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Oh, hello. I'm Terry Quinn. I'm a clinical academic based in University of Glasgow. My clinical work is mostly in the field of stroke and my academic work is mostly around the syndromes of old age and particularly how they interact with cardiovascular disease. And I'm going to share with you some thoughts on the concept of frailty and how it applies to stroke. So I shall call up my slave. Ok. So we're going to talk about frailty. I've called the talk celebrating the effort because for many people, frailty has been seen as something of a taboo, something not to be spoken about. And I hope if I do anything in the next 15 to 20 minutes or so I persuade you the is something that we need to be thinking about. My contact details are at the bottom of this slide and if anything that I see is of interest or you want to follow up on it. I'm very, very pleased to hear from you. So we should always start our talks with our disclosures and conflicts of interest and I've been doing work in this ty and stroke space. So I have funding from the chief scientist office in Scotland for work on identifying and managing frailty. I've worked with healthcare improvement Scotland on a program of screening for ty and unscheduled care and then a whole program grants from the Stroke Association to look at sequelae of stroke. And I run an international consortium looking at 10 stroke and you can immediately see a problem here and my free to work traditionally, stroke hasn't been included in that stroke has not been seen as important to, to research. And the conversant is also true and my stroke work frailty hasn't been seen as an important concept and that's something I want to challenge. So what I plan to do over the next few slides is take some of the arguments that have been put to me about why faty is not important in stroke and just provide a counterargument. So let's start with a thing I often hear, which is that is really not defined stroke, physicians and urologist want to deal with things that have a definition. Well, actually frailty as defined and ty is something that we recognize all the time. So here we have two men who chronologically may well be the same age but clearly biologically, they're different. And that difference is frailty and people have tried to operationalize this concept of realty. So it's not true to say we don't have definitions if anything, we have too many definitions. So here, here are just some of the definitions that I pull from white papers and consensus documents. They're all a little bit different, but they have some common themes. And the first theme is around aging. Clearly frailty is related to older age. However, frailty and older age are not synonymous. Even if we think about the group that epidemiologically we would call the oldest old, which be those people aged over 85. It's still the minority of them that living with frailty when we're working in secondary care, we sometimes get a biased view because the people we see often are those people living with and we don't see the healthy older adults who are living in the community and not requiring hospital care. The other concept in these definitions of free is something about a system failure and inability to cope with an external insult and that's defined in various ways here. But let me try and illustrate it with a cartoon. So in the green, as a robust older adult, they're living their life, they then have an insult. That could be a stroke, it causes a period of functional problems, but they recover and they go back to where they were now contrast the green line with the red line, which is someone living with frailty. And you can see that their function is already declining even without an external insult, the response they have to that external insult, that episode of illness or stroke or whatever is exaggerated, the recovery is slow, it's poor, they don't recover to where they were before. And often the trajectory of the decline also changes. So let's take that and let's illustrate it now with stroke. So here we have a robust older adult and we have some different stroke syndromes. So we have a ti a and it causes by definition, a transient loss of function, but there's full recovery, then we have a minor stroke, it causes a larger change in function, perhaps large enough that the person has a period of dependency and needs help. But with intervention, they get back to where they were before. A major stroke, a much larger change in function, a longer period of dependency, more interventions are needed, the recovery is staggered, the person doesn't get back to their baseline, but they still make a recovery. Now, let's compare those three stroke syndromes now and some that's living with frailty. And first of all, you can see the ti a which by definition is transient may not be transient. For the person living with frailty, it could have long lasting effects. A minor stroke has an exaggerated response levels of disability that you might not expect based on the stroke insult itself. And the person gets nowhere near back to where they were before. And for the person with frail to the major stroke is effectively a terminal event. If you're interested in the area, I would really commend you to read this paper that was published in practical neurology. TY for neurology is a practical guide and it was accompanied by an editorial that gave I thought a very nice pictorial illustration of frailty and stroke insults. So down here we have someone that is a robust older adult and someone that's a robust older adult that has an impairment due to stroke, same flavor. But this one is frail, you have the same stroke deficit but very clearly, this one is much less likely to cope with any further insult. Ok. So you may well say there's a definition for frailty. But what, what's the underlying pathology? What's the underlying mechanism? Well, again, we have, we have some understanding of that and there are various theories of the free to construct. One of the series was proposed by this man. This is Ken Rockwood from Canada and he said, well, frailty is a cumulative burden over the life course, we have various things that go wrong and each one leaves us a little bit weaker and a little bit more vulnerable. And he said you can quantify this, you can create a quantitative ty index if you count up the number of, of insults from list. So let's illustrate the frailty index. And I rad my kids toy covers for this illustration. So the tower here is a robust older adult, the bus as an insult like a stroke. So you can see when stroke happens. The tower wobbles, but it recovers thinking about this cumulative burden of frailty model. Let's think about things that can go wrong over the life course. So perhaps anemia, cardiac disease falls, depression, all of the things that are related to unsuccessful over aging. Each one is like taking a block from the tower. So now let's see how the tower responds to the stroke. You can see there's a complete system failure, the system can't cope with that insult of a stroke, but some people may be even more frail due to even more cumulative burden over the life course. So let's add in some other things associated with unsuccessful aging. And you can see now that it really only takes a very minor insult to cause major major problems if I, if I can digress and be political for a moment. Another system that's really seen cumulative burden is the UK NHS and I'm worried about its ability to withstand external pressures. So based on that model, you can see how we really have a potentially vicious circle. The person with frailty through cumulative burden has an increased number of risk factors when they have their stroke. The stroke is more severe, they're less likely to recover, they're less likely to respond to treatment, they're more likely to have complications. And this in turn makes them even more likely to have a further stroke. And you're without intervention, there's really no escape from this vicious circle other than through mortality. And that all sounds very negative and that ends quite negative. We think about cumulative burden. We think about things that go wrong where I'm going with my research at the moment is about what are the things that protect us? What are the things that perhaps give us resilience and watch this space for more research on that topic. Another theory of frailty was proposed by this Lady Mary free from North America and she said that we can clinically assess for frailty. There's a frailty phenotype il is a syndrome that has recognizable features and the teachers are here or unintentional weight loss, exhaustion, weakness, sen behavior, and slowness, slow walking speed. And an authorization is an operationalization for each of them is presented here on the slide and here's a, a final construct of this one's closer to home. It's from Bernard Isaacs. We worked where I'm sitting just now in the University of Glasgow Department of Academic Geriatric Medicine. And he said you can recognize frailty because when an older adult with frailty becomes unwell, the response to that illness is stereotyped. He told us that when an older adult with fri becomes unwell, really, there are only four things that tend to happen no matter what the illness, whether it's a heart attack, a pneumonia, a stroke, the person either falls or has a change in their gait and balance or they become sedentary or they become confused or they lose control of continence. And he called these four things, the geriatric giants and some people have added two more geriatric giants personal with fail to when they become unwell, is likely to suffer from medical harm, iatrogenesis and they're also likely to become socially isolated. So, thinking of those four classic geriatric giants, do we see them in stroke? Well, of course, we do falls are very common in stroke, sarcopenia, age-related muscle loss. Again, very common dementia delirium, incredibly common urinary incontinence also common. So you can see that based on these geriatric giants, frailty and stroke do seem to have a close relationship. So why then do some people say? Well, I don't see any fr tea in my clinical practice as a stroke physician, as a neurologist. Well, perhaps that's because you're not looking or perhaps it's because you're not seeing the majority of people that actually prevent present to secondary care. So I still do a bit of general medicine. And here's a a typical general medical part of the ward round and you'll immediately see there aren't very many 20 year olds here, secondary care, contemporary medicine is really the care of older adults and often the older adults living with frailty. So we had a look, we collated all the published papers that described the prevalence of frailty and people when they present with an acute stroke. So what we're really describing here as pre stroke, frailty and people that present to acute stroke services. And what can you see? Well, you can see most of the papers are relatively recent. A lot of the peoples come from the UK. But I draw your attention to the column showing free the prevalence, some of those numbers really very high. And if we consider the syndrome of pre frailty, that's people that are at risk of frailty high. Or still, if you perform meta analysis, if you try and to create a summary estimate, you're looking at about one in four people prevent presenting with stroke or living with frailty before their stroke. And you have to think are our systems ready for that. And if you say to me, well, that sounds ridiculous to him. There can't be one in four people presenting with stroke that have frailty. Well, I'd say to you let's look at other other settings in the community, everything but older adults, frailty is about one in 10 across the hospital for older adults. Free is anything up to one and two or one in three care homes. It's higher. I actually think the estimate here is an underestimate if we think about UK care homes and an acute stroke. As we've said, the frailty is about one in four. You will notice as you look at those columns of frailty prevalence and pre frailty prevalence, there was a lot of variation, a lot of heterogeneity and that's partly because of the different ways that the frailty was assessed with a frailty index or a ty or, or with other validated measures So we had a look at F TY and our stroke service in North Glasgow. So for a period, every consecutive admission with confirmed stroke was asses for frailty. We used a ty index and we found that about 28% had frailty, but another 50% or more had pre frailty. So a risk of frailty with the stroke. So almost 80% had some frailty syndrome. We also assessed for frail to using the phenotypic approach, using a questionnaire. We found exactly the same, but 28% of people were frail. So our data agreeing with the data from that meta analysis. So if I've convinced you that faty is important, you might say, OK, I find that it's important, but I don't have time to assess for it or you may say, well, actually, I already assess for these things. So how do you assess for ty? Well, it's not the classical neurological approach. There's no Tendon Hammer, there's no imaging and you can think about the assessment of frailty as really operating on a spectrum from a very comprehensive research level assessment through to really screening or triage. And it's probably more at the screening or triage stage that people working in stroke, people working in urology need to be operated, you need to identify those people who perhaps need further input from someone with expertise and ty care and in stroke that's challenging. So here we have someone that's had a substantial stroke they're in a stroke, high dependency unit, I acute stroke unit, lots of monitoring and clearly at the moment, if we were to apply the frailty phenotype, their grip strength would be weak because of the stroke. They, they're not walking, they're not active. They're likely to feel exhausted. They may be nil by mouth. They're likely to be losing weight. So they would tick all of the boxes for the ty phenotype. But you would hope some of this will recover and they're not necessarily frail. That's why when we assess free, we're really looking at the person before the stroke and we saw this and our data in North Glasgow first. When we apply, when we tried to apply the ty phenotype, we could only do it in a proportion of everyone that came to the unit. Lots of the people couldn't complete the assessment. So do we have easier ways to assess Ty? Well, I think we do. Here's one that's gaining a lot of traction in the UK. This is a clinical ty scale. It's an ordinal hierarchical scale that ranges from being very fit to being really severely frail. And for each category, there's a definition and a little infographic in Scotland, we wanted to create something that was even more simple. So we created this realty assessment tool based on the letters frail and this is something that's now being used for unscheduled admissions aged over 65 and both these things, the clinical free scale. And the the the assessment tool developed in Scotland could easily be applied to people presenting with stroke. I said there was no imaging that helps diagnose frailty. But actually, we've been having a look at imaging for the assessment of frailty. So people that come through our service have assessment of their carotid vasculature using a CT angiogram or an Mr angiogram. We wondered if you could use those images to have a look at the muscles, their size and their quality and derive sarcopenia. And what we found was that you could do that. And when you do it, adding that sarcopenia measure to another measure of frailty really becomes very predictive for poor outcomes. So you're adding value, you're adding prognostic utility by looking at an imaging marker of sarcopenia and adding it to other frailty assessments within the field of stroke. A scale that's often used as the modified ranking scale described by John Rankin here, another Glasgow graduate. And people may say, well, I I apply ranking to look at the person's function before the stroke, the so called pre stroke ranking. So I don't need to look at realty. But if you look at the ranking scale and if you look at it's wording, it's really not designed to look at how the person was before their stroke. And for that reason, my group and many other groups have shown that actually the pre stroke modified Dr in scale, if it's used with no training and no guidance as essentially a random number generated. So you may say all of this may be true for a select group of people, but frailty is really not important and the people that I look after. Well, let's think about the importance of realty, but think about what faty means. So these aren't data from stroke, these are data from across all older adults. And what we're looking at here are different levels of frailty based on that clinical frailty scale and what they mean in terms of the length of stay, the chance of readmission, the chance of death. And you can see that when you get to the the higher levels of frailty, frailty levels of seven or eight or nine, the prognosis there, it really, it's, it's not good. You're looking at a prognosis that's similar to the prognosis that you might have with many metastatic cancers. And so you can think in this sense, frailty is almost a lens in which you view the patient and you can use that to decide about the most appropriate treatment. One of my friends and collaborators, Nick Evans from Cambridge published this really intriguing paper. They looked at frailty and all the admissions to their stroke service. And unsurprisingly, there was a lot of frailty and the people with frailty had poor outcomes. But they also found that as frailty increased, the benefit from an intervention like thrombolysis decreased. And this raises a possibility that I think is very important that frailty may be a moderator of treatment effect. And treatments that are effective across the whole stroke population may not necessarily be effective or as effective. And people who are living with advanced fail with colleagues in Belfast, we had a look at mechanical thrombectomy for stroke and rates of frailty and outcomes. So again, there were a sizable proportion of people who had ty who had a a thrombectomy and their outcomes are very quick to the strongest predictor of disability in three months. And people have said, well, surely this is a self fulfilling prophecy. If you think people with fail, you are going to do badly, you're not going to give them the same care. But when we looked at markers of quality of care for thrombectomy. So things like the time to imaging, the rates of recanalization, actually, they were the same in the two groups. So whatever is driving the poor outcomes, it's not a systems failure. If you work in the outpatient setting, again, free is prevalent there and again, free is associated with poor outcomes. These are data from my collaborators in University of Leicester, looking at people that were assessed in their ti a clinic and looking at outcomes by TY status. So you might finally see you're convinced that frailty is a problem, but you're only interested in things you can treat. So, is there a treatment for frailty? Well, there isn't a drug treatment for frailty, at least not yet. But we do have a treatment and it's comprehensive geriatric assessment, cold assessment. But the assessment is really a misnomer because assessment is only part of a package that's also interventional. And you can see how the comprehensive geriatric assessment takes in the physical psychiatric, the functional and it puts it in the context of caregivers and home environment. And that's then used to create a bespoke intervention. And it works here as the Cochrane review, looking at comprehensive Geriatric Assessment and through Comprehensive Geriatric assessment, older adults are more likely to return home, less likely to be admitted to a care home. We have guidance. So in the UK, there's this very useful book er jointly published by British Geriatric Society and other societies, the silver book and it looks at how to incorporate into acute hospital systems. But going back to a point that I raised earlier stroke isn't mentioned here. I did some work with the chief scientist office to look to see, can we define a bundle of care, a package of care that everyone identified with? Ty should have something that can be done by anyone, even if they have no particular expertise in the process is outlined in the purple box. But the process for this talk is less important than what we found. We found that there are key things that should be done for anyone that's found to have frailty and they're not rocket science you really represent good medical nursing care, but they're often not done now for people working in stroke, they may recognize that list because it looks very similar to the list of things that have been proven to be effective in stroke care, the components of an effect stroke unit. So you could argue that although stroke and frailty often aren't mentioned together, good stroke care is essentially good for health care. And that then comes to the, the final point I want to make that. I think we're in danger of thinking in silos and thinking that frailty is somehow separate from stroke and that stroke and fail somehow separate from dementia. And I think that's not the case. And I think thinking in this way isn't person centered. And I really want to avoid having a situation like this where we have an older adult living with Ty, they've had a stroke. So a stroke specialist looks after the stroke, but someone else looks after their frailty, they develop a delirium and someone else looks after that. And my real worry as as stroke surface become, become much more hyper acute, much more interventional. Some of those more basic but important aspects of care may be lost. And I wouldn't want people to interpret this as me saying that interventional stroke care isn't important. It's incredibly important. It's life changing, it's life saving for many people. We need to have it. But I think it also needs to be complimented by a service that's fit for purpose for older adults living with Ty perhaps will benefit less from those hyper acute therapies but will benefit more from good nursing care, good medical care, good care from allied health professionals. So hopefully I've convinced you that Ty has definition their underlying theories. There's a law of it assessment in terms of screening is something you can do, although it's not so easy in stroke fruit is associated with outcomes and there are things you can do if you identify it. So thank you for listening. Hopefully some food for thought there. As I said at the beginning of the talk, if any of this is of interest, my contact details are at the bottom of the slide. So thank you.