SP - Stroke

Introduction

Despite the knowledge that oral anti-coagulation (OAC) is effective in secondary prevention of stroke, prescribing rates are low in frail older patients with atrial fibrillation (AF), dementia, and high fall risks. A joint decision-making approach between clinicians, patients and carers is needed to negotiate the risk-benefit balance. The aim of this participatory study was to engage with a group of older adults, their carers and healthcare professionals to identify key themes that will inform a planned qualitative study exploring frail older patients’ acceptance of and adherence to OAC.

Methods

We identified a group of twenty-eight adults (aged >65 years) and carers from community partners: ‘Ageing Well’ platform, Health Watch team, and the University of the Third Age (U3A) in Brighton and Hove, East Sussex, UK. Using two case vignettes of hypothetical OAC decisions, we hosted two virtual focus group meetings with the above cohort, followed by a virtual meeting with four geriatricians, two pharmacists, a GP and a patient champion. Inductive thematic analysis was performed on the group discussions by two researchers independently. 

Results 

Five key themes were identified as crucial to include in the future qualitative study discussions : (i) age should not be a barrier to anti-coagulation (ii) individualised, holistic assessment by a specialist is mandatory (iii) annual review of anti-coagulation should be performed, revisiting patients and carers' understanding of the risks and benefits (iv) patient and carer education should be tailored to their medical and social background, and (v) quality of life should be a key factor in OAC decisions.

Conclusion

Engaging with a group of older adults in a co-development exercise helped identify key themes for a future study of anti-coagulation in frail older adults with AF.

Abstract Content - Introduction Frailty is an important clinical syndrome of increased vulnerability to stressors. The impact of frailty on stroke is a growing research area. We carried out a systematic review for an up to date picture of the prevalence of frailty and its impact on a wide range of outcomes Methods We searched Medline, Embase and CINAHL for studies referencing frailty and stroke. We assessed quality of studies using National Heart, Lung, and Blood Institute (NHLBI) quality assessment tools. We collated prevalence of frailty and impact on outcomes after stroke or transient ischaemic attack (TIA). Meta-analysis was conducted to determine pooled odds ratios (OR) and 95% confidence intervals (CI). Where possible, we carried out metanalysis on outcome data. Results We included 28 studies (n=111,787). Studies used the Clinical frailty scale (CFS), (n=6, 10,967). a frailty index (n=10, 19134), Hospital Frailty Risk Score (HFRS) (n=4, 18,373), frailty phenotype (n=4, 10,838), or other assessment methods (n=8, 50,568). Pooled prevalence of frailty was 36% (95% CI 29-43%). Including pre-frailty, prevalence was 48% (40-56%). Increased CFS (n=738) was associated with increased in-hospital mortality, OR=2.43 (95% (CI 1.54-3.84).Higher frailty was associated with higher 28 day, 90 day and one year mortality, higher stroke severity, and NIHSS, mRS and dependency on discharge. Conclusion Increased frailty is associated with multiple adverse outcomes following a stroke, including mortality, worsened functional outcome, and increased dependency at discharge. There was heterogeneity in frailty measures used, precluding meta-analysis.

INTRODUCTION: Frailty assessment in stroke is not commonly integrated into clinical practice, despite current clinical recommendations. Pre-stroke frailty is associated with longer-term mortality, length of admission, and disability. Similarly, anticholinergic burden (ACB) is not routinely reviewed, even though it is associated with cognitive and physical impairment, increased hospital admissions, and higher mortality in older people. Healthcare Improvement Scotland-Frailty (HIS-Frailty) is a novel tool for the evaluation of frailty in older people. Our aim was to compare and correlate the identification and severity of frailty with HIS-Frailty to the Rockwood Clinical Frailty Scale (CFS) in stroke. We also used the ACB Score to determine if there was a difference in ACB between hospital admission and discharge in these patients.

METHODS: We conducted a prospective, observational, single-center study in a stroke unit. Patients with a cerebrovascular diagnosis were included. We compared frailty assessment through linear correlation and ACB through mean difference in scores. Results were considered statistically significant if p-value < 0.05 and highly statistically significant if p-value < 0.005. SPSS® 26.0 was used to perform data analysis.

RESULTS: We included 145 patients. 110 (76%) were older than 60 years and 75 (52%) were male. Most admissions were due to ischemic stroke (67%), closely followed by TIA (14%). Forty-eight (32%) were classified as frail. There was a strong positive correlation between HIS-Frailty and the CFS (r = 0.95; p <0.00001; R2 = 0.91). Seventy-nine (55%) patients had significant ACB. There was no significant difference between ACB at admission and discharge (MD = 0.010, CI 95% -0.52 to 0.54; p = 0.97).

CONCLUSION: HIS-Frailty may prove to be a consistent and easy tool for the systematic identification of frailty in stroke patients, in accordance with best clinical practice guidelines. We should standardise measures to reduce ACB after stroke.

Introduction

Diagnosis of Transient Ischaemic Attack [TIA] is important to minimise risk of future strokes. This retrospective descriptive study aimed to evaluate sociodemographic and risk factor differences between TIA and TIA ‘mimics’ in patients presenting to an inner-city neurovascular clinic.

Methods

Data was obtained over a 2-year period [2019-2020] for all new patients assessed in a consultant-provided daily week-day neurovascular service that serves a million multi-ethnic, population. Data collected included socio-demographic details, clinical risk factors, source of referral and final clinical diagnoses.

Results

Of 1764 patients, 39% [694] were diagnosed as TIA; 61% [1070] were TIA mimics with 40 distinct differential diagnoses. Compared to TIA mimics, TIA patients were older [mean (SD): 69.3(13.8) vs 59.7(16.1), p<0.001]; higher prevalence of TIA mimics in females vs males [66%vs54%; p<0.001]. There were proportionately more patients with TIA mimics from Black and minority ethnic groups (401/610:66%) compared whites (669/1154:58%) [p=0.034]. Compared to TIA mimics, TIA patients had higher prevalence of hypertension [56%vs40%, p<0.001], Diabetes [22%vs14%, p<0.001], Atrial Fibrillation [10%vs4%, p<0.001], Chronic Heart Disease [18%vs9%, p<0.001] and moderate to severe carotid stenosis [5%vs0.4%, p<0.001]. Prevalence of other risk factors in TIA patients included Patent Foramen Ovale [1.4%], Cardiolipin Antibodies [3.2%], and Thrombophilia [2.3%]. 14% of TIA patients had no identifiable risk factors.

Discussion

This large survey has described socio-demographic [age, gender and ethnicity] differences and prevalence of risk factors between TIA patients and TIA mimics. These differences may be useful in terms accurate diagnosis of TIA by experienced clinicians. This study provides valuable information for clinicians and researchers of stroke services in future.