The magnitude of disability among elderly stroke survivors is substantial. There have been few community-based estimates of the contribution gender and older age make to stroke-related disability and ...outcome. Using the original Framingham Study cohort, we documented gender-specific neurological deficits and disability differences in stroke survivors at six months post-stroke. Logistic regression analyses were performed to estimate odds ratios, comparing men and women, and adjusting for age, and age and stroke subtype. Age and gender-matched controls were then compared to distinguish stroke-related disability from disability associated with general aging. Results showed that almost half (43%) of all elderly stroke survivors in the cohort had moderate to severe neurological deficits. In the crude analyses, women were more dependent in ADLs (33.9% vs 15.6%), less likely to walk unassisted (40.3% vs 17.8%), and living in nursing homes (34.9 % vs 13.3%). After adjusting for age and stroke subtype, it was older age that accounted for the severity of disability. When compared to age and gender-matched controls, stroke cases were significantly more disabled in all domains studied. In this elderly cohort, more women experienced initial strokes and were more disabled at 6 months post-stroke than men. However, older age at stroke onset, not gender or stroke subtype, was associated with greater disability. Health care providers need to understand that strokes occur later in life for women and that because of age, women are at greater risk for disability and institutionalization.
It is a well-described clinical phenomenon that females live longer than males, yet tend to experience greater levels of co-morbidity and disability. Females can therefore be considered both more ...frail (because they have poorer health status) and less frail (because they have a lower risk of mortality). This systematic review aimed to determine whether this ageing paradox is demonstrated when the Frailty Index (FI) is used to measure frailty.
Medline, EMBASE and CINAHL databases were searched for observational studies that measured FI and mortality in community-dwellers over 65years of age. In five-year age groups, meta-analysis determined the sex differences in mean FI (MD=mean FIfemale−mean FImale) and mortality rate.
Of 6482 articles screened, seven articles were included. Meta-analysis of data from five studies (37,426 participants) found that MD values were positive (p<0.001; MD range=0.02–0.06) in all age groups, indicating that females had higher FI scores than males at all ages. This finding was consistent across individual studies. Heterogeneity was high (I2=72.7%), reflecting methodological differences. Meta-analysis of mortality data (13,127 participants) showed that male mortality rates exceeded female mortality rates up until the 90 to 94-years age group. Individual studies reported higher mortality for males at each level of FI, and higher risk of death for males when controlling for age and FI.
The pattern of sex differences in the FI and mortality of older adults was consistent across populations and confirmed a ‘male-female health-survival paradox’.
•The male-female health-survival paradox: females live longer than males but with poorer health.•Studies using the Frailty Index (FI) consistently show that at any given age, females have higher FI scores than males.•Females tolerate this frailty better, as demonstrated by a lower mortality rate at any given FI score or age.•The FI model provides a framework for investigating the mechanisms that underpin this sex paradox.
To assess the value of blood neurofilament light chain (NfL) as a biomarker of recent, ongoing, and future disease activity and tissue damage and its utility to monitor treatment response in ...relapsing-remitting multiple sclerosis.
We measured NfL in blood samples from 589 patients with relapsing-remitting multiple sclerosis (from phase 3 studies of fingolimod vs placebo, FREEDOMS and interferon IFN-β-1a, TRANSFORMS) and 35 healthy controls and compared NfL levels with clinical and MRI-related outcomes.
At baseline, NfL levels (pg/mL) were higher in patients than in healthy controls (30.5 and 27.0 vs 16.9,
= 0.0001) and correlated with T2 lesion load and number of gadolinium-enhancing T1 lesions (
< 0.0001, both). Baseline NfL levels, treatment, and number of new or enlarging T2 lesions during the studies predicted NfL levels at the end of study (all
< 0.01). High vs low baseline NfL levels were associated (estimate 95% confidence interval) with an increased number of new or enlarging T2 lesions (ratio of mean: 2.64 1.51-4.60;
= 0.0006), relapses (rate ratio: 2.53 1.67-3.83;
< 0.0001), brain volume loss (difference in means: -0.78% -1.02 to -0.54;
< 0.0001), and risk of confirmed disability worsening (hazard ratio: 1.94 0.97-3.87;
= 0.0605). Fingolimod significantly reduced NfL levels already at 6 months (vs placebo 0.73 0.656-0.813 and IFN 0.789 0.704-0.884), which was sustained until the end of the studies (vs placebo 0.628 0.552-0.714 and IFN 0.794 0.705-0.894;
< 0.001, both studies at all assessments).
Blood NfL levels are associated with clinical and MRI-related measures of disease activity and neuroaxonal damage and have prognostic value. Our results support the utility of blood NfL as an easily accessible biomarker of disease evolution and treatment response.
To compare the accuracy of the modified Fried Index (mFI) and the Clinical Frailty Scale (CFS) to predict death or patient-reported new disability 90 days after major elective surgery.
The ...association of frailty with patient-reported outcomes, and comparisons between preoperative frailty instruments are poorly described.
This was a prospective multicenter cohort study. We determined frailty status in individuals ≥65 years having elective noncardiac surgery using the mFI and CFS. Outcomes included death or patient-reported new disability (primary); safety incidents, length of stay (LOS), and institutional discharge (secondary); ease of use, usefulness, benefit, clinical importance, and feasibility (tertiary). We measured the adjusted association of frailty with outcomes using regression analysis and compared true positive and false positive rates (TPR/FPR).
Of 702 participants, 645 had complete follow up. The CFS identified 297 (42.3%) with frailty, the mFI 257 (36.6%); 72 (11.1%) died or experienced a new disability. Frailty was significantly associated with the primary outcome (CFS adjusted odds ratio, OR, 2.51, 95% confidence interval, CI, 1.50-4.21; mFI adjusted-OR 2.60, 95% CI 1.57-4.31). TPR and FPR were not significantly different between instruments. Frailty was the only significant predictor of death or new disability in a multivariable analysis. Need for institutional discharge, costs and LOS were significantly increased in individuals with frailty. The CFS was easier to use, required less time and had less missing data.
Older people with frailty are significantly more likely to die or experience a new patient-reported disability after surgery. Clinicians performing frailty assessments before surgery should consider the CFS over the mFI as accuracy was similar, but ease of use and feasibility were higher.
Background: Frailty has been shown to be associated with disability in the previous studies. However, it is not clear how consistently or to how much degree frailty is actually associated with the ...future disability risks.
Methods: A systematic review of the literature was conducted using Embase, MEDLINE, CINAHL, PsycINFO, and the Cochrane Library for any prospective studies published from 2010 to September 2015 examining associations between baseline frailty status and subsequent risk of developing or worsening disabilities among community-dwelling older people. A meta-analysis was performed to synthesize pooled estimates.
Results: Of 7012 studies identified through the systematic review, 20 studies were included in the meta-analysis. Twelve studies examined activities of daily living (ADL) disability risks, two studies examined instrumental activities of daily living (IADL) disability risks, and six studies examined both ADL and IADL disability risks. Overall, frail older people were more likely to develop or worsen disabilities in ADL (12 studies, pooled OR = 2.76, 95% CI = 2.23-3.44, p < 0.00001; 5 studies, pooled HR = 2.23, 95% CI = 1.42-3.49, p < 0.00001) and IADL (6 studies, pooled OR = 3.62, 95% CI = 2.32-5.64, p < 0.00001; 2 studies, pooled HR = 4.24, 95% CI = 0.85-21.28, p = 0.08). Prefrailty was also associated with incident or worsening disability risks to a lesser degree in most pooled analyses. High heterogeneity observed among 12 studies with OR of ADL disability risks for frailty was explored using subgroup analyses, which suggested methodological quality and mean age of the cohort were the possible causes.
Conclusion: This systematic review meta-analysis quantitatively showed that frail older people are at higher risks of disabilities. These results are important for all related parties given population aging worldwide. Interventions for frailty are important to prevent disability and preserve physical functions, autonomy, and quality of life.
Implications for Rehabilitation
Although frailty has been shown to be associated with disability and considered as a precursor of disability, it is not clear how consistently or to how much degree frailty is actually associated with the future disability risks.
This systematic review and meta-analysis quantitatively shows frailty is a significant predictor of incident and worsening ADL and IADL disabilities.
It is a pressing priority to develop interventions for frailty to prevent disability and preserve older people's physical functions, autonomy, and quality of life.
The effect of endovascular thrombectomy that is performed more than 6 hours after the onset of ischemic stroke is uncertain. Patients with a clinical deficit that is disproportionately severe ...relative to the infarct volume may benefit from late thrombectomy.
We enrolled patients with occlusion of the intracranial internal carotid artery or proximal middle cerebral artery who had last been known to be well 6 to 24 hours earlier and who had a mismatch between the severity of the clinical deficit and the infarct volume, with mismatch criteria defined according to age (<80 years or ≥80 years). Patients were randomly assigned to thrombectomy plus standard care (the thrombectomy group) or to standard care alone (the control group). The coprimary end points were the mean score for disability on the utility-weighted modified Rankin scale (which ranges from 0 death to 10 no symptoms or disability) and the rate of functional independence (a score of 0, 1, or 2 on the modified Rankin scale, which ranges from 0 to 6, with higher scores indicating more severe disability) at 90 days.
A total of 206 patients were enrolled; 107 were assigned to the thrombectomy group and 99 to the control group. At 31 months, enrollment in the trial was stopped because of the results of a prespecified interim analysis. The mean score on the utility-weighted modified Rankin scale at 90 days was 5.5 in the thrombectomy group as compared with 3.4 in the control group (adjusted difference Bayesian analysis, 2.0 points; 95% credible interval, 1.1 to 3.0; posterior probability of superiority, >0.999), and the rate of functional independence at 90 days was 49% in the thrombectomy group as compared with 13% in the control group (adjusted difference, 33 percentage points; 95% credible interval, 24 to 44; posterior probability of superiority, >0.999). The rate of symptomatic intracranial hemorrhage did not differ significantly between the two groups (6% in the thrombectomy group and 3% in the control group, P=0.50), nor did 90-day mortality (19% and 18%, respectively; P=1.00).
Among patients with acute stroke who had last been known to be well 6 to 24 hours earlier and who had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone. (Funded by Stryker Neurovascular; DAWN ClinicalTrials.gov number, NCT02142283 .).
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