.281-1.953; p<0.001) in cluster 3.

CONCLUSION

Among patients with dementia, the risk for 5-year mortality was highest in the subpopulation characterized by fracture, urinary and pulmonary infection, upper gastrointestinal bleeding, and nasogastric intubation, rather than cancer or cardiometabolic comorbidities. These findings may improve decision-making and advance care planning for patients with dementia.

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.

Multisystem physiological perspective of human frailty and its modulation by physical activity

"Frailty" is a term used to refer to a state characterized by enhanced vulnerability to, and impaired recovery from, stressors compared with a nonfrail state, which is increasingly viewed as a loss of resilience. With increasing life expectancy and the associated rise in years spent with physical frailty, there is a need to understand the clinical and physiological features of frailty and the factors driving it. We describe the clinical definitions of age-related frailty and their limitations in allowing us to understand the pathogenesis of this prevalent condition. Given that age-related frailty manifests in the form of functional declines such as poor balance, falls, and immobility, as an alternative we view frailty from a physiological viewpoint and describe what is known of the organ-based components of frailty, including adiposity, the brain, and neuromuscular, skeletal muscle, immune, and cardiovascular systems, as individual systems and as components in multisystem dysregulation. By doing so we aim to highlight current understanding of the physiological phenotype of frailty and reveal key knowledge gaps and potential mechanistic drivers of the trajectory to frailty. We also review the studies in humans that have intervened with exercise to reduce frailty. We conclude that more longitudinal and interventional clinical studies are required in older adults. Such observational studies should interrogate the progression from a nonfrail to a frail state, assessing individual elements of frailty to produce a deep physiological phenotype of the syndrome. The findings will identify mechanistic drivers of frailty and allow targeted interventions to diminish frailty progression.

Physical Frailty and Brain White Matter Abnormalities: The Atherosclerosis Risk in Communities Study

BACKGROUND

Physical frailty is associated with increased risk for dementia and other neurologic sequelae. However, the neurobiological changes underlying frailty and frailty risk remain unknown. We examined the association of cerebral white matter structure with current and future frailty.

METHODS

Atherosclerosis Risk in Communities Study Neurocognitive Study participants who underwent 3T brain MRI were included. Frailty status was classified according to the Fried criteria. Cerebral white matter integrity was defined using white matter hyperintensity (WMH) volume and microstructure, measured using diffusion tensor imaging fractional anisotropy (FA) and mean diffusivity (MD). Multivariable linear regression was used to relate baseline frailty to white matter structure; multivariable logistic regression was used to relate baseline white matter to frailty risk among participants nonfrail at baseline.

RESULTS

In the cross-sectional analysis (N = 1 754; mean age: 76 years), frailty was associated with greater WMH volume, lower FA, and greater MD. These associations remained consistent after excluding participants with a history of stroke or dementia. Among participants nonfrail at baseline who completed follow-up frailty assessment (N = 1 379; 6.6-year follow-up period), each standard deviation increase in WMH volume was associated with 1.46 higher odds of frailty at follow-up. Composite FA and MD measures were not associated with future frailty; however, secondary analyses found several significant white matter tract-specific associations with frailty risk.

CONCLUSION

The current study demonstrates a robust association of WMH volume with current and future frailty. Although measures of white matter microstructure were altered in frail individuals, these measures were not generally associated with progression from nonfrail to frail status.

Association Between Pollution and Frailty in Older People: A Cross-Sectional Analysis of the UK Biobank

OBJECTIVES

Frailty is a relevant issue in older people, being associated with several negative outcomes. Increasing literature is reporting that pollution (particularly air pollution) can increase the risk of frailty, but the research is still limited. We aimed to investigate the potential association of pollution (air, noise) with frailty and prefrailty among participants 60 years and older of the UK Biobank study.

DESIGN

Cross-sectional.

SETTINGS AND PARTICIPANTS

Older participants (age ≥ 60 years) participating to the UK Biobank.

METHODS

Frailty and prefrailty presence were ascertained using a model including 5 indicators (weakness, slowness, weight loss, low physical activity, and exhaustion). Air pollution was measured through residential exposures to nitrogen oxides (NO_x) and particulate matter (PM_2.5, PM_2.5-10, PM₁₀). The average residential sound level during the daytime, the evening, and night was used as an index for noise pollution.

RESULTS

A total of 220,079 subjects, aged 60 years and older, was included. The partial proportional odds model, adjusted for several confounders, showed that the increment in the exposure to NO_x was associated with a higher probability of being in both the prefrail and frail category [odds ratio (OR) 1.003; 95% CI 1.001-1.004]. Similarly, the increase in the exposure to PM_2.5-10 was associated with a higher probability of being prefrail and frail (OR 1.014; 95% CI 1.001-1.036), such as the increment in the exposure to PM_2.5 that was associated with a higher probability of being frail (OR 1.018; 95% CI 1.001-1.037).

CONCLUSIONS AND IMPLICATIONS

Our study indicates that the exposure to air pollutants as PM_2.5, PM_2.5-10, or NO_x might be associated with frailty and prefrailty, suggesting that air pollution can contribute to frailty and indicating that the frailty prevention and intervention strategies should take into account the dangerous impact of air pollutants.

Transitions in frailty state 12 months after kidney transplantation: a prospective cohort study

BACKGROUND

Frailty is associated with several unfavorable outcomes after kidney transplantation (KTx). However, limited information is available regarding the transitions in frailty state and its components after KTx. This study aimed to evaluate the transitions in physical frailty phenotype and its components over a period of 12 months after KTx.

METHODS

In this prospective single-center cohort study, we measured physical frailty phenotype (PFP) and its components at the time of admission for KTx and 12 months after KTx. The evaluation includes five components: weakness (grip strength analysed by sex and body mass index quartiles), physical activity (kcals/week based on the Minnesota Leisure Time Physical Activity questionnaire), exhaustion (self-report using the Center for Epidemiological Studies Depression Scale), gait speed (time taken to walk 15 feet based on sex and height-specific cutoff), and unintentional weight loss (self-report of unintentional weight loss > 10 lbs in the last year). The exhaustion and physical activity components are validated in the Brazilian population. Each component is scored as 0 or 1 according to its presence or absence, and a PFP score of 3-5 defines frailty, 2 is intermediate, and 0-1 is rated as non-frail. We used the McNemar and Wilcoxon test to compare physical frailty phenotype and its components between the two periods.

RESULTS

Among 87 patients included in the study, 16.1% were classified as frail, 20.7% as intermediately frail, and 63.2% as non-frail. Sixty-four patients were included in the analysis to evaluate transitions in frailty. At the time of admission for KTx, 15.6% of patients were defined as frail compared to 4.7% of patients at 12 months after KTx (p = 0.023). Among the physical frailty phenotype components, the proportion of patients who scored in the weight loss category 12 months after KTx was significantly lower than that at the time of KTx (6.3% vs 34.4%, p < 0.001).

CONCLUSIONS

There was a 69.9% reduction in the prevalence of frail patients at the end of the 12-month follow-up after KTx. Among the components of frailty, weight loss showed a significant improvement.

Crosstalk between the aging intestinal microflora and the brain in ischemic stroke

Aging is an inevitable phenomenon experienced by animals and humans, and its intensity varies from one individual to another. Aging has been identified as a risk factor for neurodegenerative disorders by influencing the composition of the gut microbiota, microglia activity and cognitive performance. The microbiota-gut-brain axis is a two-way communication path between the gut microbes and the host brain. The aging intestinal microbiota communicates with the brain through secreted metabolites (neurotransmitters), and this phenomenon leads to the destruction of neuronal cells. Numerous external factors, such as living conditions and internal factors related to the age of the host, affect the condition of the intestinal microflora in the form of dysbiosis. Dysbiosis is defined as changes in the composition and function of the gut microflora that affect the pathogenesis, progress, and response to treatment of a disease entity. Dysbiosis occurs when changes in the composition and function of the microbiota exceed the ability of the microflora and its host to restore equilibrium. Dysbiosis leading to dysfunction of the microbiota-gut-brain axis regulates the development and functioning of the host’s nervous, immune, and metabolic systems. Dysbiosis, which causes disturbances in the microbiota-gut-brain axis, is seen with age and with the onset of stroke, and is closely related to the development of risk factors for stroke. The review presents and summarizes the basic elements of the microbiota-gut-brain axis to better understand age-related changes in signaling along the microbiota-gut-brain axis and its dysfunction after stroke. We focused on the relationship between the microbiota-gut-brain axis and aging, emphasizing that all elements of the microbiota-gut-brain axis are subject to age-related changes. We also discuss the interaction between microbiota, microglia and neurons in the aged individuals in the brain after ischemic stroke. Finally, we presented preclinical and clinical studies on the role of the aged microbiota-gut-brain axis in the development of risk factors for stroke and changes in the post-stroke microflora.

Effects of the COVID-19 Pandemic on Physical Function of Community-Dwelling People with Disabilities in Japan

In 2020, COVID-19 spread throughout the world, and international measures such as travel bans, quarantines, and increased social distancing were implemented. In Japan, the number of infected people increased, and a state of emergency was declared from 16 April to 25 May 2020. Such a change in physical activity could lead to a decline in physical function in people with disabilities. A retrospective study was conducted to determine the impact of the pandemic on the physical function of disabled persons living in the community. Data were collected at four points in time: two points before the declaration of the state of emergency was issued and two points after the declaration period had ended. Time series data of physical function at four points in time were compared for 241 people with disabilities. The mean age was 72.39 years; 157 had stroke, 59 musculoskeletal disease, and 26 other diseases. Overall, there was a long-term decrease in walking speed (p < 0.001) and a worsening of the Timed Up-and-Go (TUG) score (p < 0.001) after the period of the state of emergency. The TUG score worsened only in the group with a walking speed of 1.0 m/s or less before the state of emergency (p = 0.064), suggesting that this group was more susceptible.

Genetically predicted frailty index and risk of stroke and Alzheimer's disease

BACKGROUND AND PURPOSE

Previous studies have reported the association between frailty and stroke or Alzheimer's disease (AD). However, the causality remains unclear. The aim of the present study was to evaluate whether genetically predicted frailty is associated with the risk of stroke or AD by a Mendelian randomization (MR) study.

METHODS

Genetic variants associated with the frailty index (FI) were obtained from a large genome-wide association study (GWAS). Summary-level data for stroke and AD were adopted from the corresponding large GWAS of individuals of European ancestry. The inverse variance weighted method was used for estimating causal effects. Multivariable analysis was performed for further adjustment.

RESULTS

The present MR study indicated a suggestive association between genetically predicted FI and a higher risk of any stroke (odds ratio 1.360, 95% confidence interval 1.006-1.838, p = 0.046). Regarding the subtypes of stroke, genetically predicted FI was associated with a higher risk of large artery atherosclerosis stroke (LAS) (odds ratio 2.487, 95% confidence interval 1.282-4.826, p = 0.007). No causal links were identified between genetically predicted FI and any ischaemic stroke, intracranial haemorrhage, cardioembolic stroke, small artery stroke, AD or AD-by-proxy. Multivariable MR analysis indicated that the association of genetically predicted FI with LAS was attenuated after adjustment for inflammatory bowel disease (p = 0.114).

CONCLUSIONS

The MR study suggested that genetically predicted FI may be associated with an increased risk of any stroke. Subgroup analysis indicated a suggestive association between genetically predicted FI and the risk of LAS. The underlying mechanisms need further 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.

Frailty prevalence and impact on outcomes in patients with atrial fibrillation: A systematic review and meta-analysis of 1,187,000 patients

Frailty is a clinical syndrome characterized by a reduced physiologic reserve, increased vulnerability to stressors and an increased risk of adverse outcomes. People with atrial fibrillation (AF) are often burdened by frailty due to biological, clinical, and social factors. The prevalence of frailty, its management and association with major outcomes in AF patients are still not well quantified. We systematically searched PubMed and EMBASE, from inception to September 13th, 2021, for studies reporting the prevalence of frailty in AF patients. The study was registered in PROSPERO (CRD42021235854). 33 studies were included in the systematic review (n = 1,187,651 patients). The frailty pooled prevalence was 39.7 % (95 %CI=29.9 %-50.5 %, I² =100 %), while meta-regression analyses showed it is influenced by age, history of stroke, and geographical location. Meta-regression analyses showed that OAC prescription was influenced by study-level mean age, baseline thromboembolic risk, and study setting. Frail AF patients were associated with a higher risk of all-cause death (OR=5.56, 95 %CI=3.46-8.94), ischemic stroke (OR=1.59, 95 %CI=1.00-2.52), and bleeding (OR=1.64, 95 %CI=1.11-2.41), when compared to robust individuals. In this systematic review and meta-analysis, the prevalence of frailty was high in patients with AF. Frailty may influence the prognosis and management of AF patients, thus requiring person-tailored interventions in a holistic or integrated approach to AF care.

The Association Between Cardiometabolic Risk Factors and Frailty in Older Adults: A Systematic Review

Background and Objectives

Enhanced management and prevention of frailty depend on our understanding of the association between potentially modifiable risk factors and frailty. However, the associations between potentially modifiable cardiometabolic risk factors and frailty are not clear. The purpose of this review was to appraise and synthesize the current evidence examining the associations between the cardiometabolic risk factors and frailty.

Research Design and Methods

Multiple databases, including MEDLINE (via PubMed), Embase (via Elsevier), and Web of Science (via Clarivate), were searched extensively. Studies that examined cardiometabolic risk factors and frailty as main predictors and outcome of interest, respectively, among older adults (≥60 years) were included. The Joanna Briggs Institute critical appraisal tools were used to evaluate the quality of studies. PRISMA (2020) guided this review, and findings were synthesized without meta-analysis. This systematic review was registered in PROSPERO (CRD42021252565).

Results

Twelve studies met the eligibility criteria and were included in the review. Abdominal obesity, hyperglycemia, and multiple co-occurring cardiometabolic risk factors were associated with the increased likelihood of frailty in older adults. There was inconsistency across the studies regarding the associations between dyslipidemia, elevated blood pressure, and frailty.

Discussion and Implications

Understanding the association between cardiometabolic risk factors and frailty can have translational benefits in developing tailored interventions for the prevention and management of frailty. More studies are needed to validate predictive and clinically significant associations between single and specific combinations of co-occurring cardiometabolic risk factors and frailty.

Aging Microbiota-Gut-Brain Axis in Stroke Risk and Outcome

The microbiota-gut-brain-axis (MGBA) is a bidirectional communication network between gut microbes and their host. Many environmental and host-related factors affect the gut microbiota. Dysbiosis is defined as compositional and functional alterations of the gut microbiota that contribute to the pathogenesis, progression and treatment responses to disease. Dysbiosis occurs when perturbations of microbiota composition and function exceed the ability of microbiota and its host to restore a symbiotic state. Dysbiosis leads to dysfunctional signaling of the MGBA, which regulates the development and the function of the host's immune, metabolic, and nervous systems. Dysbiosis-induced dysfunction of the MGBA is seen with aging and stroke, and is linked to the development of common stroke risk factors such as obesity, diabetes, and atherosclerosis. Changes in the gut microbiota are also seen in response to stroke, and may impair recovery after injury. This review will begin with an overview of the tools used to study the MGBA with a discussion on limitations and potential experimental confounders. Relevant MGBA components are introduced and summarized for a better understanding of age-related changes in MGBA signaling and its dysfunction after stroke. We will then focus on the relationship between the MGBA and aging, highlighting that all components of the MGBA undergo age-related alterations that can be influenced by or even driven by the gut microbiota. In the final section, the current clinical and preclinical evidence for the role of MGBA signaling in the development of stroke risk factors such as obesity, diabetes, hypertension, and frailty are summarized, as well as microbiota changes with stroke in experimental and clinical populations. We conclude by describing the current understanding of microbiota-based therapies for stroke including the use of pre-/pro-biotics and supplementations with bacterial metabolites. Ongoing progress in this new frontier of biomedical sciences will lead to an improved understanding of the MGBA's impact on human health and disease.

Effect of frailty on outcomes of endovascular treatment for acute ischaemic stroke in older patients

BACKGROUND

frailty has been shown to be a better predictor of clinical outcomes than age alone across many diseases. Few studies have examined the relationship between frailty, stroke and stroke interventions such as endovascular thrombectomy (EVT).

OBJECTIVE

we aimed to investigate the impact of frailty measured by clinical frailty scale (CFS) on clinical outcomes after EVT for acute ischemic stroke (AIS) in older patients ≥70 years.

METHODS

in this retrospective cohort study, we included all consecutive AIS patients age ≥ 70 years receiving EVT at a single comprehensive stroke centre. Patients with CFS of 1-3 were defined as not frail, and CFS > 3 was defined as frail. The primary outcome was modified Rankin Score (mRS) at 90 days. The secondary outcomes included duration of hospitalisation, in-hospital mortality, carer requirement, successful reperfusion, symptomatic intracranial haemorrhage and haemorrhagic transformation.

RESULTS

a total of 198 patients were included. The mean age was 78.1 years and 52.0% were female. Frail patients were older, more likely to be female, had more co-morbidities. CFS was significantly associated with poor functional outcome after adjustment for age, NIHSS and time to intervention (adjusted odds ratio [aOR] 1.54, 95% confidence interval [CI] 1.04-2.28, P = 0.032). There was trend towards higher mortality rate in frail patients (frail: 18.3%; non-frail: 9.6%; P = 0.080). There were no significant differences in other secondary outcomes except increased carer requirement post discharge in frail patients (frail: 91.6%; non-frail: 72.8%; P = 0.002).

CONCLUSIONS

frailty was associated with poorer functional outcome at 90 days post-EVT in patients ≥ 70 years.

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.

Kinesiophobia in Elderly Polish Patients After Ischemic Stroke, Including Frailty Syndrome

INTRODUCTION

In patients after stroke, the relationship between the occurrence of kinesiophobia and the accompanying frailty syndrome, as well as the acceptance of the disease and the level of mood, has not been recognized so far. The aim of this study was to determine the prevalence of kinesiophobia in elderly Polish people after ischemic stroke, including the frailty syndrome and the associations between the prevalence of kinesiophobia and feelings of anxiety and degree of the illness acceptance.

METHODS

A cross-sectional study was used to achieve the study objectives. The study involved 152 hospitalized patients aged of minimum 60 (mean age 63), qualified for post-stroke rehabilitation, including 76 women and 76 men. The patients were divided into two groups, with kinesiophobia (119 persons) and without kinesiophobia (33 persons). The Tampa Scale of Kinesiophobia (TSK), the Tilburg Frailty Indicator (TFI), the Hospital Anxiety Depression Scale (HADS) and the Acceptance of Illness Scale (AIS) were used. Study results were calculated using MedCalc Software.

RESULTS

Kinesiophobia has been demonstrated in 78% of people after ischemic stroke. The values of TFI and HADS were higher in the patients with kinesiophobia (p<0.001). In patients with ischemic stroke, it was shown that the level of kinesiophobia increased with higher anxiety (p<0.001), higher total TFI score, (p<0.05), and a lower level of illness acceptance (p<0.001).

CONCLUSION

The occurrence of kinesiophobia in elderly Polish people after ischemic stroke is common and the determinants of its development are the coexistence of the frailty syndrome, anxiety and a low level of illness acceptance. In post-stroke patients, the presence of kinesiophobia should be considered, especially in the situation of comorbid frailty syndrome. The issue of kinesiophobia in patients after stroke requires further in-depth research, especially in the field of cognitive-behavioral prevention aimed at ways to reduce this phenomenon.

Association between Poor Oral Health and Frailty in Middle-Aged and Older Individuals: A Cross-Sectional National Study

OBJECTIVES

Older adults with poor oral health may be at higher risk of being pre-frail or frail. However, very few studies have examined this association in Latin American countries and middle-aged individuals. Therefore, we aimed to investigate the association between oral health and frailty status among Chilean adults ≥40 years.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

We included 3,036 participants ≥40 years from the Chilean National Health Survey 2016-2017.

METHODS

Frailty status was assessed with a 49-item frailty index, while the number of teeth, self-reported oral health, tooth decay, use of prostheses, and oral pain were the oral health conditions included. To assess the association between oral health conditions and frailty, we used multinomial logistic regression models status adjusted for sociodemographic and lifestyle variables.

RESULTS

Overall, 40.6% and 11.8% of individuals were classified as pre-frail and frail, respectively. After adjusting for confounders, individuals with ≤20 teeth had a higher likelihood of being frail (odds ratio (OR): 1.94 [95% CI: 1.18-3.20]) than people with >20 teeth. Moreover, people with bad or very bad oral health, as well as oral pain, had a higher likelihood of being pre-frail (OR: 2.04 [95% CI: 1.40-2.97] and OR: 2.92 [95% CI: 1.58-5.39], respectively). Middle-aged individuals with fewer teeth and poor self-reported oral health had a higher likelihood of being pre-frail and frail than people ≥60.

CONCLUSIONS AND IMPLICATIONS

Individuals with poor global oral health were more likely to be pre-frail or frail. This association seems to be stronger in people <60 years old. Our results are consistent with previously published reports.

Predictors of Transition to Frailty in Middle-Aged and Older People With HIV: A Prospective Cohort Study

BACKGROUND

People with HIV (PWH) have increased frailty risk at younger ages compared with the general population. Multimorbidity is associated with frailty, yet effects of specific comorbidities on transition to frailty in PWH are unknown.

SETTING

Prospective study of 219 PWH age 45 years or older in the National NeuroAIDS Tissue Consortium.

METHODS

Frailty status was categorized using Fried frailty phenotype criteria. Comorbidities [bone disease, cardiovascular disease, cerebrovascular disease, liver disease, renal disease, diabetes, chronic obstructive pulmonary disease (COPD), hypertension, obesity, cancers, neuropsychiatric conditions] were assessed from longitudinal data. Associations between baseline comorbidities and transition to frailty within 30 months were analyzed using Kaplan-Meier and Cox regression models. Grip strength was assessed using mixed-effects models.

RESULTS

At baseline, the median age was 61 years, 73% were male 98% were on antiretroviral therapy, 29% had ≥3 comorbidities, 27% were robust, and 73% were pre-frail. Cerebrovascular disease, diabetes, and COPD were independent predictors of transition to frailty within 30 months in models adjusted for age, sex, and multimorbidity (≥3 additional comorbidities) [hazard ratios (95% confidence intervals) 2.52 (1.29 to 4.93), 2.31 (1.12 to 4.76), and 1.82 (0.95 to 3.48), respectively]. Furthermore, cerebrovascular disease, diabetes, COPD, or liver disease co-occurring with multimorbidity was associated with substantially increased frailty hazards compared with multimorbidity alone (hazard ratios 4.75-7.46). Cerebrovascular disease was associated with decreased baseline grip strength (P = 0.0001), whereas multimorbidity, diabetes, and COPD were associated with declining grip strength (P < 0.10).

CONCLUSIONS

In older PWH, cerebrovascular disease, diabetes, COPD, or liver disease co-occurring with multimorbidity is associated with substantially increased risk of becoming frail within 30 months. Interventions targeting these comorbidities may ameliorate frailty and age-related functional decline in PWH.

Long sleep duration is associated with cognitive frailty among older community-dwelling adults: results from West China Health and Aging Trend study

OBJECTIVE

To investigate the association between sleep duration and cognitive frailty among older adults dwelling in western China.

METHODS

We used the baseline data from West China Health and Aging Trend (WCHAT) study. Sleep duration was classified as short sleep duration (< 6 h), normal sleep duration (6-8 h) and long sleep duration (≥ 9 h). Fried frailty criteria and Short Portable Mental Status Questionnaire were used to measure cognitive frailty. Multinomial logistic regression was conducted to estimate odds ratio (OR) and 95% confidence interval (CI).

RESULTS

A total of 4093 older adults (age = 67.8 ± 5.9 years, 1708 males and 2385 females) were included in the analysis. The prevalence of cognitive frailty was 11.8% among older adults in western China. Approximately 11.9% participants had short sleep duration (< 6 h); 22.2% had a long sleep duration (≥ 9 h). After adjusting for covariates, only long sleep duration was significantly associated with high risk of cognitive frailty (OR = 2.07, 95%CI = 1.60-2.68, P <  0.001) in western China older adults compared to normal sleep duration.

CONCLUSIONS

Long sleep duration was significantly related to cognitive frailty in older adults. Intervention for long sleep duration may be helpful to prevent cognitive frailty.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR1800018895 .

Self-Efficacy Is a Modifiable Factor Associated with Frailty in Those with Minor Stroke: Secondary Analysis of 200 Cohort Respondents

BACKGROUND

Owing to the improvement in acute care, there has been an increase in the number of people surviving stroke and living with its impairments. Frailty is common in people with stroke and has a significant impact on the prognosis after stroke. To reduce frailty progression, potentially modifiable factors should be identified. Increasing levels of self-efficacy influence both behaviour and physical functioning, and therefore it could be a potential target to prevent frailty.

METHODS

This is a prospective cohort study that involved the secondary analysis of the RISE data to examine the relationship between self-efficacy and frailty. The RISE study is a longitudinal study that consists of 200 adults aged 18+ years after their first stroke event. Data were collected from the respondents at 3 weeks, 6 months, 12 months, and 24 months after their discharge from the hospital. Frailty was assessed using the multidimensional frailty index with scores ranging from 0 to 1, and self-efficacy was assessed using the SESx scale, which was dichotomized as low/moderate or high. Frailty trajectories were examined using the repeated linear model. The generalized estimating equation was used to examine the relationship between self-efficacy and frailty at baseline and in the future (6-24 months). The B coefficients were reported at 95% CI before and after adjusting for potential confounders (age, gender, stroke severity, education, and social support).

RESULTS

A total of 200 responses were analysed, and the mean age of the respondents was 67.78 ± 11.53. Females made up 64% of the sample, and the mean frailty score at baseline was 0.17 ± 0.09. After adjusting for confounders, respondents with low self-efficacy had an approximately 5% increase in their frailty scores at baseline and in the 24-month follow-up period compared to those with high self-efficacy.

CONCLUSION

The result from this study showed that self-efficacy was significantly associated with frailty after stroke. Our findings suggest that self-efficacy may play a role in frailty progression among stroke survivors.

Oral function, nutritional status and physical status in Japanese independent older adults

OBJECTIVES

To clarify the associations among oral status, nutritional status and physical status in Japanese independent older adults.

BACKGROUND

It is important to focus on factors affecting physical status associated with life dysfunction, long-term care and mortality. However, there are very few reports of the associations among oral status, nutritional status and physical status.

MATERIALS AND METHODS

Patients who visited the Preventive Dentistry Clinic at Okayama University Hospital from November 2017 to January 2019 participated in this cross-sectional study. Number of teeth, periodontal condition and oral function were recorded. Bacteria counts in tongue dorsum, oral wettability, tongue pressure, tongue and lip movement function [oral diadochokinesis (ODK)], masticatory ability, bite force and swallowing function were measured. Nutritional status was assessed by the Mini Nutritional Assessment. Physical frailty status and Elderly Status Assessment Set were also evaluated. These variables were analysed by structural equation modelling (SEM).

RESULTS

Data from 203 patients were analysed (63 males and 140 females). Patients ranged in age from 60 to 93 years. The final model of the path diagram was completed by SEM. ODK was positively associated with nutritional status, and nutritional status was negatively associated with frailty. Age was associated with ODK, nutritional status and frailty.

CONCLUSION

Based on the associations among age, ODK, nutritional status and frailty, maintaining tongue movement function may contribute to good nutritional status and physical status in Japanese independent older adults.

Potential Mechanisms of Acute Standing Balance Deficits After Concussions and Subconcussive Head Impacts: A Review

Standing balance deficits are prevalent after concussions and have also been reported after subconcussive head impacts. However, the mechanisms underlying such deficits are not fully understood. The objective of this review is to consolidate evidence linking head impact biomechanics to standing balance deficits. Mechanical energy transferred to the head during impacts may deform neural and sensory components involved in the control of standing balance. From our review of acute balance-related changes, concussions frequently resulted in increased magnitude but reduced complexity of postural sway, while subconcussive studies showed inconsistent outcomes. Although vestibular and visual symptoms are common, potential injury to these sensors and their neural pathways are often neglected in biomechanics analyses. While current evidence implies a link between tissue deformations in deep brain regions including the brainstem and common post-concussion balance-related deficits, this link has not been adequately investigated. Key limitations in current studies include inadequate balance sampling duration, varying test time points, and lack of head impact biomechanics measurements. Future investigations should also employ targeted quantitative methods to probe the sensorimotor and neural components underlying balance control. A deeper understanding of the specific injury mechanisms will inform diagnosis and management of balance deficits after concussions and subconcussive head impact exposure.

Arterial stiffness and frailty - A systematic review and metaanalysis

Frailty and cardiovascular disease share some of the pathophysiologic features. Our objective was to review and metaanalyse the available published evidence on the topic. We performed a comprehensive literature search for studies where pulse wave velocity (PWV) or carotid-ankle vascular index (CAVI) has been linked with frailty in older persons. Of the initial 362 abstracts, after the application of the PRISMA approach, 5 were analysed in detail. We calculated within-study and pooled standardised mean differences of aortic stiffness measures between frail and non-frail (0.62 [0.31-0.92], p < 0.0001, I2 = 88%), and pre-frail and non-frail (0.32 [0.14-0.51], p = 0.0006, I2 = 72%) groups. In two studies it was possible to extract directly or calculate based on published data the odds ratios for the concomitant frailty, associated in one case with CAVI greater by 1 m/s and in another with cfPWV >13 m/s, indicating greater probability of concomitant frailty given greater aortic stiffness. Across the studies, the prevalence of hypertension, diabetes mellitus, hyperlipidaemia, and smoking tended to increase from non-frail, to pre-frail, and frail groups, presenting a possibility of important confounding, but also a common pathophysiology. In conclusion, the pooled analysis of the published cross-sectional study results indicates a relation between aortic stiffness and frailty in older subjects. However, well designed prospective studies are needed to answer the questions of causality.

Admission and Readmission/Death Patterns in Hospitalized and Non-hospitalized First-Ever-in-a-Lifetime Stroke Patients During the First Year: A Population-Based Incidence Study

Background: Hospitalization and readmission rates after a first-ever-in-a-lifetime stroke (FELS) are considered measures of quality of care and, importantly, may give valuable information to better allocate health-related resources. We aimed to investigate the hospitalization pattern and the unplanned readmissions or death of hospitalized (HospS) and non-hospitalized stroke (NHospS) patients 1 year after a FELS, based on a community register.

Methods: Data about hospitalization and unplanned readmissions and case fatality 1 year after a FELS were retrieved from the population-based register undertaken in Northern Portugal (ACIN2), comprising all FELS in 2009–2011. We used the Kaplan–Meier method to estimate 1-year readmission/death-free survival and Cox proportional hazard models to identify independent factors for readmission/death.

Results: Of the 720 FELS, 35.7% were not hospitalized. Unplanned readmission/death within 1 year occurred in 33.0 and 24.9% of HospS and NHospS patients, respectively. The leading causes of readmission were infections, recurrent stroke, and cardiovascular events. Stroke-related readmissions were observed in more than half of the patients in both groups. Male sex, age, pre- and post-stroke functional status, and diabetes were independent factors of readmission/death within 1 year.

Conclusion: About one-third of stroke patients were not hospitalized, and the readmission/death rate was higher in HospS patients. Still, that readmission/death rate difference was likely due to other factors than hospitalization itself. Our research provides novel information that may help implement targeted health-related policies to reduce the burden of stroke and its complications.

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

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.