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Available online 16 February 2022
Frailty in people over 80 years after an ischemic stroke treated with mechanical thrombectomy
Fragilidad en mayores de 80 años tras trombectomía mecánica por un ictus isquémico
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Alicia Murias Quintanaa,
Corresponding author
amuriasquintana@hotmail.com

Corresponding author.
, Lorena Benavente Fernándezb, Germán Morís de la Tassab
a Enfermería, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
b Servicio de Neurología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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Tables (3)
Table 1. Clinical variables and pharmacological treatment of the study population, n (%); (n = 65).
Table 2. Results of the variables on the stroke episode, n (%); (n = 65).
Table 3. Results of Frail scale on frailty, n (%); (n = 28).
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Abstract
Introduction

Although the advanced age is not an exclusion criterion for the stroke treatments, is characterized by a frailty state that affected the evolution and prognosis in such patients.

Objectives

To describe the possibility of a relation between frailty in elderly people (≥ 80 years old) after mechanical thrombectomy, and clinical severity, and to describe stroke clinical features.

Methods

Observational study in people over 80 year-old who suffered an ischemic stroke and underwent to mechanical thrombectomy, between February and October 2018. Data about cardiovascular risk factors, medical treatment, stroke episode and frailty were collected.

Results

The sample was constituted by 65 people. A 72% suffered hypertension and 43% atrial fibrillation. A 75% did not take anticoagulants. A 82% did not suffer complications with the procedure, and a complete arterial reperfusion was achieved in 83%. A 27.69% (n = 28) was not fragile. There was statistical association between age and frailty (P = .003).

Discussion

In our sample, the neurological and functional state caused by the stroke were more severe (described by the NIHS and Rankin modified scales score), but the recovery after hospital discharge was more positive. Elderly survivor patients were characterized as no fragile. The recovery after a stroke should be measured in functionality and quality of life terms, and not only using the age data.

Keywords:
Cardiovascular diseases
Frail elderly
Stroke
Resumen
Introducción

Aunque la edad en el ictus no condiciona los tratamientos de reperfusión, lleva implícitamente una fragilidad que condiciona el estado funcional y probablemente el pronóstico y la evolución.

Objetivos

Estudiar la fragilidad en pacientes con ictus isquémico tratados con trombectomía mecánica y de ≥ 80 años de edad.

Método

Estudio observacional en población ≥ 80 años tras sufrir un ictus isquémico y tratarse con trombectomía mecánica, entre febrero y octubre de 2018. Se recogieron variables sobre factores de riesgo cardiovascular, tratamiento concomitante, datos correspondientes al episodio del ictus (gravedad neurológica y funcional con las escalas NIHS y Rankin modificada) y fragilidad (entrevista telefónica, enero-febrero 2019).

Resultados

La muestra fue de 65 personas. El 72% padecían hipertensión arterial y el 43%, fibrilación auricular. El 75% no estaban a tratamiento anticoagulante. El 78% fueron tratados antes de 6 h. El 82% no sufrieron complicaciones neurológicas. Se consiguió una reperfusión arterial completa en el 83%. El 27,69% puntuaron como no frágil (n = 28). Se observó relación estadística entre la fragilidad y la edad (p = 0,003).

Discusión

A nivel neurológico y funcional los ictus presentaban puntuaciones mayores (más graves) en las escalas NIHS y Rankin modificada respecto a otros estudios de investigación. Los pacientes más mayores que sobrevivieron al ictus son en su mayoría no frágiles, por lo que la recuperación debería medirse en términos de funcionalidad y calidad de vida y no tanto en base a la edad cronológica.

Palabras clave:
Enfermedades cardiovasculares
Anciano frágil
Ictus
Full Text
Introduction

Stroke is a cerebrovascular disease that poses a major social, health and economic problem, and is the leading cause of death in women in Spain.1 Around 80% of strokes are ischaemic.2

Age and gender are the non-modifiable risk factors for stroke.3 However, there are other risk factors that can be addressed: hypercholesterolaemia, hyperglycaemia, dyslipidaemia, previous cardiovascular disease, tobacco, alcohol and/or other drug use, physical inactivity, overweight/obesity and hypertension (HTN).3 Fifty percent of strokes are attributed to the latter.4 Factors associated with death after stroke are age, male gender, HTN, atrial fibrillation, previous stroke or neurological deficit at discharge.5

It was not until 2015 that mechanical thrombectomy became established as the standard treatment in patients with stroke caused by occlusion of arteries of the proximal anterior circulation.6 This method widens the therapeutic window and can be applied up to 8h in the anterior circulation and 24h in the posterior circulation, supported by higher recanalization rates (45%-81%) and a notable reduction in the number of haemorrhages associated with fibrinolytic therapy.7,8

The stroke code is used for the emergency care of stroke patients. In Asturias, the latest update was implemented in March 2019. The most relevant feature was the elimination of age limits as an exclusion criterion for treatment.9 These modifications and Europe’s population change in recent years (an older population with associated chronic diseases),10 have given rise to the concept of "frailty". Linda Fried et al.11 conducted the first pioneering study focusing on this phenomenon, defining it as an increased risk of suffering adverse health effects. The result was the creation of the "frailty phenotype".11 Stroke results in functional limitations characteristic of the "frail elderly"; however, frailty has been little studied in this population.10

Functional independence is examined currently, but other areas including the performance of tasks or work and psychological aspects, among others, are neglected.12 The elimination of age limits in the stroke code of Asturias (Spain)9 means that this research study is based on the fact that, although age is not an exclusion criterion, it does imply a state of frailty that really determines functional status, and probably the prognosis and progress of patients who have or have not undergone the abovementioned treatments. However, there is little literature on this subject and there are no adequate scales to enable us to decide whether mechanical thrombectomy should be used in our patients. Therefore, the aim of the research study was to explore frailty in patients with ischaemic stroke treated with mechanical thrombectomy and aged ≥80 years.

Method

This is an observational study conducted between June 2018 and May 2019 in the Hospital Universitario Central de Asturias (HUCA).

The Ethics Committee of the Principality of Asturias (number 227/18) approved the project.

The entire population that met the following inclusion criteria was selected: age ≥ 80 years, based on the elimination in 2018 of the age limits of the Asturias stroke code,9 updated in March 2019; having suffered an ischaemic stroke and undergone mechanical thrombectomy, regardless of whether recanalization was unsuccessful, between February and October 2018. The databases of the HUCA Interventional Neuroradiology Department were used for this purpose. Those who did not speak Spanish and with incomplete/missing data in the records of the Neuroradiology Department were excluded. The population diagram is shown in Fig. 1.

Figure 1.

Progression of the sample.

(0.3MB).

Some time after the stroke, as they did not appear in the records, data on frailty (Frail scale) and functional dependence according to the modified Rankin scale (mRs), 12 were obtained through telephone interviews with the patients between January and February 2019, and therefore the progression time following the stroke varied. The remaining variables were collected from the computerised medical records. They were grouped into three categories: cardiovascular risk factors,3 relevant concomitant treatment,13 and data corresponding to the stroke episode.

Cardiovascular risk factors were recorded as discrete numerical age, and the rest dichotomously: sex (male/female), HTN, diabetes mellitus, dyslipidaemia, ischaemic heart disease, lower limb ischaemia, atrial fibrillation, active neoplasia, chronic kidney failure, and previous stroke (yes/no).

Concomitant treatment was divided into antiplatelet drugs (single, double, none), anticoagulants (vitamin K antagonists, direct, low molecular weight heparin, none), antihypertensives (single, various, none), antidiabetic agents (oral, insulin, both, none), and lipid-lowering drugs (statins, fibrates, various, none). These were classified as nominal qualitative variables.

The variables chosen to describe the stroke episode were: time to recanalization (≤1h30', 1h30'-3h, 3h-4h30', >4h30'-6h, >6h, missing values), neurological (oedema, hydrocephalus, haemorrhagic transformation, others not covered, several of the above, none) and systemic complications (anaemia, heart failure, urinary tract infection, respiratory infection, ischaemic heart disease, symptomatic bradycardia, puncture sites, other, several, none) after reperfusion, TICI score (Thrombolysis in Cerebral Infarction scale)14 (0, 1, 2A, 2B, 3), aetiology of stroke (cryptogenic, cardioembolic, atherothrombotic, other, several, none), atherothrombotic, other, according to TOAST [Trial of ORG 10172 in Acute Stroke Treatment Subtype Classification]),15 length of hospital stay in days, NIHS score (National Institutes of Health Stroke scale)16 on admission, after thrombectomy and at discharge (0 points, 1-5 points, 6-15 points, 16-20 points, ≥21 points), functional independence according to baseline mRs12 score, at discharge and at the time of the call (from 0 to 6 points), destination at discharge (home, socio-health centre, death and missing data) and rehabilitation at discharge (yes, not required, not applicable, death, missing values).

Finally, we chose the Frail questionnaire17 to assess the existence or otherwise of frailty, which assesses fatigue, endurance, ambulation, comorbidities, and weight loss. If 3 or more of these parameters are altered, the patient is considered frail.

Statistical analysis

For the statistical analysis, percentages of the categories of each variable were calculated using Microsoft Office Excel and SPSS version 18.0.

Secondly, to determine the statistical tests to use, we tested the normality of the age variable using the Anderson-Darling test. The normality of the continuous variables was established using the same test and the quantile-quantile graph. Statistically significant differences between two groups in normal variables was studied using the t-test, and the non-parametric Kruskal-Wallis test was used for non-normal variables.

Results

Of the total sample (65 patients), 77% were women and the mean age was 87 ± 4.71 years. Fig. 1 explains the progression of the sample.

Cardiovascular risk factors and pharmacological treatment are shown in Table 1, where we observe 72.31% of patients with HTN, followed by 50.77% with dyslipidaemia. Regarding concomitant treatment, 63% were not on antiplatelet therapy, 75% did not use anticoagulants and 66.15% were not treated with lipid-lowering drugs. Factors related to stroke (Table 2) showed 78% of patients with a wait of <6h until recanalization, 81% with no neurological complications, 41.54% with no systemic complications, and 83.08% with a TICI score 3-2b. The NIHS16 score went from 50.77% with ≥16 points on admission to 79.99% with ≤15 at discharge. Modified Rankin Scale values 3, 4 and 5 were found in 24.66% on admission.

Table 1.

Clinical variables and pharmacological treatment of the study population, n (%); (n = 65).

Cardiovascular risk factors
  Yes  No 
Hypertension  47 (72.31%)  18 (27.69%) 
Diabetes mellitus  19 (29.23%)  46 (70.77%) 
Dyslipidaemia  33 (50.77%)  32 (49.23%) 
Ischaemic heart disease  18 (27.69%)  47 (72.31%) 
Lower limb ischaemia  9 (13.85%)  56 (86.15%) 
Known atrial fibrillation  28 (43.08%)  37 (56.92%) 
Active neoplasia  5 (7.69%)  60 (92.31%) 
Chronic kidney failure  5 (7.69%)  60 (92.31%) 
Previous stroke  15 (23.08%)  50 (76.92%) 
Pharmacological treatment
Antiaggregant  Simple  Double  None   
  24 (36.92%)  0 (0%)  41 (63.08%)   
Anticoagulant  Vitamin K antagonists  Direct oral anticoagulants  Low-molecular-weight heparin  None 
  0 (0%)  14 (21.54%)  3 (4.69%)  48 (75%) 
Antihypertensive  Simple  Several  None   
  19 (29.23%)  33 (50.77%)  13 (20%)   
Antidiabetic  Oral  Insulin  Both  None 
  9 (13.85%)  4 (6.15%)  1 (1.54%)  51 (78.46%) 
Lipid-lowering  Statins  Fibrates  Several  None 
  19 (29.23%)  2 (3.08%)  1 (1.54%)  43 (66.15%) 
Table 2.

Results of the variables on the stroke episode, n (%); (n = 65).

Time to recanalization  ≤ 1 h 30 min  1 h 30 min-3 h  > 3 h-4 h 30 min  > 4 h 30 min-6 h  > 6 h  Missing values 
  0 (0%)  9 (13.85%)  20 (30.77%)  22 (33.85%)  12 (18.46%)  2 (3.08%) 
Neurological complications  Oedema  Hydrocephalus  Haemorrhagic transformation  Other  Several  None 
  0 (0%)  0 (0%)  11 (16.92%)  1 (1.54%)  0 (0%)  53 (81.54%) 
Systemic complications  Anaemia  Heart failure  Urinary tract infection  Respiratory infection  Ischaemic heart disease   
  0 (0%)  0 (0%)  5 (7.69%)  9 (13.85%)  0 (0%)   
  Asymptomatic bradycardia  Local due to puncture  Other  Several  No   
  0 (0%)  1 (1.54%)  11 (16.92%)  12 (18.46%)  27 (41.54%)   
TICI index  2A  2B   
  6 (9.23%)  0 (0%)  5 (7.69%)  16 (24.62%)  38 (58.46%)   
Aetiology of stroke  Cryptogenic  Cardioembolic  Atherothrombotic  Other     
  6 (9.52%)  48 (76.19%)  6 (9.52%)  5 (7.69%)     
Length of hospital stay (days)  Mean  Minimum  Maximum       
  15 days  3 days  71 days       
NIHSS on admission  6-15 points  16-20 points  ≥ 21 points       
  32 (49.23%)  24 (36.92%)  9 (13.85%)       
NIHSS after thrombectomy  0 points  1-5 points  6-15 points  16-20 points  ≥ 21 points   
  5 (7.69%)  16 (24.62%)  31 (47.69%)  10 (15.38%)  3 (4.62%)   
NIHSS at discharge  0 points  1-5 points  6-15 points  16-20 points  ≥ 21 points   
  12 (18.46%)  30 (46.15%)  10 (15.38%)  2 (3.08%)  0 (0%)   
Baseline mRs  0, asymptomatic  1, with no significant disability  2, mild disability  3, moderate disability     
  24 (32.88%)  16 (21.92%)  15 (20.55%)  15 (20.55%)     
  4, moderate/severe disability  5, severe disability  6, death       
  2 (2.74%)  0 (0%)  0 (0%)       
mRs at discharge  0, asymptomatic  1, with no significant disability  2, mild disability  3, moderate disability     
  5 (6.85%)  4 (5.48%)  13 (17.81%)  25 (34.25%)     
  4, moderate/severe disability  5, severe disability  6, death       
  9 (12.33%)  5 (6.85%)  12 (16.44%)       
mRs at time of call  0, asymptomatic  1, with no significant disability  2, mild disability  3, moderate disability     
  3 (4.62%)  3 (4.62%)  1 (1.54%)  9 (13.85%)     
  4, moderate/severe disability  5, severe disability  6, death  Missing data     
  10 (15.38%)  2 (3.08%)  23 (35.38%)  14 (21.54%)     
Destination on discharge  Home  Social health centre  Missing data       
  43 (66.15%)  8 (12.31%)  3 (4.62%)       
Rehabilitation on discharge  Yes  Not required  Not applied  Missing data     
  29 (44.62%)  13 (20%)  10 (15.38%)  2 (3.08%)     

There was a total of 23 deaths at the end of the data collection from medical records. Of these, 14 died before telephone calls were made. Of these, 6 died of broncho-aspiratory pneumonia.

Data on frailty were obtained for a total of 28 patients, 27.69% of whom were non-frail. In terms of the relationship between frailty and patient age, the results showed statistically significant differences (p = .033), age being higher in the non-frail patients (Table 3).

Table 3.

Results of Frail scale on frailty, n (%); (n = 28).

• Frail person  10 (15.38%)       
• Non-frail person  18 (27.69%)       
t-test result applied to the variables age and frailty
Frailty  Mean  Standard deviation  Standard deviation po. 
Frail  10  83.70  3.74  1.92 
Non-frail  18  87.17  3.93  .93 
Difference=μ (Frail) – μ (Non-frail) (t-test)         
95% CI for difference: (–6.61; –.32)  p = .033       
Discussion and conclusions

We found few studies in our country on cerebrovascular disease in older age groups and its subsequent progression.13 However, these studies repeat the idea that the incidence of stroke increases with increasing age. Moreover, elderly people who have suffered a stroke are associated with greater polypharmacy, more admissions, and a poorer perception of their state of health.10 In ischaemic aetiology, the patient's previous physical condition is associated with higher mortality after stroke compared to haemorrhagic aetiology.13

In this study, the sociodemographic characteristics of the sample are consistent with other studies. In the elderly population, ischaemic stroke predominates in the female sex,13,18 possibly related to women’s longer life expectancy.19

As in other studies,13,18 HTN is the most important and dyslipidaemia is the second most important cardiovascular risk factor. In atrial fibrillation, discrepancies have been observed with other studies in which the sample is >80 years.18,20 In this research study the percentage of atrial fibrillation was higher (43% versus 25%18,20), which could be because the mean age of the patients was 87 years and the percentages of atrial fibrillation seem to increase at ≥85 years.13

We highlight the high percentage who were not taking anticoagulants, despite the considerable number of diagnoses of atrial fibrillation. This is because, according to studies, treatment with anticoagulants decreases in the elderly population.12

While atherothrombotic aetiology is recorded as the most frequent in general stroke series,2,21 in this sample it is cardioembolic aetiology, which seems to be explained by the high percentage of atrial fibrillation in this population.13

Regarding neurological complications, haemorrhagic transformation was the most relevant neurological complication and at higher rates than in other studies.6 In any case, it should be considered that the literature reviewed6 covers thrombectomy in general, whereas this research study only includes patients ≥80 years old, which could be a selection bias in comparing them. It is also important to note that all haemorrhagic transformations present on control neuroimaging, symptomatic and non-symptomatic, are included in this paper. On the other hand, the arterial recanalization rates (TICI index) 14 are above those obtained in randomised studies,22 approaching the 85% success rate reported in the solitaire study.19 Endovascular techniques have increased survival in acute ischaemic stroke.23

The mean hospital stay in this study is higher than in other studies (12 days),13 whereas the number of patients returning home after discharge is consistent, although it decreases by 20% in those <85 years.13 On the other hand, the number of patients undergoing rehabilitation increased by almost 34%, which is considered positive as it translates into greater therapeutic involvement in this older age group. This, in turn, could explain the fact that at discharge many patients do not return home because they are transferred to the rehabilitation hospital.

Dependence and functional impairment prior to the stroke episode could determine a worse functional status at discharge,20 and therefore we used the modified Rankin scale12 to assess these parameters. The functional status of this sample on admission was notably more positive than in other studies, with only 2.7% with moderate-severe disability (mRs12 ≥4points), compared to 36% in other research studies with those ≥85 years.13 Deaths during hospital stay were fewer, resulting in higher rates of patients with moderate-severe disability at discharge. This did not occur at the time of telephone contact, where the number of deaths increases, probably because there is a survival bias as the sample is an elderly population.

Previous neurological status could also be a determining factor in the subsequent situation.20 We observed a marked severity in stroke, with more than half having severe neurological deficit on admission (NIHS16 >16 points), compared to 5 and 11 points for the median calculated in other similar research studies,13 at <85 and ≥85 years, respectively. At discharge, more than half had recovered adequately (NIHS13 0-5). Although a priori the severity of stroke in the sample was higher, admissions were longer and more patients had undergone rehabilitation, progression was better in neurological terms and in terms of functional dependence.

Although there is a relationship between chronological and biological age, frailty could explain the vulnerability of older people to adverse health effects, leading to states of institutionalisation and dependence.10,24 There are very few studies on stroke in the elderly population,21 and even fewer on frailty and its possible relationship with stroke, despite the evident relationship between being a frail older adult and greater cardiovascular deterioration, diminished ability to carry out activities of daily living, and greater social isolation.25 The need to measure the health of older people in terms of function, quality of life, resources and support is increasingly being recognised. In 2014, the Ministry of Health, Social Services and Equality published a consensus document that discussed frailty for the first time.26 The document argued that "functional status prior to the development of disability and dependence is one of the best indicators of health and is a better predictor of disability than morbidity".26

Although frailty has not been associated with stroke, further research is needed, as there seems to be a trend linking a better previous functional status with stroke prognosis.20 We observed a relationship between age and frailty. The older patients who survive stroke are those who are the least frail, with survival in frail states only possible at younger ages. In other words, the study could open doors to future lines of research on the idea that the progression of patients after suffering a stroke does not depend so much on age as on other factors, such as multi-pathology or previous functional disability.13 And although everything is related to the concept of frailty, the sample was too small to determine this relationship.

Although the data were not sufficient, the fact that the mRs12 scale only measures physical parameters21,27 means we must consider future lines of research on stroke in elderly people, and determine which aspects are important in deciding which therapies are best, to improve survival with adequate functional conditions and choose the diagnostic lines to achieve this.

Limitations

In collecting data on frailty by telephone interview, there were significant data missing on the population, and therefore the final sample from which this data could be obtained was too small to establish potential relationships.

The time between the stroke event and the collection of data on frailty and functional dependence differed between patients for logistical reasons.

The population chosen was considered elderly, and therefore we considered a possible selection bias for comparison with other studies, and a survival bias.

Funding

No funding was received for this study.

Conflict of interests

The authors have no conflict of interests to declare.

Acknowledgements

We would like to thank the entire team of the Interventional Neuroradiology Department of the Hospital Universitario Central de Asturias.

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Please cite this article as: Murias Quintana A, Benavente Fernández L, Morís de la Tassa G. Fragilidad en mayores de 80 años tras trombectomía mecánica por un ictus isquémico. Rev Cient Soc Esp Enferm Neurol. 2022. https://doi.org/10.1016/j.sedene.2021.07.001

Copyright © 2021. Sociedad Española de Enfermería Neurológica
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