sumj - volume 3 - issue 1

Acting Editor for this Issue: Kevin Barr [Year 3 Mental Health Nursing Student; University of Dundee

School of Nursing & Midwifery]

Editor-In-Chief: Laura Fraser [Year 5 Medical Student; University of Dundee Medical School]

Deputy Editor: Kevin Barr [Year 3 Mental Health Nursing Student; University of Dundee School of

Nursing & Midwifery]

IT Manager: Naomi McIlvenny [Year 5 Medical Student; University of Dundee Medical School]

Head Reviewer: Rebecca Grant [Year 1 Medical Student; University of St Andrews Medical School]

Features Commissioner: Lauren Copeland [BMSc Year Medical Student; University of Dundee Medical

School]

National PR Representative: James Millar [Academic Foundation Doctor; NHS Grampian]

Dr David Booth: General Practitioner & Doctors Patients and Communities Facilitator; University of

Dundee

Prof Jeremy Hughes: Consultant Nephrologist, NHS Lothian; Reader in Nephrology, University of

Edinburgh

Dr Hannah Lord: Consultant Oncologist; Ninewells Hospital & Medical School

Lloyd Hughes: Year 5 Medical Student, University of Dundee Medical School; Editor-In-Chief 2011-2013

John Jungpa Park: Editor-In-Chief of Res Medica 2012/2013; Medical Student, University of Edinburgh

Dhairya Lakhani: Vice President, Medical Students’ Association of India; Year 3 MBBS, Sumandeep

Vidyapeeth University

[Editorial] PP. 4-5

K. Barr (Guest Editor for this Issue)

A Career Involving Clinical Research – Potential Tracks to Success PP. 6-9

J. Iredale

Critical Appraisal of a Research Paper PP. 10-17

A. MacInnes & T. Lamont

Acute Stroke – Diagnosis and Management PP. 18-27

G. Smith

Stroke Rehabilitation PP. 28-36

G. Smith

What is the Scope of Autonomy in Medical Practice? PP. 37-42

S. Falahati

Public Health Challenges in India PP. 43-46

D. Lakhani, S. Kumar, S. Gohel, S. Kumar

Electroencephalography – An Overview PP. 47-53

H. Duncan, K. Spillane, I. Morrison

Frailty: What does it mean for Clinical Care Provision? PP. 54-64

C. Reynaud, T. McHugh, R. Romero-Ortuno

The Autonomous Practitioner (Editorial)

Kevin Barr (Year 3 Mental Health Nursing Student, University of Dundee)

Deputy Editor – Scottish Universities Medical Journal

Guest Editor for this Issue

As Acting Editor for this issue, I would like to take this opportunity to welcome you to the first

issue in the third volume of the Scottish Universities Medical Journal (SUMJ). It is with great

pleasure and pride that we present to you a wealth of literature detailing modern concerns

within the medical arena, and we have articles in this issue which should cater for our entire

readership.

The issue of autonomy in contemporary health care has produced great discussion in recent

years1, but what happens when management and clinical policy limits the autonomy of health

care professionals? Falahati2 addresses this in the article ‘What is the Scope of Autonomy in

Medical Practice’2, whereby the weight of autonomy is pitted alongside other ethical principles.

It is true that if we are to be autonomous practitioners we must make effective decisions, but

how do the decisions we make affect our ability to practise ethically? Falahati examines this

argument in detail, thus presenting an effective and successful article.

In this issue we present two articles by Dr Gemma Smith, who examines the ways in which

available tools can help in the assessment and management of those suffering from a

suspected stroke. Smith does this by inspecting the mortality and morbidity rates associated

with stroke3, therefore looking at ways to treat the condition, such as anti-coagulant therapy

and blood pressure control. In her article ‘Secondary Prevention and Rehabilitation after a

Stroke’4, Smith goes further by looking at the risks of recurring strokes, making suggestions on

possible interventions which can be made for stroke management. Indeed, Smith asserts that

the rehabilitation process should involve input from the multi-disciplinary team, leading to the

question of whether or not multi-disciplinary working limits autonomy and independent

practice in contemporary health care.

This issue of the SUMJ also includes an article by Professor John Iredale which looks at the

potential tracks to success in a career involving clinical research5. Iredale offers tips to medical

students who intend to pursue a career as a clinical academic by examining the ways in which

students can access such courses. He finishes by stating that PhD funding has never been

better; indeed, the Wellcome Trust has almost doubled the number of PhD opportunities

available for UK medical graduates5. Therefore, if you are interested in developing a career in

clinical academia, Professor Iredale’s article is both informative and inspiring.

In this issue of the SUMJ we are once again delighted to publish articles from a wide range of

disciplines, spanning myriad levels of experience and knowledge. The SUMJ continues to pride

itself on publishing the work of Doctors, Consultants, Clinical Lecturers, Medical Students,

Nursing Students and all other health professionals, and it is the time and effort of these

individuals which ensures the journal goes from strength to strength.

We would like to thank all of the contributors who continue to submit articles, and to once

again clarify that all submitted articles are taken into consideration by the committee.

I would like to finish by thanking all of my fellow committee members for their support and

assistance throughout my time as Deputy Editor of the SUMJ. Throughout the year I have been

given opportunities to expand my knowledge and improve my practice, and working for the

journal has provided me with great pleasure and satisfaction. As this is the last issue under my

editorship, I would like to thank the committee and our readership. Most importantly, I would

like to wish good luck to the future SUMJ committee, and I hope that the journal continues to

improve under the new committee which will be elected in the near future.

Thank you.

References

1. SAKHANI, D., and COULTER, I. (2009). ‘The Politics of Inter-Professional Working and the

Struggle for Autonomy in Nursing’. Social Science and Medicine, 68, PP. 1221-1228.

2. FALAHATI, S. (2014). ‘What is the Scope of Autonomy in Medical Practice?’ Scottish

Universities Medical Journal, 3(1).

3. SMITH, G. (2014). ‘Acute Stroke – Diagnosis and Management’. Scottish Universities

Medical Journal, 3(1).

4. SMITH, G. (2014). ‘Secondary Prevention and Rehabilitation after a Stroke’. Scottish

Universities Medical Journal, 3(1).

5. IREDALE, J. (2014). ‘A Career Involving Clinical Research – Potential Tracks to Success’.

Scottish Universities Medical Journal, 3(1).

A Career Involving Clinical Research – Potential Tracks to Success

Professor John Iredale DM, FRCP, FMedSci, FRSE (Professor of Medicine; Dean of Clinical

Medicine Director of MRC/UoE Centre for Inflammation Research)

Correspondence – John Iredale: [email protected]

In whatever branch of medicine we work as clinicians, research rightly underpins and informs

what we say, do and deliver in our practice. It is therefore axiomatic that all doctors need to be

research aware and UK Medical Schools have an extraordinarily strong tradition of introducing

research opportunities and projects to medical students. Indeed, Medical Schools can be seen

as a major engine of medical research in the UK, research which is acknowledged to be at the

forefront internationally. These opportunities vary from vacation projects to intercalated BScs

embedded within the medical curriculum. But importantly, medical progress and innovation

additionally depend on the UK generating and maintaining a cohort of doctors who as juniors

and seniors spend a significant part of their working week engaged in research – medical

academics. Their research may be orientated to deliver improvements in care, novel treatments

or enhanced understanding of disease pathogenesis. For my money, this job – that of the

medical academic or clinician scientist - offers the most exciting, challenging and stimulating of

careers and establishes a lifetime flush with opportunities, intellectual challenge and

achievement.

On a UK basis, the last 20 years have been characterised by a renaissance in basic, clinical and

translational research. Driven by the rapid developments of key technologies in, for example

the field of genetics, this renaissance has also been the result of concerted efforts by Medical

Schools, research funders including the Medical Research Council and the Wellcome Trust, the

NHS, the NIHR and Chief Scientists Office, NHS Education Scotland (NES) and the Academy of

Medical Sciences, to establish robust career pathways for doctors interested in becoming

clinician scientists. In turn, this career focus has driven the development of structured

programmes orientated to support junior doctors interested in research and developing their

careers as clinician scientists to achieve their goals and develop their research pedigree

alongside their clinical competences, leadership skills and other aspects of their professional

development. This model career pathway in England and Wales links academic FY programs

with academic clinical fellowships (or ACFs) from which candidates can emerge into specialist

training and/or PhD research before going on to become clinical lecturers and position

themselves for more senior research funding. This structure resulted from two National

reports; The Savill report commissioned by the Academy of Medical Sciences in 2000 and the so

called “Walport Report” delivered in March 2005.

The Universities and NHS in Scotland responded in a slightly different way to the Savill and

Walport reports, establishing a parallel but distinct career structure. In Scotland academic

training falls under the umbrella of SCREDS (The Scottish Clinical Research Excellence

Development Scheme) which is steered and diverted by representation from NES and the

Scottish Universities. Under the aegis of SCREDS, each Scottish medial school has established an

academic career track (with relatively subtle variations from one school to another) which

provides a fertile environment for clinical academic careers. Most importantly each of these

schemes provides support and mentorship – vital for sustaining career enthusiasm and

direction whilst juggling the twin challenges of clinical and academic training. Termed clinical

academic tracks or CATs, these programmes link academic FY ( and non-academic FY) schemes

with core and specialist training (ST) opportunities and support to obtain funding for PhD

studies at the ST stage in addition to providing postdoctoral SCREDS/NES funded clinical

lectureships. More detailed information on each of these schemes is available on the individual

websites of the Scottish Universities listed below.

How then does a medical student interested in developing a career as a clinical academic

negotiate their way through the clinical academic training schemes to success? The first major

milestone in such a career is to establish ones credentials as motivated and interested in

research. This might take the form of undertaking an Intercalated BSc; or for those who can’t

make such a commitment, contributing to research projects as an undergraduate and the early

phases of clinical training is invaluable as a means of gaining experience and building the

academic component of one’s CV.

Each of the Scottish Universities, collaboratively with their local Health Board and NES, now

offer an academic FY scheme. These vary in their configuration but provide the trainee with the

opportunity to undertake some research and, in some cases, formal research training in specific

methodologies such as statistics. The rich eco system of differently composed academic FY

programmes offers a range of research experience for medical graduates. However, not all

candidates may be able to access such positions or there may those who (like the author) were

“late developers” and realised that they have an interest in research after this stage, perhaps in

core training or specialist training.

It is important to recognise that not getting a place on an academic FY scheme does not close

the door to an academic career. Indeed, some of the most impressive individuals that I’ve

interviewed for national schemes have come from non-academic FY and ST positions. But a

characteristic feature of these individuals is long standing engagement and delivery of research

even while undertaking busy clinical training jobs (see my comments above). The secret to

success at both the FY and ST stages, whether in an academic or non-academic position, is good

mentorship. Seek the support of a successful academic in your institution who understands the

system and can offer you advice as you make critical choices. Such an individual is also well

equipped to steer you to research opportunities and other researchers that may support and

assist you as you develop your career.

Just as with academic FY positions, in creating Clinical Academic Tracks at the core and

specialist training stages, the differences in approaches between the individual Scottish

Universities and Medical Schools have created a landscape rich and varied with respect to

opportunities; opportunities that will suit the range of aspirations and requirements that

individual trainee clinician scientists require. In broad terms, each University teaching hospital

has core training and opportunities linked with academic clinical groups and specialties. My

personal view is that the aspiring academic should place emphasis on gaining a specialist

training (ST) position. Because it is generally during ST training that individuals are best placed

to take the next major step in an academic career; that of taking an out of programme

experience to undertake a PhD. The PhD is the essential building block of an academic career

and one which should remain the focus of the aspiring academic clinician scientist. Additionally,

all Universities have been allocated SCREDS/NES funded clinical lectureships which allow those

who have completed a PhD to complete their higher specialist training combining academic

endeavour with their further clinical training and thereby ensuring that clinical competences

are complimented by the development of a strong academic pedigree that will position the

doctor to apply for future research grants and if appropriate further fellowships.

It is impossible in a brief summary such as this to describe in detail the various schemes and

opportunities. It is suggested the reader uses the web based material listed below. But

examples of the variation in approach developing clinical academic tracks include the focus in

Glasgow on a series of core training positions that have been grouped to provide research

opportunities, mentorship and support under the GATE scheme. Edinburgh has a portfolio of

Wellcome Trust funded PhDs that are advertised and deployed to provide doctoral

opportunities for successful trainees. In Edinburgh these have been linked with clinical

lectureships to provide a form of “run-through” academic training (ECAT lectureships) so that

the successful doctoral student exits to a lectureship and can complete training in their

competencies together with accruing critical academic experience to reach the next stage in

their career.

Whilst working towards and achieving funding for a PhD may seem somewhat distant and

daunting at this stage, it is an eminently achievable goal for the keen, motivated and tenacious.

There has never been a better time to apply. Key funders have significantly enhanced PhD

funding in the last 10 years. For example, through their portfolio and national schemes, the

Wellcome Trust has doubled the number of PhD opportunities available for UK medical

graduates. Additionally investment by the Medical Research Council and other major charities

including Cancer Research UK has enhanced the available PhD opportunities for medial

graduates.

So what are the take home messages from this, necessarily, brief synopsis of academic tracks in

Scotland? For the medical students and young junior doctors interested in an academic career,

the key issues are to demonstrate a commitment to research and academic endeavour; become

involved in research projects and relish the chance that a busy clinical job provides not only for

clinical experience but to provide research questions and opportunities. Retain a focus on your

ambition and career and understand that the key building block over the 5 to 7 years after you

qualify will be obtaining funding for and delivering a PhD. Don’t be daunted by the idea of

working towards and obtaining funding for a PhD; there has never been a better time to do so

in terms of the funding opportunities or, arguably a more exciting time to become involved in

research, given the wealth of technologies that can now be applied to clinical questions.

Finally and most importantly seek and exploit mentorship. The value of high quality mentorship

at all stages of a clinical career, but particularly as you emerge from medical school into the

professional clinical arena, cannot be underestimated.

Websites for Scottish Academic Career Track Programmes

Aberdeen - http://www.abdn.ac.uk/acat

Dundee - http://medicine.dundee.ac.uk/dcat

Edinburgh - http://www.ecat.ed.ac.uk

Glasgow - http://www.gla.ac.uk/colleges/mvls/graduateschool/academicandclinicaltraining/

Critical Appraisal of a Research Paper

Andrew MacInnes, BDS (Hons.) MFDS, RCPS (Glasgow), Senior House Officer1

Thomas Lamont, BDS, MFDS, RCPS (Glasgow), Clinical Research Fellow/Honorary Restorative StR2

1Dundee Dental Hospital

2University of Dundee

Correspondence - Andrew MacInnes: [email protected]

ABSTRACT

Whether studying for your professional examinations or planning the care of your patients, critical

appraisal is a vital skill for healthcare professionals. Evidence based healthcare involves the integration

of the best available evidence, clinical experience and patient preference when making decisions related

to patient care. Research papers provide information on current practice and new developments in the

diagnosis, prevention and treatment of disease. It is a fundamental skill to be able to identify and

appraise the best available evidence in order to integrate it with your own clinical experience and

patients values. In this article we hope to provide you with a robust and simple process for assessing the

trustworthiness of articles and assessing their value to your clinical practice.

Key Words: Evidence-Based Medicine, Critical Appraisal and Research Design

Introduction

Whether studying for your professional examinations or planning the care of your patients, critical

appraisal is a vital skill for healthcare professionals. Evidence based healthcare involves the integration

of the best available evidence, clinical experience and patient preference when making decisions related

to patient care. Research papers provide information on current practice and new developments in the

diagnosis, prevention and treatment of disease. It is a fundamental skill to be able to identify and

appraise the best available evidence in order to integrate it with your own clinical experience and

patients values. During the final years of Dental school and early years as a graduate part of our roles

has been to discuss with patients their diagnoses and treatment options in an evidence-based manner.

This requires up to date and accurate knowledge of the available evidence. Critical Appraisal is a method

of carefully and systematically examining articles to assess their value and their place in the literature. In

this article we hope to provide you with a robust and simple process for assessing the trustworthiness of

articles and assessing their value to your clinical practice.

Background

Once an article is identified, critical appraisal involves a structured approach to examining evidence to

assess its value and clinical relevance to modern practice. This allows practitioners to recognise studies

which are biased or poorly designed and therefore ensure only the most reliable information is

incorporated into clinical practice. As the medical profession evolves, undergraduate and junior

practitioners are increasingly expected to be aware of current develo

outlines the three important components in providing evidence based healthcare.

Figure 1 – Providing evidenced based healthcare

An important part of the process is an understanding of the

Figure 2, below, highlights the differing study designs and their relative robustness and reliability.

Evidence from meta-analysis of randomised control trials, such as systematic reviews carried out by the

Cochrane Collaboration, are considered to be the gold standard in evidence. These involve the

aggregation of the highest quality studies available with careful appraisal and statistical analysis of the

findings. These, in turn, may form the basis for evidence b

aid the translation of best available evidence into clinical practice

and the prerequisite body of evidence needed, in many areas of healthcare these are not available and

alternate study designs are utilised.

Clinical Expericance


are biased or poorly designed and therefore ensure only the most reliable information is


practitioners are increasingly expected to be aware of current developments in patient care.

outlines the three important components in providing evidence based healthcare.

Providing evidenced based healthcare – three important components

An important part of the process is an understanding of the differing levels of the evidence hierarchy.


analysis of randomised control trials, such as systematic reviews carried out by the

ane Collaboration, are considered to be the gold standard in evidence. These involve the


findings. These, in turn, may form the basis for evidence based clinical practice guidelines that serve to

aid the translation of best available evidence into clinical practice2. Due to the nature of these studies


alternate study designs are utilised.

Evidence Based

Healthcare

Best Available Evidence

Patient Preference


are biased or poorly designed and therefore ensure only the most reliable information is


pments in patient care. Figure 1

differing levels of the evidence hierarchy.


analysis of randomised control trials, such as systematic reviews carried out by the

ane Collaboration, are considered to be the gold standard in evidence. These involve the


ased clinical practice guidelines that serve to

. Due to the nature of these studies


Although assessment of the level of evidence is a significant aspect of critical appraisal, it is essential to

note that studies utilising designs recognised as one of the lower level

value to the profession and increase the body of evidence available, e.g. case, correlation or

comparative studies may be a precursor to assess a hypothesis before a randomised control trial can be

designed. Therefore, different critical appraisal tools may be utilised to assess the varying study designs

available. Additionally, some study questions may preclude themselves to a particular study design

a double blind, randomised control trial of parachutes may not be app

the most appropriate study design to answer the different type of questions being asked.

Figure 3 –

Ia•Evidence from meta

Ib•Evidence from at least one RCT

IIa

•Evidence from at least one well designed, controlled trial which is not randomised

IIb•Evidence from at least one well designed experimental trial

III•Evidence from case, correlation and comparitive studies

IV•Evidence from a panel of experts

Therapy

Prevention

Aetiology

Harm

Prognosis

•Validating cohort study with good reference standardsDiagnosis

•Prospective cohort study with adequate followDifferential Diagnosis

•Prospective cohort study with adequate followSymptom Prevalence Study

Figure 2: Levels of Evidence


note that studies utilising designs recognised as one of the lower levels of evidence may still have a



ent critical appraisal tools may be utilised to assess the varying study designs

available. Additionally, some study questions may preclude themselves to a particular study design

a double blind, randomised control trial of parachutes may not be appropriate! Figure 3 demonstrates


Research design for different clinical questions

Evidence from meta-analysis of RCTs

Evidence from at least one RCT

Evidence from at least one well designed, controlled trial which is not randomised

Evidence from at least one well designed experimental trial

Evidence from case, correlation and comparitive studies

Evidence from a panel of experts

•Randomised controlled trial




•Cohort Study with >= 80% follow-up

Validating cohort study with good reference standards

Prospective cohort study with adequate follow-up

Prospective cohort study with adequate follow-up


s of evidence may still have a



ent critical appraisal tools may be utilised to assess the varying study designs

available. Additionally, some study questions may preclude themselves to a particular study design2, i.e.

ropriate! Figure 3 demonstrates


Carrying out Critical Appraisal

Critical appraisal may be carried out utilising various assessment tools. These involve the evaluation of

different aspects of the paper and, in turn, highlight important characteristics of the paper and study

design used. A useful resource to aid the assessment of the multiple study designs employed is the

critical skills assessment programme (CASP)

Critical Skills Appraisal Programme (CASP)

Founded in 1993 the CASP program is a non-profit entity that provides resources, learning and

development opportunities to support critical appraisal skills development in the UK1. It provides critical

appraisal checklists for different types of study designs to enable comprehensive and robust protocols

for critically appraising a research paper. This section breaks critical appraisal down to assess 7 main

points of a research paper. Similar to the CASP methodology we will assess the important features of

any research paper and highlight key points that should be evaluated.

Initial Assessment

The initial assessment of a research paper involves a generalised look at the details of the article and the

publication it is appearing in. It may be of value to look at the year the article was published in and

ascertain if new evidence has been added to the literature since this publication. Conversely, it is also

important to note that seminal papers may have been published a significant time ago and, although the

studies are old, these may still be of significance to modern practice.

The presence of a peer review process in journal acceptance protocols also adds robustness to the

assessment criteria for research papers and hence would indicate a reduced likelihood of publication of

poor quality research. Other areas to consider may include authors declarations of interest and potential

market bias.

Problem

Appraisal of the paper hypothesis and problem addressed by the study is a crucial facet of critical

appraisal. For a study to have value it must address a significant or relevant problem within healthcare

and usually provide new or meaningful results. A useful structure for assessing the problem addressed in

the article is the Problem Intervention Comparison Outcome (PICO) method. This involves identifying if

the research has a focused question (problem), appropriate and clearly stated management strategy

(intervention), a suitable control or alternative (comparison) and that the desired results or patient

related consequences have been identified (outcomes). The current literature should have been

reviewed and commonly will support the hypothesis, which should be clearly stated.

Methodology

The study design of the research is fundamental to the usefulness of the study. Several types of study

design, noted in Figure 4, are available and each has their advantages and disadvantages. Suboptimal

study design can incorporate bias into the study and subsequently skew results.

Assessment of the data collection tool and its relevance to the problem is important, i.e. if the problem

involved assessment or measurement of a disease is the method of doing this appropr

sensitive. The data collection of a study should be objective and the results reproducible. Additionally, it

is important to consider if the amount of time allocated for data collection was appropriate and

relatable to the clinical course of the disease or intervention being studied.

Figure 4. Different Study Designs

Participants/Sample Population

Analysis of the sample population utilised in the research will give an indication as to the relevance of

the study results to individual clinical practice. To minimise any bias within a study the sample

population should be representative of the populatio

should be allocated randomly within the study. It is also imperative to consider the sample size in the

study and identify if the study is adequately powered to produce statistically significant results

values quoted are <0.05.

Data Analysis and Results

The results of the study should be presented in a suitable manner with the main result, whether it

supports or opposes the paper hypothesis, clearly demonstrated. The use of charts and graphs sho

highlight the data collected and facilitate analysis of the outcomes.

Correct statistical analysis of results is crucial to the reliability of the conclusions drawn from the

research paper. Depending on the study design and sample selection method emp

or inferential statistical analysis may be carried out on the results of the study. It is important to identify

if this is appropriate for the study.

Conclusion of Paper

Analysis of the conclusions drawn from the study involves assess

the results and an overall general assessment of study outcome. When critically appraising the

Study Designs

Descriptive

- Cross sectional

- Case report

- Case series

- Survey


involved assessment or measurement of a disease is the method of doing this appropr



se of the disease or intervention being studied.



population should be representative of the population being studied as a whole and, ideally, participants


study and identify if the study is adequately powered to produce statistically significant results


supports or opposes the paper hypothesis, clearly demonstrated. The use of charts and graphs sho

highlight the data collected and facilitate analysis of the outcomes.


research paper. Depending on the study design and sample selection method employed, observational


Analysis of the conclusions drawn from the study involves assessment of the author’s interpretation of


Study Designs

Analytical

Observational

- Case Control

- Cohort Studies

Experimental

- Randomised control trial


involved assessment or measurement of a disease is the method of doing this appropriately specific and





n being studied as a whole and, ideally, participants


study and identify if the study is adequately powered to produce statistically significant results, i.e. p


supports or opposes the paper hypothesis, clearly demonstrated. The use of charts and graphs should


loyed, observational


ment of the author’s interpretation of


conclusions of a study it is vital to consider if the results are precise enough to infer a conclusion and

also whether the data was shown to be statistically significant, i.e. p value <0.05.

Appraisal of the conclusions should also ensure recommendations stated were appropriate for the

results achieved and also within the scope of the study. The authors should also address shortcomings in

the study and discuss how this may have affected the results and recommendations proposed.

Overall Assessment

After careful analysis of the different aspects of the research paper the final stage of critically appraising

a research paper is assessing the relevance of its findings to the profession. The reported outcomes of

the diagnostic, preventative or treatment intervention should be assessed focusing on the balance of

potential benefits and drawbacks when compared to accepted alternatives.

Summary

In conclusion, critical appraisal is a fundamental skill in modern practice for assessing the value of

research papers and providing an indication of their relevance to the profession. As the medical

profession evolves and studies providing information on the diagnosis, prevention and treatment of

diseases are published it is crucial to be able to discern the best available evidence. Practitioners are

then able to, through systematic reviews or guidelines, synthesise the available evidence in order to

identify if a change in practice is indicated. Critical appraisal is a skills-set developed throughout a

professional career that facilitates this and, through integration with clinical experience and patient

preference, permits the practice of evidence based medicine and dentistry.

References

1Critical Appraisal Skills Programme, About CASP, http://www.casp-uk.net/about-casp/

2Richards, D., et al. (2008). Evidence-Based Dentistry: Managing Information for Better Practice, Quintessence

Publishing Company, Incorporated.

3Centre For Evidence Based Dentistry, http://www.cebd.org/

4David L Sackett, William M C Rosenberg, J A Muir Gray, R Brian Haynes, and W Scott Richardson. Evidence based

medicine: what it is and what it isn’t. BMJ 1996; 312: 71-72

5Richards, D. and Lawrence, A. Evidence-based dentistry (personal view). British Dental Journal 1995 Oct 7; 179(7):

270-3. (PDF)

Acute Stroke – Diagnosis and Management

Dr Gemma Smith (Specialty Trainee in Elderly Care and Stroke Medicine)

Correspondence - Gemma Smith: [email protected]

ABSTRACT

Stroke (noun): a sudden disabling attack… caused by an interruption in the flow of blood to the brain,

especially through thrombosis.

Stroke is a considerable cause of mortality and morbidity in the UK. The field of stroke medicine has

changed considerably in recent years with the development of hyper-acute treatments such as

thrombolysis, specialist stroke units and a better understanding of secondary prevention. Mortality

rates may have decreased but diagnostics have become more sensitive and it is not clear whether

incidence of stroke is falling overall. It is predominantly a problem of advancing age and many of those

suffering a stroke will be from the older age bracket. This often raises interesting challenges in the

diagnosis and management process due to the complex needs of the patient in the bed.

This article will review the tools available to assist in the systematic assessment and treatment of people

with a suspected stroke.

Key Words: stroke; imaging; thrombolysis

Background

Stroke is a considerable cause of mortality and morbidity in the UK. The field of stroke medicine has

changed considerably in recent years with the development of hyper-acute treatments such as

thrombolysis, specialist stroke units and a better understanding of secondary prevention. Mortality

rates may have decreased2

but diagnostics have become more sensitive and it is not clear whether

incidence of stroke is falling overall3,4

. It is predominantly a problem of advancing age and many of those

suffering a stroke will be from the older age bracket. This often raises interesting challenges in the

diagnosis and management process due to the complex needs of the patient in the bed.

This article will review the tools available to assist in the systematic assessment and treatment of people

with a suspected stroke. The change in stroke services has meant that acute events are now often

admitted directly to acute stroke units as these are proven to provide optimal care in the acute and sub-

acute phases5. In some cases this means that they are omitted from the experience of the acute general

medical take. They remain however, an important general medical emergency.

Recognition and Diagnosis

Rapid diagnosis of a stroke is the first step to instigating appropriate treatment. In the case of

thrombolysis, where potent fibrinolytic drugs are given to restore cerebral blood supply, the faster a

stroke is recognised and treated, the better the outcome6. Strokes are not “black and white” clinical

entities however and many “mimics” have similar symptoms that can lead to diagnostic uncertainties.

The symptoms of a stroke are due to the acute interruption of the blood supply to an area of the brain.

This can be through blockage of a blood vessel (infarcts) or haemorrhage. Infarcts can be caused by

emboli, usually from thrombus in the carotid arteries or left atrium, or from in-situ clot formation. In

both haemorrhagic strokes and infarcts the onset is sudden. The vascular territory involved and the

presence of associated symptoms may assist in the diagnosis.

• Anterior circulation – weakness, sensory deficits, dysphasia (expressive and receptive), visual

field defects, dyspraxia and higher cortical dysfunction, contralateral signs.

• Posterior circulation – visual field defects, ataxia and vertigo, inco-ordination, cranial nerve

deficits, ipsilateral signs.

To allow rapid identification of these stroke patterns and to assist in the exclusion of other possible

diagnoses, the following screening tools have been developed.

F.A.S.T.

This stands for Face, Arm, Speech, Time and has been the subject of a national television awareness

campaign. It is used by paramedics and emergency department triage staff to screen for stroke

symptoms and can be up to 81% sensitive7. It prompts assessment for facial asymmetry, arm weakness,

slurred or disordered speech and then rapid transfer to the appropriate acute care setting for further

assessment. FAST is not infallible and is particularly prone to missing posterior circulation events.

R.O.S.I.E.R8.

This tool is for Recognition of Stroke in the Emergency Room. It was developed to help emergency

department staff assess possible stroke patients and provides some tools for screening out mimics such

as hypoglycaemia, seizures and syncope. It has a sensitivity of 93% and specificity of 83%8. See Table 1.

Table 1 – ROSIER score

Is the blood glucose above 3.5mmol? If not, treat and re-assess.

1. Has there been loss of consciousness or syncope? Yes (-1) No (0)

2. Has there been seizure activity? Yes (-1) No (0)

3. Is there NEW ACUTE onset (or on awakening from sleep) of:

• Asymmetrical face weakness Yes (+1) No (0)

• Asymmetrical arm weakness Yes (+1) No (0)

• Asymmetrical leg weakness Yes (+1) No (0)

• Speech disturbance Yes (+1) No (0)

• Visual field defect Yes (+1) No (0)

Score >0 suggests a stroke diagnosis.

Paramedic teams trained in the use of FAST screening will often refer patients directly to acute stroke

units. Use of the ROSIER scale in emergency departments and medical admissions units allows self-

presenting patients or those admitted via GPs to be assessed rapidly so that appropriate admission

pathways and investigations can be instigated promptly.

Following assessment with screening tools, patients with suspected strokes should have a thorough

history taken and a comprehensive neurological examination. This may need to be simultaneous with

the ordering of investigations such as CT imaging if the patient may be a candidate for thrombolysis as

will be discussed later.

History and Examination

Timing is a crucial point when taking a patient’s history of a suspected stroke. The onset of symptoms is

usually sudden, with all deficits occurring together, as opposed to a “marching” or progressive deficit.

The time of onset is vital, especially when considering patients for thrombolysis that must be initiated

within 4.5 hours of symptom onset9. It is necessary to clearly determine when the patient was last well.

Often patients wake up with symptoms however they may have got up in the night or spoken to their

partner in the early hours of the morning and the time they were last well can still be identified.

It is useful when reviewing neurological symptoms to consider them as positive or negative. Positive

symptoms involve gaining a quality such as extra movements or shaking, added sensations such as

prickling or burning and extra visual signs such as flashing lights. Negative symptoms describe the loss of

a normal function such a weakness, loss of sensation, loss of comprehensible and useful speech, loss of

vision (full or partial) or incoordination. Strokes generally produce negative symptoms. The presence of

positive symptoms can sway the assessing physician towards a diagnosis of a mimic. The negative

symptom of loss consciousness is rarely a feature of stroke (Table 2).

Table 2- Positive and negative features on examination and stroke mimics

Positive symptom Stroke Mimic

Flashing lights and colours in vision. Migraine

Shaking or jerking limbs. Seizures (focal or generalized).

Tingling / prickling sensation. Radiculopathy, herpes zoster infection.

Negative symptom Stroke Mimic

Loss of consciousness Syncope, seizures.

Associated symptoms mainly have a role in identifying mimics or increasing the suspicion of an intra-

cerebral haemorrhage. Haemorrhagic strokes may present with headache, nausea and vomiting, which

are otherwise uncommon in strokes but may also be present in migraine. Confusion and agitation can

occur with intra-cranial haemorrhages or non-stroke diagnoses such as infection or hypoglycaemia. A

medication history is also important, particularly if patients are taking antiplatelet or anticoagulant

therapy.

When considering the diagnosis of a stroke it is useful to look at the vascular risk factors of the patient.

This provides a guide to the probability of a stroke but also as a target for future secondary prevention.

Hypertension, diabetes, smoking, hyperlipidaemia, family history, male gender, age and other

vasculopathies are potent indicators of stroke risk however strokes are still possible in those without

these factors.

Each patient with a suspected stroke should have a thorough neurological examination including

assessment of motor and sensory modalities and cerebellar function. Pronator drift is an excellent sign

of subtle motor weakness. Higher cortical function such as speech and praxis should be assessed.

Speech quality, fluency and word finding skills can be assessed throughout taking the history. Providing

simultaneous stimuli to bilateral visual fields or sensory pathways can identify inattention. The inability

to identify when both sides are stimulated suggests cortical dysfunction. Cranial nerve examinations

should differentiate between upper and lower motor neuron facial weakness and should include an

assessment of visual fields. Neurological examination findings can be applied to the National Institute

for Health Stroke Scale (NIHSS) to give a way of communicating and monitoring stroke severity. The

application of this scale in a reproducible way requires training. The examination findings will also allow

the stroke to be classified as per the Bamford Classification10

. This gives some guide of mortality and

morbidity with a total anterior circulation stroke carrying a higher chance of both.

Total anterior circulation stroke (TACS) – All three of the following: 1.Unilateral weakness (and/or

sensory deficit) of face, arm and leg 2. Homonymous hemianopia 3. Higher cerebral dysfunction

(dysphasia, visuospatial disorder).

Partial anterior circulation stroke (PACS) – Two of the following: 1.Unilateral weakness (and/or sensory

deficit) of face, arm and leg 2. Homonymous hemianopia 3. Higher cerebral dysfunction (dysphasia,

visuospatial disorder).

Lacunar stroke (LACS) – One of the following: 1. Unilateral weakness (and/or sensory deficit) of face and

arm, arm and leg or all three. 2. Pure sensory stroke. 3.Ataxic hemiparesis.

Posterior circulation stroke (PoCS) – One of the following: 1. Cerebellar or brainstem syndromes 2. Loss

of consciousness3. Isolated homonymous hemianopia

Please note that both TACS and PACS involve the anterior and middle cerebral arteries (ACA and MCA),

whilst the PoCS involves the posterior circulation.

Transient Ischaemic Attack

TIAs can present with symptoms in either of the vascular territories described above but resolve entirely

within 24 hours and usually in less than one hour. Amaurosis fugax, described as a curtain coming over

the vision in one eye and resolving rapidly is also a form of TIA. TIAs can generally be managed as an

outpatient and therefore should rarely be seen on medical admission units having been assessed and

referred from GPs or emergency departments.

Following a TIA, the risk of progression to a full stroke within the next 7 days can be predicted by the use

of the ABCD2 score (Table 3).

Once diagnosed with a TIA, with particular emphasis that all symptoms should have resolved entirely,

patients can be commenced on an antiplatelet agent. An ABCD2 score of 4 or less can be referred for

assessment in a TIA clinic. The aim of this service is to identify modifiable risk factors, in particular

carotid stenosis that may be amenable to surgical intervention, and atrial fibrillation for which oral

anticoagulants may be appropriate. TIA clinics are often run five or even seven days a week to allow

rapid access. A score greater than 4 carries a very significant risk of progressing to a stroke and these

cases should be assessed within 24 hours with carotid imaging, as should patients presenting with

crescendo TIAs (more than one episode in a week). In centres without seven-day TIA clinics this may

require admission to hospital.

Investigations

Once a stroke is suspected clinically, the appropriate investigation should be pursued urgently to allow

optimal treatment.

Laboratory tests

A blood glucose level is necessary to exclude hypoglycaemia as a stroke mimic and this can usual be

done as a bedside finger prick test. Blood tests should be sent for full blood count and biochemistry. A

coagulation screen should be sent particularly if a bleed is suspected, if the patient is anti-coagulated or

if thrombolysis is being considered. In the days after a stroke, thyroid function tests, lipid profile and ESR

are also useful investigations.

Table 3 – ABCD2 score

A – age > 60 (1 point)

B – blood pressure >140/90 (1 point)

C – clinical picture:

Unilateral weakness (2 points)

Speech disturbance (1 point)

D – Duration

>60 minutes (2 points)

1-59 minutes (1 point)

D – Diabetes (1 point)

Total out of max. 7

Imaging and their common appearances

CT remains the mainstay in acute radiological investigation in suspected stroke. This should happen

urgently, within 1 hour, in cases being considered for thrombolysis and those cases with a low Glasgow

come score (GCS), signs of meningism or a high suspicion of intra-cerebral bleed11

. All strokes should

have imaging within 24 hours of presenation11,12

.

The role of CT in the immediate phase is mainly to exclude the presence of intracranial haemorrhage.

Intra-cerebral, subarachnoid, subdural and extradural bleeds have a characteristic appearance on CT.

Intra-cerebral haemorrhages are generally rounded, well-circumscribed lesions within the brain

parenchyma (Figure 1). They may have surrounding oedema or extend into the ventricles.

Infarcted cerebral tissue appears unchanged on CT scans in the first few hours. The changes seen later

develop at a range of 2-3 Hounsfield units per hour. The human eye can only detect a difference in

contrast of over 6 Hounsfield units so a clinically apparent stroke will only become radiological apparent

after a few hours.

There are patterns on CT that can indicate cerebral infarction, particularly when applied with the

suspected vascular territory. There may be a loss of differentiation between grey and white matter.

When this occurs in the insular region it is referred to as the insular ribbon sign. Loss of differentiation

may also occur between structures such as the basal ganglia and internal capsule. There may be sulcal

effacement due to underlying oedema. Clot may be visible in the proximal middle cerebral artery,

“dense MCA” sign (Figure 2) or as a “dot sign” if a more distal branch has been occluded. In the posterior

circulation, a hyper-dense basilar artery may be visible (Figure 3) and a high suspicion of impending

occlusion is necessary in patients presenting with nausea and vertigo and posterior circulation signs.

Cerebellar and brainstem strokes are poorly imaged on CT and may require MRI if the diagnosis is in

doubt.

Figure 1: CT of an intra-cranial bleed

Figure 2: Dense MCA Sign

Figure 3: Hyper

Images used with permission from (Fig1) www.radiologysigns.tumblr.com

(Fig 3) www.bjcardio.co.uk

MRI has become a useful tool in stroke diagnosis in recent years. This is primarily due to the use of

diffusion weighted imaging (DWI). Acute infarcts will appear bright on DWI for up to fourte

detailed images produced with MRI, as well as the superior imaging of the posterior intra

structures makes this modality useful when a PoCS is suspected or if the diagnosis or vascular territory is

in doubt. Other MRI modalities such a

The availability of MRI, particularly out of hours, means that it does not have a place in the hyper

phases of stroke management and is unlikely to replace CT in the near future however it remains a

useful adjunct.

Figure 3: Hyper-dense basilar artery

www.radiologysigns.tumblr.com (Fig 2) ww.med-ed.virginia.edu/courses/rad/headct/infection9.html


diffusion weighted imaging (DWI). Acute infarcts will appear bright on DWI for up to fourte

detailed images produced with MRI, as well as the superior imaging of the posterior intra


in doubt. Other MRI modalities such as gradient echo can identify microhaemorrhages.

The availability of MRI, particularly out of hours, means that it does not have a place in the hyper


ed.virginia.edu/courses/rad/headct/infection9.html


diffusion weighted imaging (DWI). Acute infarcts will appear bright on DWI for up to fourteen days. The

detailed images produced with MRI, as well as the superior imaging of the posterior intra-cranial


s gradient echo can identify microhaemorrhages.

The availability of MRI, particularly out of hours, means that it does not have a place in the hyper-acute


Imaging of the cerebral blood supply, particularly at a carotid level, can assist in identifying the

pathophysiology of embolic strokes. Plaque formation causing stenosis in the internal carotid arteries

leads to thrombus formation that then embolises to more distal cerebral vessels. This imaging can be

done by Doppler measurements in the acute phase after stroke so decisions can be made about carotid

endarterectomy. The use of CT angiography is becoming increasingly popular as new hyper-acute

treatments including intra-arterial thrombolysis and mechanical clot retrieval are investigated. These

interventions rely on early and detailed imaging of the cerebral blood supply. It is also useful in cases of

suspected carotid or vertebral dissection. CT angiography is often not routinely available out of normal

working hours and its use is at the discretion of stroke physicians and radiologists.

Cardiac investigations

The aim of cardiac investigations in stroke patients is to identify atrial fibrillation as a source of cardiac

emboli. In the acute phase, this can be done with a bedside 12 lead ECG. In time, patients with embolic

strokes will need further cardiac investigations to guide secondary prevention measures.

Treatment and Management

In the acute phase, there are several important areas of stroke care to consider including treatment of

the acute event and prevention of complications. Haemorrhagic strokes may need discussion with the

neurosurgeons.

Apart from thrombolysis or antiplatelet measures, the management of these cases has many similarities

to cerebral infarcts and is discussed below. For cerebral infarcts, specific treatment options need to be

considered.

Acute Treatment Options

Thrombolysis

All stroke patients presenting with a suspected cerebral infarction and a time of onset within 4.5 hours

should be considered for thrombolysis. This requires the urgent exclusion of haemorrhage and

discussion with a stroke consultant. Thrombolysis has been shown to improve functional outcome

though it has no effect on mortality. It involves the giving of an intravenous fibrinolytic agent

(recombinant tissue plasminogen activator).

Thrombolysis is licensed for adults of all ages and benefit has been confirmed in the elderly beyond the

age of 80 years9. Treatment is most effective when the “door to needle” time is shortest. The primary

risk of treatment is haemorrhage, either intra- or extra-cranial. Asking about contraindications can

minimise this risk.

Contraindications include a time of onset greater than 4.5 hours prior to treatment, blood pressure

>180mmHg systolic or > 110mmHg diastolic, blood glucose >22 or <2.8mmol, abnormal clotting or

known anti-coagulation, thrombocytopenia, established infarct on CT, history of haemorrhage, recent

surgery, previous strokes in patients with diabetes, seizure activity at any time in the presentation and

pre-existing significant disability. Some contraindications are relative where others absolute. Some may

be modifiable, such as blood pressure. The issue of pre-existing disability relates to the aim of

thrombolysis to improve the chances of good functional recovery, this requires a reasonable premorbid

level of function.

Stroke physicians will review each case on an individual basis and balance the risks and benefits. The

counselling undertaken before thrombolysis can be complex and emotional for patients and relatives.

After thrombolysis patients require intensive monitoring in a specialist unit and repeat scan after 24

hours to exclude haemorrhagic transformation. Following this they can be started on high dose aspirin.

Antiplatelet and anticoagulant therapy

For those patients not having thrombolysis but in whom a haemorrhage has been excluded, the

mainstay of treatment is high dose aspirin (300mg daily). This is continued for fourteen days after the

initial event with the aim of reducing the risk of a further embolic event. Long-term antiplatelet therapy

is with clopidogrel.

Anticoagulant therapy is usually omitted for fourteen days post-stroke. In those on anticoagulants at the

time of infarction the decision to continue or stop may be taken by the stroke consultant and depends

on the infarct size and risks involved.

Blood pressure control

Blood pressure levels often rise around the time of an acute stroke. The risk of allowing blood pressure

to rise is that intra-cerebral haemorrhage may expand and cerebral infarcts may develop haemorrhagic

transformation. Lowering blood pressure in the acute phase after a stroke is contentious as it may be

that the rise seen is a physiological response to maintain cerebral perfusion. Ideally blood pressures

should be kept below 180mmHg but advice should be taken from a stroke specialist.

Nutrition and hydration

Many stroke patients will have an unsafe swallow in the early phases after the event. A ward based

swallow assessment should be completed as soon as possible. In those with an unsafe swallow,

medication should be reviewed and either suspended or given via an alternative route (rectal,

intravenous or topically). Intravenous fluids can be given and artificial feeding should be considered

within the first 24 hours by a nasogastric tube. Aspiration pneumonia is a common complication of

stroke and a low threshold for treatment should be maintained.

Thrombo-embolism prophylaxis

Thrombo-embolic events are an important cause of death following stroke. Routine prophylaxis with

low molecular weight heparin carries risks. It is contra-indicated in acute haemorrhagic stroke and can

increase the risk of haemorrhagic transformation in cerebral infarction. Graduated compression

stockings have been shown to cause more harm than benefit including pressure damage in stroke

patients and are now contraindicated13

. Recent research suggests the use of intermittent pneumatic

compression stockings can be used to reduce thrombo-embolic risk14

and the case for using low

molecular weight heparin can be discussed on a case-by-case basis dependent on the individual risk.

Review of patients with acute strokes

All stroke patients should be transferred to the acute stroke unit as soon as possible after admission.

They should be seen within the next 24 hours by a stroke consultant or associate specialist and within 72

hours by the multidisciplinary team therapists.

The Next Step

The aim of all management in stroke is two fold, to restore as much function as possible to the individual

and to reduce the chance of future similar events. The former relies on rehabilitation and the skills of

the multidisciplinary team. The latter has grown from an evidence base that can then be tailored to each

individual patient’s needs. These issues will be reviewed in the next article on stroke care.

References

1. Oxford English Dictionary http://www.oxforddictionaries.com/definition/english/stroke

2. Lee S et al. UK stroke incidence, mortality and cardiovascular risk management 1999–2008: time-trend

analysis from the General Practice Research Database. BMJ Open 2011;1:e000269 doi:10.1136/bmjopen-

2011-000269

3. Wolf P A et al. Secular trends in stroke incidence and mortality. The Framingham Study. Stroke.1992; 23:

1551-1555

4. Brown RD et al. Stroke incidence, prevalence, and survival: secular trends in Rochester, Minnesota,

through 1989. Stroke; a Journal of Cerebral Circulation [1996, 27(3):373-380]

5. Indredavik B et al. Benefit of a Stroke Unit: A randomized controlled trial Stroke 1991;20:1026-1031.

6. Hack W et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS,

and NINDS rt-PA stroke trials. Lancet. 2004;363:768–774.

7. Whiteley WN et al. Clinical Scores for the identification of stroke and transient ischaemic attack in the

emergency department: a cross-sectional study. Neurol Neurosurg Psychiatry. 2011 Sep;82(9):1006-10.

doi: 10.1136/jnnp.2010.235010. Epub 2011 Mar 14.

8. Nor AM et al. The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and

validation of a stroke recognition instrument. Lancet Neurol. 2005 Nov;4(11):727-34.

9. P Sandercock et al. The benefits and harms of intravenous thrombolysis with recombinant tissue

plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a

randomised controlled trial. Lancet. 2012 June 23; 379(9834): 2352–2363.

10. Pittock SJ et al. The Oxfordshire Community Stroke Project classification: correlation with imaging,

associated complications, and prediction of outcome in acute ischemic stroke. J Stroke Cerebrovasc Dis.

2003 Jan;12(1):1-7.

11. http://guidance.nice.org.uk/CG68/QuickRefGuide/pdf/English CG68: Stroke.

12. http://www.sign.ac.uk/pdf/qrg108.pdf Guideline 108: Management of patients with stroke or TIA:

assessment, investigation, immediate management and secondary prevention

13. The CLOTS trial collaboration. Effectiveness of thigh-length graduated compression stockings to reduce

the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial.

The Lancet, Volume 373, Issue 9679, Pages 1958 - 1965, 6 June 2009

14. The CLOTS trial collaboration. Effectiveness of intermittent pneumatic compression in reduction of risk of

deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled

trial. The Lancet, Volume 382, Issue 9891, Pages 516 - 524, 10 August 2013

Secondary Prevention and Rehabilitation after a Stroke

Dr Gemma Smith (Specialty Trainee in Elderly Care and Stroke Medicine)

Correspondence - Gemma Smith: [email protected]

ABSTRACT

After an acute stroke, consideration of secondary prevention and rehabilitation should start as soon as

possible. The risk of recurrent stroke is high but it can be reduced by pharmacological or even surgical

interventions. Stroke rehabilitation concentrates on addressing neurological deficits, preventing

complications, maintaining health and addressing the psychological impact the event may have had.

Stroke management in this phase of care requires multidisciplinary team input and may take place over

days, weeks, months or even years. The interventions required should be personalised for the

individual’s needs.

Key Words: stroke; rehabilitation; prevention

Introduction

After an acute stroke, consideration of secondary prevention and rehabilitation should start as soon as

possible. The risk of recurrent stroke is high but it can be reduced by pharmacological or even surgical

interventions. Stroke rehabilitation concentrates on addressing neurological deficits, preventing

complications, maintaining health and addressing the psychological impact the event may have had.

Stroke management in this phase of care requires multidisciplinary team input and may take place over

days, weeks, months or even years. The interventions required should be personalised for the

individual’s needs.

Secondary Prevention

The risk of recurrent stroke following a first event is significant1 (fig 1). Thus, the task of secondary

prevention should start immediately. This includes clot prevention, blood pressure and cholesterol

control, specific therapies around carotid or cardiac disease and lifestyle measures. The implementation

of any secondary prevention measure should be balanced with the needs of the individual and patients

should understand the goals of these therapies to encourage future concordance.

Figure 1: Risk of Stroke Recurrence prior to optimal treatment

Time from first stroke. Risk of recurrence.

30 days 3-10%

1 year 5-14%

5 years 25-40%

Clot Prevention

In the first fourteen days following an ischaemic stroke, high dose aspirin (300mg daily) is most effective

at preventing further events. It inhibits platelet aggregation and therefore clot formation. After this

time, aspirin can be stopped and clopidogrel 75mg commenced. Previously, aspirin was used in

conjunction with dipyridamole and this regimen is still used when clopidogrel is not tolerated due to

allergy. All antiplatelet regimens carry an increased risk of bleeding.

Antiplatelet agents aim to prevent in situ thrombus formation or embolic events arising from carotid

artery disease. Alternative agents are required for stroke occurring from cardio-embolic disease. Atrial

fibrillation carries an increased risk of stroke due to the development of thrombus within the left atrial

appendage. All patients should be screened for atrial fibrillation following a stroke with ambulatory ECG

monitoring. For young patients with no cardiac history this can be completed over twenty-four hours

however older patients or those with structurally abnormal hearts may benefit longer periods of

monitoring2, 3

. An echocardiogram can inform the risk of atrial fibrillation by looking for atrial

enlargement and valvular disease.

The CHA2DS2Vasc score4

was developed to help guide treat patients who had atrial fibrillation, and has

superseded the CHADS2 score in some centres. The components of this scale and points tally are as

follows:

Congestive heart failure – 1 point

Age ≥75 years – 2 points / 65-74 - 1 point

Diabetes Mellitus 2 – 1 point

Gender – female 1 point / male 0 points

Hypertension consistently above 140/90 mmHg (or treated hypertension) – 1 point

Previous stroke or TIA – 2 points

Vascular disease (such as peripheral vascular disease) – 1 point

The total score correlates with the annual risk of a stroke, and can help guide treatments of atrial

fibrillation (Fig 2).

Figure 2: CHA2DS2Vasc score and the annual risk of stroke in patients with atrial fibrillation

Patients scoring 2 or more should be considered for oral anticoagulant therapies. Historically this has

been coumarin therapy, usually warfarin, monitored with international normalised ratio (INR)

measurements (target range 2-3). In recent years, other anticoagulants have emerged. Dabigatran is a

direct thrombin inhibitor and Rivaroxaban and Apixaban are direct factor Xa inhibitors. These drugs

require no monitoring and data suggest a reduced likely of bleeding complications5, 6,7

. However if

bleeding does occur they are do not have a specific antidote. The risk of bleeding can be quantified to

some extent using the HAS-BLED8 score but other factors such as co-morbidities, dependency and falls

may play a role in rationalising therapy and decisions should be individualised. In some patients

conversations with stroke physicians may be advisable. Anticoagulant therapy is usually commenced 14

days after an acute stroke.

Echocardiograms carried out to look for cardiac sources of emboli occasional identify patent foramen

ovale (PFO). This is not uncommon in the general population and the role of these lesions in stroke is not

entirely clear. The possibility of paradoxical embolus, emboli arising from thrombus in the deep venous

circulation and crossing the atrial septum to reach the arterial circulation, must be considered. In the

absence of confirmed venous thrombus, antiplatelet rather than anticoagulant therapy is the mainstay

of secondary prevention and the role of closing these PFOs is unclear. Valvular lesions seen on

echocardiogram may also need specialist intervention and the guidelines above for atrial fibrillation

relate to non-valvular disease.

Blood Pressure

In the acute phase following a stroke, control of hypertension is guarded as cerebral perfusion may rely

on a degree of systemic hypertension. Levels above 180 / 110mmHg however, may carry an increased

risk of enlargement of an intra-cerebral haemorrhage or haemorrhagic transformation of an infarct and

should be addressed. Long-term blood pressure control should be aimed at maintaining readings at

CHA2DS2-VASc Score Annual Stroke

Risk %

0 0

1 1.3

2 2.2

3 3.2

4 4.0

5 6.7

6 9.8

7 9.6

8 6.7

9 15.2

<140/90mmHg, or <130/80mmHg for those patients with diabetes or chronic kidney disease and has

been shown to reduce the risk of further events9, 10

. The choice of antihypertensive agent is probably not

important, it is the lowering of blood pressure that is significant, however often other indications for

specific agents may exist. Selection of hypertensive agents is usually selected based upon national or

local guidelines. The benefit of lowering blood pressure is seen in older age groups though over-

treatment of hypertension may increase the risk of orthostatic hypotension and falls.

Cholesterol

The role of hyperlipidaemia on the pathogenesis of vascular disease, include stroke, is well documented

and there is good evidence that statin therapy reduces stroke risk11

. LDL cholesterol is a more specific

target for reduction than total cholesterol though both can be used to guide therapy. An LDL level

<2.0mmol and total cholesterol <3.5mmol is ideal. Patients sometimes wish to try dietary measures to

reduce cholesterol before starting treatment. If statin therapy is not tolerated, other lipid lowering

agents can be used, such as ezetimibe, though the evidence base is less clear. In haemorrhagic strokes,

the role of statins is contentious.

Carotid Disease and Intervention

In patients suffering an ischaemic stroke or TIA, the source of embolus may be atherosclerotic disease in

the internal carotid artery. If this disease causes significant stenosis then surgery may be indicated in the

form of carotid endarterectomy (CEA). This significantly reduces the chance of further strokes,

particularly in the higher degrees of stenosis (>70% by NASCET criteria)12

. Carotid stenosis is routinely

assessed by doppler ultrasound. Two systems exist (fig 3)13

, the North American Symptomatic Carotid

Endarterectomy Trial (NASCET) and the European Carotid Surgery Trialists' Collaboration group (ECST).

These take different measurements for comparison to the stenosed area. NASCET compares the normal

distal lumen, ECST uses the diameter of the carotid bulb. A NASCET measurement of 50-99% stenosis or

ECST measurement of 70-99% stenosis is an indication for surgery to be considered. Carotid imaging and

referral to the appropriate vascular surgical team should take place within one week of symptom onset

and surgery should take place within two weeks of symptom onset if it is to go ahead. In cases where

the internal carotid artery is completely occluded there is no role for CEA.

Carotid surgery is a major undertaking and many people who experience a stroke or TIA have significant

other co-morbidities that make them unfit for surgery. The aim of CEA is to prevent future disabling

strokes. For this reason, people who are already significantly disabled, by their stroke or other

conditions, to do not stand to gain the same benefit as those with good functional status. This must be

judged carefully on an individual basis. The difference between surgery on the carotid artery of the

dominant or non-dominant cerebral hemisphere may be significant. Incidental stenosis of the

asymptomatic carotid is not an uncommon finding on doppler ultrasound but currently there is no role

for routine surgery on these lesions.

For those patients in whom CEA is not appropriate due to surgical risk, carotid stenting may be

indicated. This is now supported by NICE as an alternative to CEA14

. It is a less invasive procedure, the

stent is placed via angiography, and some trial data suggest equivalent efficacy.

In patients receiving carotid intervention of any kind, medical treatment and control of vascular risk

factors should still be optimised.

Figure 3 – Classification of Carotoid Stenosis

Lifestyle Changes

All patients who suffer a stroke or TIA should be advised to stop smoking and should be offered contact

with smoking cessation services. This has shown to reduce the chance of all future vascular events

including stroke and myocardial infarction.

Other lifestyle measures that have been proven to be effective include taking regular cardiovascular

exercise and eating a diet high in fruit and vegetables. Alcohol intake should be moderated.

Rehabilitation and the Multi-Disciplinary Team

All patients admitted with a stroke should be reviewed within 24 hours by the multidisciplinary team

(MDT). Input can then be tailored to their needs and rehabilitation started promptly. Not all patients will

require input from all members of the multidisciplinary team.

MDT input can happen on the acute stroke unit, in a rehabilitation centre or at the patient’s own home.

It should continue as long the patient is receiving benefit and making progress but should not persist

when there is no hope of further improvement as this can be psychologically distressing.

Physiotherapy

The role of physiotherapy following a stroke does not just centre around increasing strength and

assisting mobility. Following a stroke, patients may suffer from a range of problems which have a motor

component. They may have weakness, in co-ordination and imbalance, spasticity, pain and marked

functional impairment. They may also require physiotherapy involvement for respiratory secretions

following pneumonia.

The speed at which neurological motor deficits resolve depends on numerous factors such as age, pre-

morbid health and cognition. Lower limbs tend to improve more quickly than upper limbs as the area of

motor cortex which supplies the legs has some dual blood supply from both the anterior and middle

cerebral arteries. Patients with expressive or receptive dysphasia may struggle to communicate with

physiotherapists. Higher cortical function such as inattention can make it difficult for a patient to

identify one side of their body and therefore use those muscles in exercise. Fatigue and depression may

limit a patient’s interaction with therapy. This can be an extremely prominent component in some

patients.

Spasticity can develop over time following a stroke. This can restrict function and be painful and

disabling. If spasticity is left untreated it can lead to permanent muscle shortening and contractures.

These can interfere with activities of daily living; a hand with fixed finger flexion may be difficult to clean

and long nails may cause trauma to the skin. Physiotherapy will identify spasticity early and work at

preventing progression. This can be with active or passive stretching exercises. In more severe cases,

splinting or applying plaster casts can help the affected limb to assume an appropriate position. Patients

with spasticity may respond to medical therapies such as baclofen and tizanidine, though these are not

without side effects. In selected cases botulinum toxin can be injected into the muscle. Increased tone

can occasionally be used to a patients advantage. A leg with increased tone may make transferring from

a chair to bed easier than it would be with a flaccid leg.

Often the goal most important to patients following a stroke is regaining the ability to walk. This is a

complex task requiring rehabilitation of strength, balance and cognition. It is a gradual process,

progressing from using aids to help reach a standing position to walking a few steps with assistance and

then walking with increasing independence and the use of mobility aids such a wheeled walking frames

or sticks. Orthoses may be required to treat specific problems such as foot drop. Regaining balance

requires first the ability to sit and then stand and correct posture to compensate from external forces.

Once mobility is regained, the chance of returning to independent living is greatly increased.

Goal setting and standardised measurements are useful in rehabilitation. Reducing a large goal into

smaller goals can make the journey appear more manageable for patients and maintain their

motivation. Objective scales to measure strength, balance and function allow progress to be recorded

and reviewed, even when staff change between rehabilitation sessions. Power can be recorded using

the Medical Research Counsil 0-5 scale, angles of flexion and extension can be objectively measured,

balance can be assessed with the Tinnetti scale. Overall function is measured on the modified Rankin

scale but changes between grades may mask smaller degrees of improvement.

Occupational Therapy

The role of the occupational therapist is to rehabilitate patients to their activities of daily living. This

includes any activity important to the individual at their stage of life and may go beyond the basic tasks

of washing, dressing and eating.

Activities of daily living often require adequate motor function but also rely on higher cognitive function.

Following a stroke, patients may have issues with praxis (planning and executing complex tasks) and

communication, including expressive and receptive dysphasia. Concentration on the task in hand and

the ability to recall which stages have already been completed is important, as is the ability to attend to

both sides of the body and the immediate environment. Deficits in many of these areas may co-exist,

making a previously simple task challenging.

Occupational therapy enables tasks to be broken down into composite parts that can later be pieced

back together to formulate the complete process. The various stages may benefit from the use of aids to

support patients to pursue the task independently; for example, a plate guard can allow a patient with a

single functioning upper limb to feed themselves from a plate. Technology is playing an increasing role

in occupational therapy rehabilitation and many “apps” are available for use on tablet platforms to

increase concentration, planning and attention.

Cognitive assessment after a stroke often falls within the remit of occupational therapy. All stroke

patients should have a cognitive assessment post-stroke even if no obvious deficit exists. Subtle

problems may be present and may have a significant impact on a person’s ability to live independently

and safely. This cognitive assessment can be challenging, particularly in patients with speech problems.

The Montreal Cognitive Assessment tool (MoCA) is well validated but requires adjustment for those with

expressive dysphasia. Following a stroke, many patients will have a persistent cognitive deficit, labelled

as Vascular Cognitive Impairment (VCI). This is distinct to vascular dementia which is a progressive

process and may occur without evidence of clinical stroke disease but it is possible for someone with VCI

to develop vascular dementia as many of the risk factors are the same.

The most recognised role of occupational therapy is to assist the discharge of a patient by reviewing

their home environment and providing aids and assistance to make that environment appropriate for

their new needs. Despite the best rehabilitation, many patients are left with some residual difficulties

following a stroke and many of these patients are pre-morbidly older and frail with multiple co-

morbidities impacting on their ability to self-care. An assessment of the home environment will often be

carried out before discharge, sometimes with the patient themselves. Areas of attention are access in

and out of the building, enabling mobility around the house, including stairs, and transfer in and out of

bed or bath. Toileting needs may require the provision of a commode. The height of light switches,

electrical points or work surfaces may need to be adjusted if patients are now required to use a

wheelchair. Speaking aids may assist patients with dysphasia. Alarms fitted to beds and doors may alert

carers to the movements of a patient who is confused or at risk of falls.

Speech and Language Therapy

There are two main roles to speech and language therapy following stroke. Patients require assessment

and review of their ability to swallow safely. They may also need assessment of their ability to speak and

understand as even a subtle deficit could have a significant impact on their approach to rehabilitation.

Swallowing ability is usually assessed immediately post-stroke by ward nursing staff. Even people

presenting with presumed mild deficits may have difficulty swallowing safely and may be at risk at

aspiration. Swallowing is a complex task and each stage needs to happen safely to prevent aspiration.

Initial deficits in swallow function can be approached in two ways. Either diet can be adapted by

thickening fluids and providing soft or pureed diet or, in the case of entirely unsafe swallowing, artificial

enteral feeding via naso-gastric tube may be attempted. In some cases unsafe swallowing mechanisms

may persist and discussions may be had regarding long term feeding via a percutaneous endoscopic

gastrostomy (PEG) tube.

Speech is a function of the dominant cerebral hemisphere. In most right handed people this is the left

hemisphere and in a slightly smaller majority of left handed people it is the right hemisphere. Strokes

affecting the dominant hemisphere can cause issues with both the understanding of speech (receptive

dysphasia), the formation of speech (expressive dysphasia) or both. Speech changes are also possible in

non-dominant hemisphere strokes but may present with increased verbosity or conversely the inability

to speak due to apraxia rather than dysphasia.

The loss of speech and understanding can be a very emotional and frustrating issue for patients

following a stroke. Communication can be facilitated in numerous ways using picture and letter cards,

digital speech tools and gestures. The participation in conversation, though frustrating, is therapeutic to

improving speech overall. It requires time and patience but can be provided by untrained family, friends

and carers under the guidance and review of speech and language therapists. Dysphasia may impact on

mental capacity if a patient is unable to communicate their wishes.

Psychological Support

A stroke, whatever the magnitude of the neurological deficit, can have an enormous impact on the

psychological wellbeing of the person. There are numerous issues to contend with including the

acceptance of fallibility and mortality, coming to terms with possible on-going physical problems and the

need to depend on others. There may be a loss of role within society, such as that of carer or wage

earner and concerns for the future, particularly whether a further stroke will occur. In addition to these

issues of adjustment, post-stroke depression is a well-recognised phenomenon that has a neurochemical

basis. Ischaemic damage to neurones disrupts serotonergic and dopaminergic pathways that can lead to

a biological cause of depression. Depression can impact on a patient’s ability to rehabilitate. It may lead

to poor sleep, impaired appetite and subsequent low energy levels and low motivation.

Formal psychological support is of limited availability within hospital medicine as a whole. Ideally,

patients with psychological issues following a stroke would have access to assessment and therapy with

clinical psychologists. In the absence of these services there are other routes that can be pursued.

Listening, explaining and reassuring are tools that any healthcare professional can provide and the

importance of these processes should not be under-estimated. An awareness of what this event means

to the individual and not attempting to minimise these feelings is essential. Education as to the cause of

strokes and future risks following secondary prevention may provide some reassurance and the process

of rehabilitation can restore hope and the idea of a future. The Stroke Association is a charitable

organisation that can provide other forms of support including group sessions or the provision of a

“buddy” who has previously been through similar events or comes from a similar background. In some

cases, post-stroke depression requires pharmacological intervention. This is usually in the form of

selective serotonin re-uptake inhibitors. This may be short-term in nature and can be reviewed at a later

date.

Conclusion

A stroke can be a devastating event and the subsequent recovery can be a long process. Life after a

stroke may involve coping with a new disability, physical or cognitive, and with new medications.

Prompt treatment in the acute phase followed by holistic rehabilitation gives patients the best chance of

returning to independent living. Secondary prevention gives the best chance of not having to experience

the same challenge again in the future.

References

1. http://www.stroke.org/site/DocServer/NSAFactSheet_RecurrentStrokerevised.pdf?docID=998

2. Higgins P et al. Noninvasive Cardiac Event Monitoring to Detect Atrial Fibrillation After Ischemic Stroke: A

Randomized, Controlled Trial. Stroke 2013; 44: 2525-2531

3. Raymond C S et al. Prolonged Rhythm Monitoring for the Detection of Occult Paroxysmal Atrial Fibrillation

in Ischemic Stroke of Unknown Cause. Circulation. 2011; 124: 477-486

4. Hohnloser H et al. Prevention of stroke in patients with atrial fibrillation: current strategies and future

directions. Eur Heart J Suppl September 1, 2008 vol. 10 no. suppl H H4-H10

5. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran versus warfarin in

patients with atrial fibrillation. N Engl J Med. 2009;361:1139–1151.

6. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, et al. Rivaroxaban versus warfarin in

nonvalvular atrial fibrillation. N Engl J Med. 2011;365:883–891.

7. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al. Apixaban versus warfarin in

patients with atrial fibrillation. N Engl J Med. 2011;365:981–992.

8. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to

assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;

138: 1093–1100.

9. PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure lowering regimen

among 6105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001; 358: 1033–1041.

10. Chobanian AV et al. National Heart, Lung, and Blood Institute Joint National Committee on Prevention,

Detection, Evaluation, and Treatment of High Blood Pressure, National High Blood Pressure Education

Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention,

Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003; 289: 2560–

2572.

11. Amarenco P et al. Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators.

High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006; 355: 549–559.

12. Benefit of Carotid Endarterectomy in Patients with Symptomatic Moderate or Severe StenosisHenry

J.M et al for the North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med

1998; 339:1415-1425.

13. Swinnen J et al. carotid duplex ultrasound after carotid stenting. AJUM August 2010; 13 (3):20-22

14. Carotid artery stent placement for symptomatic extracranial carotid stenosis (IPG389) National Institute

for Health and Clinical Excellence. April 2011. www.guidance.nice.org.uk

What is the Scope of Autonomy in Medical Practice?

S. Falahati (University of Glasgow)

Correspondence – S. Falahati: [email protected]

ABSTRACT

Autonomy, literally meaning self-rule, is an essential ethical principle, especially within the field of

medicine. An individual with autonomy can make decisions on the basis of reflection and deliberation

[1]. In general philosophy, autonomy is thought of as “the ability to be one's own person, to live life

according to rationale and purpose that are taken as one's own and not the consequence of controlling

or distorting outside forces” [2]. Individual autonomy is a notion that cultivates both self-ownership and

self-governance and is based on ‘respect for persons‘, which states that all persons have the right “to

make their own choices and develop their own life plans” [3]. The scope of autonomy reflects how far-

reaching autonomy is, and what its boundaries are. This paper analyses the scope of autonomy in order

to achieve greater clarity, and asks if this ethical principle should be superior to the three other

principles (beneficence, non-maleficence and justice) rather than just “prima facie”.[4] Indeed, if there

were to be a single overriding principle at all, should it definitely be autonomy rather than any of the

other three? These questions will be dealt with and explored with the aid of medical ethical scenarios

which help illustrate the points raised. We will identify what the limitations of autonomy are, and how

far-reaching it is, all within the medical context.

Key Words: autonomy; medicine; independence

Introduction

Respect for autonomy is widely accepted as imperative in medical ethics within the Western world.

Although there are cultural differences on the importance of autonomy, it is on the whole the scope of

autonomy where the conflict lies. Certain medical cases can be sources of dilemma for doctors. This

raises the question whether autonomy is only truly respected on the condition that it is the overall

absolute principle to be adhered to, or whether respect for autonomy can remain intact without it being

a conclusive concept. In order to answer this question, the issue needs to be looked at from different

angles. Two aspects in dealing with this subject are in an action-based as well as a situation-based

approach [4].

Principlism is an action-based approach that is based on the development of the four principles by

Beauchamp and Childress [4]. It applies four prima facie principles [5] (‘prima facie’ meaning that the

principles are binding unless conflicting with another principle) - respect for autonomy, beneficence,

non-maleficence, and justice. Beneficence takes into account the patient’s best interests, non-

maleficence (literally meaning “to do no harm”) considers the risks and benefits to the patient, and

finally justice is doing what is fair for the patient. Beauchamp and Childress state that these four

principles can be used as a starting point in order to justify and make an ethical decision, where all the

principles are balanced against each other in order to determine which has the most weight in each

case. Casuistry is a situation-based approach where different cases impact on the moral principles

chosen, and not the other way round. Therefore, unlike principlism, the starting point for making ethical

decisions is to look at other similar cases, and from those, learn how to best handle the situation at

hand. Generally, in medical ethics principlism is preferred to casuistry. This tends to be due to the fact

that in medicine every case will be unique in its own way. Even cases that are similar in many respects

can have different outcomes due to one small difference between them. Principlism is also preferred in

cases where time is an issue, and a decision needs to be made quickly and other cases cannot be looked

upon.

Both systems of thought, however, are open to critique. The main disparagement of principlism is the

inability of choosing one principle over the other when dispute arises between principles. One could

argue that when trying to balance the principles, in the style Beauchamp and Childress advise, the

principles become open to interpretation and can become nothing more than principles that can be

manipulated to justify a hidden agenda. This lack of solid defining criteria can leave the four-principle

approach vulnerable to those with ill intentions. The same can be said of casuistry.

WD Ross [5] makes an effort to give a clearer idea of how to come to a decision when there is conflict

between two principles by mixing both the ideas of casuistry and principlism. He asserts that in times

where more than one prima facie principle is involved in a situation, the case should be analysed as

thoroughly as possible until an opinion is formed where one principle is “more incumbent” than the

other. Even with this method, a person’s idea of what is “more incumbent” is influenced by any pre-

existing judgements or prejudices that they already have.

Scope of Autonomy with Ethical Case Studies

Various ideas of autonomy have evolved from the many philosophical stances on respect for autonomy.

From Immanuel Kant [6] to John Stuart Mill [7], the intricacies of respect for autonomy differ depending

on whose model you read. The scope is even further widened when culture is brought into play. A whole

nation’s outlook on autonomy can differ vastly from that of another. In one country you may find that

autonomy is strongly based on the rights of the individual, whereas in another you may struggle to see if

respect for autonomy really exists at all. Therefore, in instances where these cultures clash, an area of

conflict can arise. Here is a possible case which highlights an example of this conflict in dealing with

respect for autonomy:

A known Jehovah’s Witness arrives in A&E, unconscious, with heavy bleeding from a road-traffic

accident. He needs an urgent blood transfusion, as without it the prognosis could be fatal. This

particular case touches upon both cultural medicine and capacity. These are concepts that deserve

being scrutinized in detail separately; however, they will be briefly discussed here.

It is against the religious belief of Jehovah’s Witnesses to undergo blood transfusions. However, there

are many factors that come into play for this individual case as well as religion. If the patient was

conscious and was verbally communicating to the doctors that he does not wish to have a blood

transfusion, then a quick decision would need to be made to determine whether the patient has the

capacity to make that choice. Kant [6] believed that autonomy does not embrace those who lack reason.

This can be a point of critique, as it narrows the scope of autonomy by eliminating all those without any

rational way of thinking. Nevertheless, the respect for an individual‘s autonomy should still be

maintained even if he lacks capacity. Assuming this patient was conscious and had capacity, it could be

argued that the patient indeed has no autonomy at all, as he is no longer self-determining and is being

led by his beliefs and religion. On the other hand, yielding your autonomy is indeed an autonomous

action in itself. This could be partial or complete, from allowing a doctor to make a decision on your

behalf, to allowing relatives to take medical custody of you, or indeed as it is in this case, to giving

yourself wholly to a higher religious power. This patient is unconscious which automatically makes him

lack capacity at that time, and although we know that he is a Jehovah’s Witness, it would be foolish to

make assumptions that if he were awake he would definitely refuse a blood transfusion. If there was

enough time, relatives could be questioned, and past notes could be studied, to build a clearer picture

as to what the patient would want. If time was an issue, then the doctor would have to make a decision

based on the four principles.

Autonomy looks to be compromised as it can only be an assumption of what the doctor believes the

patient would want. If non-maleficence is thought of, then what actually would be “not to do harm”? Is

it doing harm not to give a transfusion and let the patient die, or would it be more harmful to do so and

later find out that the patient did not wish this and will have to live with the spiritual consequences of

the doctor’s action? Beneficence and justice can also be justified either way. Beauchamp and Childress

[4] declare that when trying to balance out the principles, a degree of instinct is inevitable, and in a case

such as this a person’s own intuition will possibly be the true decision maker, and will leave the

balancing act of the principles effectively redundant.

The demand for, and refusal of, treatment are also closely bound to autonomy. The following two cases

present the issues that can arise due to this. The first case deals with the refusal of treatment that will

lead to the death of the patient, and the second considers a demand for treatment in fear of dying.

Dax Cowart was an American pilot who suffered a terrible accident in 1973 where most of his body was

severely burned by a propane explosion. The burns had severely disabled Dax, blindness and the loss of

his hands being the two most traumatic disabilities. On his way to the hospital he had refused any

medical treatment, wanting to die as he believed he would never become his normal self again. He

continued to tell the doctors that he did not want any treatment, however the doctors rejected this and

forced treatment upon Dax. He was an in-patient for 10 years, and Dax begged his doctors to let him die,

however they continued to force treatment upon him which caused him pain and suffering. Dax went on

to obtain a law degree, speaking publicly on the right to be allowed to die and still believes that at the

time of his accident the doctors should have granted him his wish.

This case occurred in the USA forty years ago. Current GMC guidance [8] in the UK states that if a patient

has capacity then he or she has the right to refuse treatment even if it results in death. In Dax’s case he

was deemed to be lacking in capacity in order to make that decision. His doctors’ justification was that

he was in too much pain to make a rational choice, yet patients like this are in pain for considerable

amounts of time. Should that necessarily mean their autonomy should be compromised because of the

pain? Dax’s doctors believed that ultimately the ends justified the means. This standpoint can be

interpreted as the doctors taking an action in order to satisfy their own moral convictions and not to do

what is in the patient’s best interest. Kant [6] believed that patients should be treated as ends in

themselves, and this gives power in restoring a balance between doctor and patient, by reducing the

natural paternalism and inequality in place.

Another possible case is that of a 28 year old female who had a family history of breast cancer. Her

mother died of breast cancer, as well as her older sister. She asked doctors for a mastectomy, and did

not want to go through any kind of screening or genetic testing. She didn’t see the point in going

through those kinds of rituals because she “knew” that she had breast cancer, and was tired of living in

fear of finding a lump in her breasts. The doctors refused to do a mastectomy without her going through

the initial procedures first.

Mill’s [7] version of autonomy is directed towards the wishes and requests of the individual. So from

that alone, it could be said that demanding various treatments is within the rights of an individual. In our

patient’s case her request for a mastectomy was not without any reason and logical thinking, so it is

hard from that to deem that she lacks capacity. However, her downright refusal and lack of compromise

with the doctors in figuring out a way to solve her problem led to an impasse for the operation she

seeks. So does autonomy allow negotiation? After all, the doctors were not against giving the patient

the operation, but only on the prerequisite that she undergoes initial tests to see if it is clinically

indicated.

Once more, this falls under Kant’s [6] idea of treating patients as ends in themselves and not merely

means. Even if the viewpoint is taken that the surgery requested was nothing more than an elective

surgery, and not a certain life-threatening situation, what is it that makes this case different from

someone who wishes to have cosmetic surgery done to his/her nose to make themselves feel better? If

the patient has full capacity, then both autonomy and beneficence would be fulfilled if the procedure

was to be done, giving the patient peace of mind and respecting her wishes. Conversely, non-

maleficence and justice can be argued to be compromised if the patient’s request was granted. As with

any surgery, there are risks involved in a mastectomy. In this case, the risks could not be assumed to

outweigh the benefits since there is no clinical evidence to indicate the need for surgery. In terms of

justice and fairness, whether or not to provide a female patient such as this with the resources available

for surgery can be questioned when there are other cases for which the need for surgery are clinically

indicated, not only for breast cancer, but various other diseases as well.

As stated above, John Stuart Mill’s [7] vision of autonomy was firmly based on the liberties and desires

of the individual. A unique case of autonomy that is distinct from others is that of the pregnant woman.

Cases of respect for autonomy involving pregnant women can be tricky to deal with, taking into account

that it is effectively the autonomy of both a female and an unborn child that is at hand. John Stuart Mills

[7] declared that self-determination was valid only on the condition that it does not cause harm to

others.

This is a necessary factor in autonomy, as an individual’s autonomy cannot be adhered to if it is causing

direct harm to another or several other human beings. Therefore, let us think of the case of a pregnant

woman who refuses to have a C-section recommended by her doctors. She has been told that if she

does not have a Caesarean, and continues to go into labour naturally, there is a significant likelihood

that her baby could have severe disability and mental retardation. Under current guidance

recommended by the GMC [9], a pregnant woman is allowed to refuse treatment that would be

beneficial to the unborn child and the rights of the unborn child are not established until it is an

independent entity from the mother (ie – until it is born). Using Mill’s attitude towards autonomy and

the requirement of respecting others to make individual autonomy valid, an argument could be made

for a change in guidelines. Of course, the standpoint of those who favour women having the right to

choose abortion is that the foetus should not be treated as a human being, rather only as something

that has the potential to become one, and so should not be allowed the same rights as a human being.

However, in this particular scenario of the mother refusing a C-section, it is not a question of

termination, as this potential has turned into a certainty. So does that mean that the mother’s

autonomy should be denied, due to the fact she is putting her unborn child at harm? The fact is that if

GMC guidance were to allow the pregnant woman’s autonomy to be infringed, this could set the

precedent for evolution to further possible restrictions as well.

It is obvious that the well-being of the mother and her unborn child are intimately tied to each other,

and even though current guidelines states that the unborn child has no rights, this is not to say that

respect for autonomy should imply that a decision is made without taking into consideration the effects

on the child. In fact some believe that morally, we have duties to those close to us, and therefore

believe that relational autonomy [10], as opposed to individual autonomy, is more justified.

Conclusion

So indeed, what is the scope of autonomy in medical practice? We have explored methods of thought

such as principlism and casuistry, different ideologies on autonomy and several specific medical ethics

cases in order to be able to answer this question. We can now see that autonomy is indeed extremely

far-reaching and has many boundaries, but what is most interesting of all is that it is the same things

that make autonomy far-reaching which can equally limit it. From a legal, cultural, and humanitarian

perspective, these are the factors which enable as well as limit autonomy. We saw that in the case of

the pregnant woman, that the principles of guidance from a governing body such as the GMC were

facilitating her autonomy, adding strength to her choice which she may not have had if those guidelines

were not there. However, in the case of the woman requesting a mastectomy, she had no right to

demand to have that procedure from a legal position or from any documented regulatory authority like

the GMC, even if she had reasons that justified her wishes. Culturally, depending on the part of the

world you are from, your autonomy can be viewed at the highest esteem, or indeed it may be an issue

not even worth discussing. Medical procedures are done on humane grounds to help alleviate the

patient’s illnesses whilst respecting his/her autonomy. In the case of Dax Cowart, it was considered

humane to treat the patient against his wishes in order to keep him alive, despite the pain he was in,

hence compromising his autonomy. Humanitarianism is also rightly considered as a boundary for

autonomy whenever it causes harm to another individual. The scope of autonomy consists of all these

concepts which give will to power to individuals, whilst simultaneously setting in place limitations.

In terms of the four principles, it could be posited that autonomy should be regarded at a higher

standard to the other three principles and be the principle that guides the others in order to make a

decision. In a doctor-patient relationship, the balance of power is naturally shifted towards the doctor. If

this position of power was to be abused and the patient’s autonomy disrespected then this can damage

the doctor-patient relationship and give the patient a sense of distrust towards the doctor. If this

attitude was to become widespread, then this would lead to a general lack of trust in the medical

profession as a whole, undermining the health care system, and reflecting badly on those who try their

best to ensure autonomy is maintained. That is why if the autonomy of a patient is held in a high regard,

to the extent that it is leading the other three principles, but not in an absolute sense, the balance in the

doctor-patient relationship can be restored, giving a greater sense of equality to the patient. Using this

approach doctors could have a clear idea of the first principle that should be looked at, and from there

relate autonomy to the other principles. It is often said that there is no right and wrong answer when it

comes to ethics, and this at times can make the process of coming to a suitable resolution all the more

challenging

References

1. Gillon, R, Medical ethics: four principles plus attention to scope, BMJ, Volume 309, Number 6948>309:184, July

1994.

2. Christman, J, Autonomy in Moral and Political Philosophy, The Stanford Encyclopaedia of Philosophy.

3. Garrett T, Baillie W, Garret R, Health Care Ethics (5th Edition).

4. Beauchamp, T, Childress, J, Principles of Biomedical Ethics (7th Edition). Oxford University Press, 2012.

5. Ross, WD, The Right and the Good, Hackett Pub Co Inc, July 1988

6. Secondary source: Parker M. Dickinson D. The Cambridge Medical Ethics workbook. CUP, 2001

Primary source: Kant, I. Groundwork of the Metaphysics of Morals.

7. Secondary source: Parker M. Dickinson D. The Cambridge Medical Ethics workbook.

CUP, 2001

Primary source: Mill, JS. Utilitarianism: On Liberty.

8. Re B (Adult, refusal of medical treatment) [2002] 2 All ER 449 Right of a patient who has capacity to refuse life-

prolonging treatment.

9. St George's Healthcare Trust v S (No 2). R v Louise Collins & Others, Ex Parte S (No 2) [1993] 3 WLR 936.10.

Parker M. Dickinson D. The Cambridge Medical Ethics workbook. CUP, 2001.

10. Parker M. Dickinson D. The Cambridge Medical Ethics workbook. CUP, 2001

Public Health Challenges in India 2013

Dhairya Lakhani (3rd

M.B.B.S.), Dr. Sunil Kumar (M.D.), Shruti Gohel (3rd

M.B.B.S.) & Dr. Supriya Kumar

(M.D.)

Correspondence - Dhairya Lakhani: [email protected]

COMMENTARY PIECE

Key Words: Health, India, Vision 2020, public private partnership

Background

In the din of a slowing economy, falling rupee, rampaging inflation, and incessant political

manoeuvrings, India’s list of challenges continues to grow. Of all these challenges, there is one that

seems insurmountable already, and worse, could soon end up becoming a calamity, aggravating the

suffering of hundreds of millions of Indians. This challenge relates to the provision of affordable,

accessible, and accountable healthcare to every single citizen of India. (1)

On just about every single measurable indicator of healthcare infrastructure, India is rapidly

deteriorating. It is easy to mistake the gleaming glass façade of modern hospitals that have come up in

the top 15-20 cities of India as a sign of India’s improving healthcare infrastructure. It is easier to get

carried away by the frequent appearance of a few celebrity doctors in the newspapers and assume that

the nation’s healthcare is in good hands. Unfortunately, the facts don’t bear this out. (2) Only 48 per

cent of the 1.35 million beds are functional and relevant and about 65 per cent of these are located in

the top 20 cities. (1)

Stark Ground Reality

It is anyone’s guess as to how many qualified doctors the country has. The most optimistic estimates put

this number at less than 5 lakh. More than 65 per cent of the operational beds are in the private sector,

and more than 80 per cent of the spending on healthcare in India is accounted for by the private sector

even though over 65 per cent of India’s population is below the poverty line or living just on its fringes.

No wonders that on an all-India basis, an Indian has to travel an average of 77 km to access basic

secondary care services. (3)

The above challenges are exacerbated by the fact that while the country is still struggling to bring

infectious diseases under control, the incidence of non-communicable diseases is also on the rise. . First,

with increasing life expectancy the epidemiological transition points towards greater incidence of non-

communicable or lifestyle diseases. This goes hand in hand with a continuing serious problem of

communicable and preventable diseases. Second, there is a lot of variation in the public provisioning of

health care - a state subject. Poor states are hard pressed for funds. Third, India is an exception across

countries in that nearly four-fifths of its health care expenditure is out-of pocket. Coupled with the

burgeoning growth of unregulated private sector care-givers, this has serious implications. These three

issues open up a number of policy questions on access to, utilisation and quality of health care.

However, the most important among them is the one, which will specifically address the concerns of the

poor and the sick. Heart diseases, diabetes, and cancer are expected to show a combined average

decadal growth of 47 per cent in future. This will add to the demand for diagnostic, therapeutic and

research facilities in tertiary care specialties. (4)

Considering some of the anticipated trends of population and trained manpower deficits in healthcare

delivery, India needs strategies that are customised to address its needs and in alignment with the

financial resource available. This calls for rigorous participation from both the public and the private

sectors. (5)

The Path Ahead

One such promising solution — though one that has performed below expectation so far — is the Public

Private Partnership (PPP) model. If implemented efficiently, it has the potential to plug many gaps in

the access to basic healthcare. PPP models should be planned and executed to leverage the expertise of

private partners in infrastructure design, strong process orientation and ‘safe’ care delivery methods.

The training of paramedical staff and doctors on specific care protocols and patient safety practices can

be devised and deployed with the support of private healthcare groups and NGOs. Medical equipment

firms can join hands with the government in provisioning IT-enabled point-of-care data management

systems for better disease prevention and immunisation tracking. Diagnostic services at all

district/identified government hospitals can be improved by engaging private players to develop

processes for effective utilisation. (2)

Information technology is one area which, if put to optimal use, can bring immense improvements in

the way we diagnose and treat medical conditions. There are many innovative interventions in the field

of mobile and electronic healthcare that have been successful in other developing markets that could be

replicated in India. New concepts like doctor on web/phone are increasingly gaining ground and can go a

long way in primary and secondary healthcare delivery. (4)

There is also an urgent need to relook at the business models that hospitals have adopted so far. The

temptation to set up world-class tertiary and quaternary multi-specialty hospitals is understandable —

and India does need them — but then how you prioritise the allocation of the available capital is also

important. (5)

Fortunately, there are many promising initiatives in the right direction — in setting up low cost, single

specialty or even a single micro — specialty primary and upgraded secondary care facilities, and setting

up of low capital day-care centres.

Providers are waking up to the need of investing in healthcare facilities that are asset-light, low on

investment and manpower requirements, and easy to scale up and replicate. Corporate players which

have so far concentrated mainly on achieving high occupancies in large multi-specialty hospitals are

venturing into formats that involve lower in-patient hospital stay, higher bed turnover and lower

operational costs. (4)

Role of Government

The government, on its part, needs to support these efforts by providing subsidies on land, and medical

equipment and tax benefits to professionals working in such organisations, especially in rural areas. It

should also take a cue from such low-cost models and consider setting up short stay medical centres at

the district/identified government hospitals that would relieve the pressure on some of the key nodal

hospitals and allow minor surgical procedures to be carried out on time and perhaps reduce the cost of

delivering care as well.

The public sector can take a slew of other measures to strengthen primary healthcare infrastructure.

Here are some pointers. Pharmacies in all government hospitals should stock generics and supply chains

should be re-vitalised to prevent stock-outs that force patients to buy medicines from private

pharmacies. There can be measures to integrate primary health centres with district hospitals to allow

for continuity of care. Child care and women’s care services should be strengthened by enhancing the

availability of trained professionals at primary care clinics and district hospitals. Nodal hospitals of the

government should be identified and equipped with strong emergency services for timely critical care.

The number of medical and paramedical colleges in under-served areas should be increased.

Another probable solution, though mired in controversy, is bringing changes in the training of

healthcare manpower and staffing patterns in hospitals. This should be directed to reduce the number

of crises that require a doctor’s intervention. Hospitals can benefit from a broad range of training

programmes to create workers with a wider array of skills such as physician assistants, nurse

practitioners and diagnostic medical sonographers. This will not only help tackle the issue of the

shortage of trained doctors, but also free up doctors to devote their skill to more complex tasks.

Interventions along these lines have been undertaken in some states like Tamil Nadu where nurses were

trained by the government and the number of positions for them increased in primary health centres.

However, such examples are sporadic and need more vigour to be duplicated in other states.

Deepening connectivity and sharing knowledge can help reduce medical errors and improve care

quality, for example through drug interaction alerts, greater use of evidence-based care protocols and

new capabilities in managing population care, which increase the potential for preventive and low cost

care for chronic conditions. (1)

Conclusion

As a formidable global economic power, accessible quality healthcare can be a key competitive strength

for India. There are three milestones on the journey towards connected healthcare which need to be

achieved – Healthcare IT adoption, Health Information Exchange and Insight-driven Healthcare. It is

imperative for the nation to relook at the current budget outlays, policies and the commitment to

deliver on this comprehensively.

References

1. R.Srinivisan-Health care In India Vision 2020.

2. Katherine E.Bliss-Key Players in Global Health-How Brazil Russia India China and South Africa are

influencing the game A report of the CSIS Global Health Policy Centre

3. Five years of NRHM 2005-2010, Ministry of Health & Family Welfare

4. Annual Report of Ministry of Human Resource Development (MHRD), 2009-10.

5. Morbidity, Health Care and The Condition of the Aged, NSS 60th Round, March 2006

Electroencephalography – An Overview

Holly Duncan (University of Dundee), Kate Spillane (PhD, MRCP), Ian Morrison (PhD, FRCP)

Correspondence – Holly Duncan: [email protected]

ABSTRACT

EEGs are commonly requested by physicians in medical wards for patients with altered conscious levels

and also in the outpatient setting for investigation of seizures. This article seeks to explain how EEG is

performed and explore the correct indications for its use.

Key Words: Electroencephalography; EEG; Indications

Electroencephalography

Electroencephalography (EEG) is the electrical study of brain activity. It was first used on humans by the

German psychiatrist, Hans Berger, in 1929 to examine electrical activity within the brain’s cortical grey

matter1 and it was later discovered that aberrant cortical activity is seen in many neuro-pathologies. It is

especially relevant in seizure disorders, in particular epilepsy. It is a non-invasive, painless procedure

that can be performed in both outpatient and inpatient settings, and usually lasts a minimum of 35-45

minutes2.

EEG & Loss of Consciousness

EEGs have a relatively low sensitivity for diagnosing epilepsy at 25-56%. In a study of over 13,000

military personnel with no history of significant illness or head injury and normal physical examinations,

0.5% had frankly epileptiform discharges on EEG. Only one of these men went on to develop clinical

epilepsy3.

Sam et al reported that epileptic EEG discharges can be seen in up to 12.3% of the community who had

no history of unprovoked seizure or epilepsy. Many of these patients had an underlying acute or

progressive cerebral disorder4, and this highlights that epileptiform discharges are present in a number

of pathologies other than epilepsy. Likewise, abnormal cortical activity is relatively common, especially

in the elderly, migraine patients, those with psychotic illness and those on psychotropic medication5.

To add further confusion, a normal EEG does not exclude a diagnosis of epilepsy. Definite epileptiform

abnormalities are seen in only 29-38% of adults with epilepsy on their first EEG recording5.

The EEG should not therefore be used in isolation to diagnose epilepsy, where history is most important,

nor should it be used to diagnose unexplained losses of consciousness. Performing the investigation in

cases of probable syncope in particular incurs the risk of a false positive result and subsequent

misdiagnosis6.

Specific Indications for EEG in Epilepsy

Classification of Epilepsy

Classification of seizure type is essential for offering prognosis and planning the correct treatment. In

particular, it is helpful to distinguish between generalised and focal onset epilepsies, where certain

medications (e.g. carbamazepine) are usually avoided in generalised epilepsies but not focal onset

epilepsies7.

Furthermore, EEG can facilitate the localisation of an epileptogenic focus and indicate localised

structural pathology underlying the seizure disorder, which is helpful if the patient is being considered

for resective surgery to cure their epilepsy1, 5, 8, and 9

.

Triggers

If stress testing during the EEG identifies photosensitive epilepsy, the patient can manage their

condition by avoiding triggers such as strobe lighting1.

Use of EEG in Intensive Care

The use of continuous EEG (cEEG) recording in Intensive Care Units (ICU) can now provide prompt and

therapeutically important data regarding cerebral function in a cohort of patients who may have only

subtle or no clinical signs10, 11

.

Investigating Periods of Altered Consciousness

EEG is important in the management of convulsive status epilepticus: for monitoring seizure activity and

assessing the response to IV treatment. This is particularly important in intensive care where

convulsions may be masked by sedation, paralysis and antiepileptic drugs5, 8, 10, and 12

.

Whilst convulsive status epilepticus should be clinically evident, a prolonged period of altered

consciousness could be due to non-convulsive status epilepticus (NCSE), which can be difficult to

distinguish from other confusional states. Privitera et al urge that all patients with persistent,

unexplained, altered consciousness receive immediate EEG13

to exclude NCSE and, where appropriate,

allow the prompt initiation of appropriate treatment8. Hirsch reports that the difference in mortality

between NCSE diagnosed at 30 minutes compared with delays of over 24 hours soars from 36% to 75%,

respectively14

.

Other Indications for EEG

There are many reported indications for EEG, including prognosticating head trauma, diagnosis of

encephalitis and dementia, measuring the depth of sedation and predicting the outcome and

management of patients in a coma of other reasons2, 10

. However, the EEG is not specific in many of

these conditions and should only be used to support diagnosis8.

Procedure

Electrodes are positioned on the scalp in an arrangement called a montage. They are placed according

to the International 10/20 System, which is based on the identification of anatomical landmarks such as

nasion and inion and the preauricular points. Electrodes are then placed at consecutive intervals fixed

distances from these points in steps of 10 or 20%; thereby allowing for variations in head size15

. These

points are labelled as Frontal pole (Fp), Frontal (F), Central (C), Parietal (P), Occipital (O) and Temporal

(T). Odd numbers denote points over the left hemisphere and even numbers the right, whilst ‘z’ denotes

zero and identifies electrodes in the midline16

. The potential difference recorded between pairs of

electrodes is amplified and displayed on a monitor2, 17, and 18

. The recorded activity is measured in

microvolts18

and represents the postsynaptic potentials of vertically orientated pyramidal cells within

the cerebral cortex17

.

Routine EEGs now commonly include so-called activation procedures to enhance the diagnostic

sensitivity. During activation, EEG recordings are made when a patient undergoes hyperventilation or

exposure to flashing lights at various frequencies (photic simulation). Binnie et al report that a waking

EEG of at least 30 minutes duration, with hyperventilation and photic stimulation, will demonstrate

inter-ictal epileptiform discharges (IEDs) in about 50% of adults with epilepsy8.

National Institute for Clinical Excellent (NICE) guidelines on the diagnosis and management of epilepsy

recommends that photic stimulation and hyperventilation should remain part of the standard EEG

assessment. The patient must however be warned that such procedures may induce a seizure and they

have a right to refuse6.

Sleep and sleep deprivation can also increase the likelihood of IEDs being recorded as some wave-forms

are more evident during sleep, and tiredness can trigger seizures. Sleep recordings are helpful in

identifying epileptiform discharges in patients who have normal EEGs in the waking state, and so can aid

epilepsy classification8. In particular, there is evidence that sleep deprivation activates IEDs in idiopathic

generalised epilepsies1.

NICE recommend that a sleep EEG is performed when routine EEG has not contributed to a diagnosis or

classification of epilepsy6.

Interpreting EEG Results

Alpha

Waves

8-13Hz rhythm is seen symmetrically and posteriorly when the eyes are closed, this activity is

attenuated in drowsiness and is blocked with eye opening. Alpha waves are normal in adults2, 17 and 18

.

Beta Waves

>13Hz activity is seen symmetrically and frontally in healthy adults. This is unaffected by eye opening

but may be absent of reduced in areas of cortical damage16

.

Theta Waves

4-7Hz rhythm is normal in children up to 13 years of age16

. It is a normal finding in drowsy adults and

becomes more apparent in light sleep. Presence of theta waves in an alert adult can indicate brain

dysfunction20

.

Delta Waves

<4Hz rhythm is normal in infants under 1 year16

. They are only normal in adults in moderate to deep

sleep and their presence in an alert adult suggests brain dysfunction20

.

Theta and delta rhythms are both seen in children and young adults with frontal and temporal

predominance and usually disappear in adulthood.

Generalised spike-wave activity is commonly seen in patients with typical absence epilepsy and may also

be seen in some generalised epilepsy syndromes, whereas focal IEDs are suggestive of partial seizure

FIGURE 3: waveforms seen on EEG. Reproduced with permission from: Medscape Reference. Jan

2013, available at: http://emedicine.medscape.com/article/1139332-overview19.

disorders such as temporal lobe epilepsy17

. Binnie et al observed that hyperventilation provokes spike-

wave activity in patients with absence seizures so consistently that the lack of this finding in an

untreated person who hyperventilates efficiently must cast doubt on the diagnosis8.

Other changes often seen on EEG include generalised slowing, indicating an encephalopathic state, and

focal excess slow activity indicating a unilateral structural lesion.

Conclusion

EEG is a commonly ordered investigation in hospital settings, often for the wrong reasons5. This leads to

misdiagnosis with potentially significant adverse outcomes. It is important that patients are only

referred for EEG in the correct clinical context i.e. to confirm clinical findings from thorough history and

examination.

Learning Points

• EEG is used to monitor cortical activity

• Activation procedures increase the diagnostic sensitivity of EEG

• When used in the correct context, EEG can be used to support a clinical diagnosis of epilepsy, classify

some seizure syndromes and identify epileptogenic foci

• It should not be used in isolation to diagnose epilepsy (in cases of suspected seizure or unexplained

loss of consciousness)

• EEG can be useful in the diagnosis and management of encephalopathies, status epilepticus and

confusional states

References

1. Smith S.J.M., EEG in the diagnosis, classification and management of patients with epilepsy. J Neurol Neurosurg

Psychiatry 2005; 76(2):ii2-ii7

2. EEG. Updated 2012 Jan 26th, cited 2012 October 15th. Available from

http://www.nhs.uk/conditions/EEG/Pages/Introduction.aspx

3. Gregory R. P., Oates T., Merry R. T. G. Electroencephalogram epileptiform abnormalities in candidates for

aircrew training. Electroencephalogr clin neurophysiol. 1992;86(1993):75-77

4. Sam M. C., So E. L. Significance of epileptiform discharges in patients without epilepsy in the community.

Epilepsia. 2001;42(10):1273-1278

5. Fowle A. J., Binnie C. D. Uses and Abuses of the EEG in Epilepsy. Epilepsia. 2000.41(3):S10-S18

6. National Institute for Health and Clinical Excellence. The epilepsies: the diagnosis and management of the

epilepsies in adults and children in primary and secondary care. 2012. London: National Institute for Health and

Clinical Excellence. CG137

7. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press,

http://www.medicinescomplete.com, Accessed on 05/11/2012

8. Binnie C. D., Stefan H. Modern electroencephalography: its role in epilepsy management. Clin Neurophysiol.

1999;110(1999):1671-1697

9. Noachtar S., Rémi J. The role of EEG in epilepsy: A critical review. Epilepsy Behav. 2009;15(2009):22-33

10. Kennedy J. D., Gerard E. E. Continuous EEG Monitoring in the Intensive Care Unit. Curr Neurol Neurosci Rep.

2012;12:419-428

11. Scheuer M. L. Continuous EEG Monitoring in the Intensive Care Unit. Epilepsia. 2002;43(3):114-127

12. Bleck T. P., Faam F.C.C.M. Status Epilepticus and the Use of Continuous EEG Monitoring in the Intensive Care

Unit (Review). Continuum (Minneap Minn).2012;18(3):560-578

13. Privitera M. D., Strasburg R. H. Electroencephalographic monitoring in the emergency department. Emerg Med

Clin North Am. 1994;12(4):1089-1100

14. Hirsch L. J. Continuous EEG Monitoring in the Intensive Care Unit: An Overview. J Clin Neurophysiol.

2004;21(5):332-340

15. Herwig U., Satrapi P., Schönfeldt-Lecuona C. Using the International 10-20 EEG System for Positioning of

Transcranial Magnetic Stimulation. Brain Topogr 2003;16(2):95-99

16. EEG: Introduction. Cited 2012 Oct 15th. Available from

http://www.medicine.mcgill.ca/physio/vlab/biomed_signals/EEG_n.htm

17. Hauser S., Kasper D. Harrison’s Neurology in Clinical Medicine. USA: McGraw-Hill, 2006

18. Lindsay W., Bone I., Fuller G. Neurology and Neurosurgery Illustrated 5th Edition. London: Churchill Livingstone,

2010

19. Waveforms seen on EEG. Cited Jan 2013, Available at: http://emedicine.medscape.com/article/1139332-

overview

20. Recording EEGs. Cited 2012 Oct 15th. Available from http://www.ebme.co.uk/arts/eegintro/eeg5.htm

21. Scottish Intercollegiate Guidelines Network. April 2003. Diagnosis and Management of Epilepsy in Adults: SIGN

Guideline 70, Edinburgh: Scottish Intercollegiate Guidelines Network

22. Ginsberg L. Neurology Lecture Notes 8th Edition. UK: Blackwell Publishing 2005

23. Scheepers B., Clough P., Pickles C. The misdiagnosis of epilepsy: findings of a population study. Seizure.

1998(7): 403-406

24. Kumar and Clark’s Clinical Medicine. 7th Edition. UK: Saunders Elservier 2009

25. Oommen K.J., Gilson G. E., Nelson J. W., Couch J. R. A study to determine the accuracy of a computerized

algorithm for interpretation of EEGs. J Okla State Med Assoc. 2001 Sept. 94(9):400-402

26. Bonnett L. J., Tudur-Smith C., Williamson P. R., Marson A. G. Risk of recurrence after a first seizure and

implications for driving: further analysis of the Multicentre study of early Epilepsy and Single Seizures. BMJ.

2010;341:c6477

27. Muniz J., Benbadis S. R. Repeating video/EEG monitoring: Why and with what results? Epilepsy Behav.

2010;18(2010):472-473

28. Zivin L., Marsan C. A. Incidence and prognostic significance of “epileptiform” activity in the EEG of non-epileptic

subjects. Brain. 1968;91(4):751-778

29. EEG and EP Lab. Updated 2012 Sept 6th; cited 2012 Oct 15th. Available from

http://www.medicine.virginia.edu/clinical/departments/neurology/facilities/outpatient/EEG_EP_lab-page

30. Salinsky M., Kanter R., Dasheiff R. M. Effectiveness of multiple EEGs in supporting the diagnosis of epilepsy: an

operational curve. Epilepsia. 1987;28(4):331-334

31. Doppelbauer A., Zeitlhofer J., Zifko U., Baumgartner C., Mayr N., Deecke L. Occurrence of epileptiform activity

in the routine EEG of epileptic patients. Acta Neurol Scand. 1993;87(5):345-352

32. History: From EEG to Quantitative EEG (QEEG). Accessed 2012 Oct 18th. Available from

http://www.brainclinics.com/history-of-the-eeg-and-qeeg

33. Tips on reading and reporting the EEG. Accessed 2012 Oct 18th. Available from

http://elsevierhealth.com/media/us/samplechapters/9780750674768/9780750674768.pdf

34. Rijsdijkl M., Leijten F.S.S., Slooter A.J.C. Continuous EEG monitoring in the Intensive Care Unit. Neth J Crit Care.

2008;12(4):157-162

35. Abend N.S., Dlugos D.J., Hahn C.D., Hirsch L.J., Herman S.T. Use of EEG Monitoring and Management of Non-

Convulsive Seizures in Critically Ill Patients: A Survey of Neurologists. Neurocrit Care. 2010;12:382-389

36. Praline J. et al. EEG d’urgence : indications réelles et résultats Emergency EEG: actual indications and results.

Neurophysiologie clinique. 2004 ;34:175-181

37. Young G.B., Campbell V.C. EEG monitoring in the intesive care unit : pitfalls and caveats. J Clin Neurophysiol.

1999;16(1):40-45

38. Vespa P.M., Nenov V., Nuwer M.R. Continuous EEG monitoring in the intensive care unit: early findings and

clinical efficacy. J Clin Neurohysiol. 1999;16(1):1-13

39. Deyne C.D., Struys M., Decruyenaere J., Creupelandt J., Hoste E., Colardyn F. Use of continuous bispectral EEG

monitoring to assess depth of sedation in ICU patients. Intensive Care Med. 1998;24(12):1294-1298

40. Velly L., Pellegrini L., Brude N. EEG en réanimation : quelles indications, quel matériel? Ann Fr Anesth Reanim.

2012 ;31(6) :e145-e153

Frailty: What does it mean for Clinical Care Provision?

Ciarán Reynaud (Year 3 MB BCh BAO, Trinity College Dublin), Tomás McHugh (Year 3 MB BCh BAO,

Trinity College Dublin), Román Romero-Ortuño (Lic Med, MSc, MRCP (UK), PhD; Department of

Medical Gerontology, Trinity College Dublin)

Correspondence – Román Romero-Ortuño: [email protected]

ABSTRACT

This article forms part of the Approaching Geriatric Patient series. Speaking to medical and nursing

students, it is common to see and be asked to assess frail older adults on medical and surgical wards.

However, there is great uncertainty about how these older adults should be managed. It is common that

students ask what aspects of frail patients’ care should and could be different compared to other

patients to improve quality of life and optimise clinical care for this increasing patient group. The

objectives of this review are: (1) to briefly outline the main operationalisations of frailty that are suitable

for clinical care provision; (2) to review the use of frailty tools in ‘aggressive’ therapeutic areas such as

surgery and oncology; (3) to review the evidence for the role of frailty in the assessment of traditional

cardiovascular risk factors and the more appropriate prescribing of medications; and (4) to make a case

for frailty as a screening tool for access to evidence-based comprehensive geriatric assessment (CGA)

services.

Key words: Frail elderly; risk assessment; individualized medicine; evidence-based medicine.

Introduction

‘Frailty’ is a commonly used term outside and inside Medicine. The definition of frail adjective from the

Cambridge Advanced Learner’s Dictionary & Thesaurus

(http://dictionary.cambridge.org/dictionary/british/) is:

‘Weak or unhealthy, or easily damaged, broken, or harmed’

Indeed, frailty is about vulnerability to poor resolution of homoeostasis after a stressor event and is a

consequence of cumulative decline in many physiological systems during a lifetime.1

Campbell & Buchner defined frailty as ‘a condition or syndrome which results from a multi-system

reduction in reserve capacity to the extent that a number of physiological systems are close to, or past,

the threshold of symptomatic clinical failure; and as a consequence the frail person is at increased risk of

disability and death from minor external stresses’.2

In the context of clinical care provision, frail older adults represent a challenge to clinicians because they

usually present with an increased burden of symptoms, are medically complex, and less able to tolerate

interventions of any kind (more prone to complications). In addition, patients who are frail have more

subtle signs and symptoms that can be easily overlooked.

In clinical care provision, some interventions can be more ‘aggressive’ than others and hence be more

complication-prone. Frail (vulnerable) adults are more likely than ‘robust’ adults to suffer complications

from a given medical intervention. While ‘fit’ people are resilient and ‘frail’ people are vulnerable,

chronological age per se cannot tell where a person is along the ‘fitness-frailty’ spectrum3, 4

, due to the

great biological heterogeneity of the population of older people.5 Frailty more closely relates to the

biological than to the chronological age of individuals.6, 7

The measurement of frailty as a surrogate for vulnerability in healthcare delivery is therefore of utmost

importance in a current world characterised by an ageing population and continuing efforts to not only

prevent and minimise iatrogenic events, but also concentrate the use of public resources in

interventions for older people that are effective and evidence-based.

The objectives of this review are: (1) to briefly outline the main operationalisations of frailty that are

suitable for clinical care provision; (2) to review the use of frailty tools in ‘aggressive’ therapeutic areas

such as surgery and oncology; (3) to review the evidence for the role of frailty in the assessment of

traditional cardiovascular risk factors and the more appropriate prescribing of medications; and (4) to

make a case for frailty as a screening tool for access to evidence-based comprehensive geriatric

assessment (CGA) services.

As an intuitive concept, frailty (i.e. vulnerability) is well recognised clinically. However, the objective

measurement (i.e. operationalisation) of the concept is still a matter of debate and there is no agreed

gold standard. Instead, there are several definition approaches, two of the most popular being the

frailty phenotype (i.e. frailty as a syndrome) and the frailty index (i.e. frailty as a state). Rather than being

competitive or mutually exclusive, both approaches are actually complementary and suitable for

different purposes or scenarios.8

A Common Operationalisation of Frailty: The Frailty Phenotype

According to the phenotypic approach, frailty is defined as a clinical syndrome in which three or more of

the following criteria are present: unintentional weight loss, self-reported exhaustion, weakness, slow

walking speed, and low physical activity.9, 10

This approach defines two additional states: pre-frail (i.e.

one or two criteria present) and non-frail (i.e. none of the criteria present). According to the biological

theory underpinning the frailty phenotype, co-morbidity is a risk factor for frailty, and frailty is a

precursor of disability.11

The original validation of this approach by Fried et al. included significant

associations with incident disease, hospitalization, falls, disability and mortality, independently of

chronological age.10

Table 1 shows the original frailty phenotype criteria as defined in the Cardiovascular

Health Study.10

Table 1. Phenotypic frailty criteria.10

Positive for frailty phenotype: ≥3 criteria present; intermediate

or prefrail: 1 or 2 criteria present. Robust or non-frail: no criteria present.

• Weight loss: unintentional weight loss of more than 10 pounds (4.5 Kg) in the last year.

• Exhaustion: for at least 3 days in the last week, “I felt that everything I did was an effort” and/or

“I could not get going”.

• Physical Activity: Based on the short version of the Minnesota Leisure Time Activity

questionnaire.12

Men: Those with Kcals of physical activity per week <383 are frail by this criterion.

Women: Those with Kcals per week <270 are frail by this criterion.

• Walk Time, stratified by gender and height:

Men Cut-off for Time to Walk 15 feet (4.6 m) criterion for frailty

Height ≤173 cm ≥7 seconds

Height >173 cm ≥6 seconds

Women

Height ≤159 cm ≥7 seconds

Height >159 cm ≥6 seconds

• Grip Strength, stratified by gender and body mass index (BMI) quartiles:

Men Cut-off for grip strength (Kg) criterion for frailty

BMI ≤24 ≤29

BMI 24.1–26 ≤30

BMI 26.1–28 ≤30

BMI >28 ≤32

Women

BMI ≤23 ≤17

BMI 23.1–26 ≤17.3

BMI 26.1–29 ≤18

BMI >29 ≤21

Because surrogates for individual frailty phenotype criteria are possible 13

, there have been attempts to

provide healthcare practitioners with phenotypic frailty assessment tools that do not require post-hoc

calculations and can be scored immediately after an individual assessment. An example is the Frailty

Instrument for Primary Care of the Survey of Health, Ageing and Retirement in Europe (SHARE-FI) 14

. This

tool is based on a modified phenotypic approach and includes two web-based frailty calculators (one for

each gender) that are freely accessible on BMC Geriatrics (http://www.biomedcentral.com/1471-

2318/10/57/additional). Their use is intended for community-dwelling adults aged 50 and over.

Translated versions of the calculators can be accessed on https://sites.google.com/a/tcd.ie/share-frailty-

instrument-calculators/. SHARE-FI has been validated against incident disability 15

and mortality.16

In an

observational study, a recent study showed that people identified as frail by SHARE-FI had worse

physical performance scores, more history of falls, more medication burden, and were more often

referred for ongoing assessment and rehabilitation 17

. An advantage of SHARE-FI is that, on average, it

takes about 6.5 minutes to administer (http://www.uakron.edu/dotAsset/8b117eba-ec49-4e57-9495-

fe41fcfbd995.pdf).

Another Common Operationalisation of Frailty: The Frailty Index

A way to operationalise frailty is by considering it as a state and counting in an individual the number of

deficits that he/she has accumulated from a given list (of usually 30 or more potential deficits). Deficits

are widely defined as symptoms, signs, diseases and disabilities that accumulate with age.18

The

number of counted deficits divided by the number of deficits considered results in a score called frailty

index (FI), which ranges from 0 (none of the deficits present) to 1 (all deficits present).

The construct validity of the FI is examined through its relationship to chronological age, and its criterion

validity is examined in its ability to predict mortality 19

, and in relation to other predictions including

disability and use of healthcare resources 20

. Table 2 and Figure 1 exemplify a 40-item FI validated in the

Survey of Health, Ageing and Retirement in Europe (SHARE).20

Table 2. 40 items for a frailty index in SHARE.20

Difficulties:

bathing or

showering

Difficulties: lifting

or carrying weights

Moderate or

vigorous physical

activity: hardly ever,

or never

High blood pressure Hip or femoral

fracture

Difficulties: dressing

Difficulties:

shopping for

groceries

Diminution in the

desire for food

and/or eating less

than usual

Heart attack

Impaired orientation

to date, month, year

and day of week

Difficulties:

getting up from

chair

Difficulties:

doing work around

the house or garden

Poor

self-perceived

health

Stroke Body mass index

(Kg/m2) deficit

Difficulties:

walking across a

room

Difficulties:

preparing a hot

meal

Long-term illness Cancer Breathlessness

Difficulties:

eating, cutting up

food

Difficulties:

taking medications Fatigue Diabetes Falls

Difficulties: reaching

or extending arms

above shoulder

Difficulties:

managing money Sad or depressed Arthritis Fear of falling

Difficulties:

using the toilet

Difficulties:

walking 100 metres Lack of enjoyment Chronic lung disease

Dizziness, faints or

blackouts

Difficulties: climbing

one flight of stairs

Difficulties:

getting in or out of

bed

Hopelessness Osteoporosis Grip strength (Kg)

deficit

Figure 1: Association of the SHARE frailty index with mortality (mean follow up: 2.4 years) by age decade

and tenth of FI, in SHARE wave 1 (men and women combined, total N = 20,547). The number on each

coloured cell represents the mortality rate (%) for that cell.

In terms of individual risk stratification, the FI is a continuous variable and primarily does not classify

people as frail or non-frail but rather assigns a score based on health status. However, Rockwood et al.

proposed FI cut-off points to define phenotypical population subgroups with increasing levels of frailty.

For example, in one of their studies they proposed FI ≤ 0.08 as ‘non-frail’, FI ≥ 0.25 as ‘frail’, and the rest

as ‘pre-frail’.21

In another of their studies, they proposed FI ≤ 0.03 as ‘relatively fit’, 0.03 < FI ≤ 0.10 as

‘less fit’, 0.10 < FI ≤ 0.21 as ‘least fit’, 0.21 < FI ≤ 0.45 as ‘frail’, and FI ≥ 0.45 as ‘most frail’.22

Age-specific

FI cut-offs have also been proposed.23

Frailty in Surgery

Surgeons and anaesthetists accept that working with frail patients is a common but challenging

scenario.24

Current surgical decision-making can be subjective (‘eyeball’25

) and often misjudges a

patient’s physiologic state.26

As a marker of low physiological reserve and vulnerability, frailty has

emerged as an independent predictor of morbidity and mortality after surgery.27-29

Crucially, frailty

improves the predictive power of ‘conventional’ surgical risk scores.30-32

To date, frailty tools have been

successfully validated (as more accurate approaches to risk stratification) in many types or surgery,

including cardiac32-35

, thoracic36

, gastrointestinal37-40

, vascular41, 42

, head and neck43

, kidney transplant44

,

and orthopaedic45

. Objective frailty assessment tools may have implications in preoperative decision

making in selecting patients who optimally benefit from surgery46

, and may prove beneficial when

weighing the risks and benefits of surgery, allowing objective data to guide surgical decision-making and

patient counselling.47

Frailty in Oncology

Frailty has also emerged as a potential aid in the vulnerability assessment of older patients undergoing

oncology (e.g. chemotherapy) treatments. Indeed, a comprehensive geriatric assessment (CGA)

approach, which also evaluates elements of frailty, may be of great interest for those oncologists who

want to identify older patients likely to develop severe toxicity and severe side effects in response to

aggressive treatment.48, 49

The use of ‘frail-friendly’ (i.e. less aggressive) chemotherapy regimens (i.e.

aimed at control of further disease progression rather than maximum tumour shrinkage) may benefit

the more vulnerable patients, lowering their rates of premature withdrawal, complications and early

mortality50

, in addition to improving their quality of life. In that light, oncology trials tailored for the

elderly or frail are needed51

, and examples of frailty-tailored oncology treatment approaches are already

available in lymphoma52

colorectal cancer53

, and gynaecologic oncology54

.

Frailty as a Framework for re-thinking ‘traditional’ Medical Risk Factors

In non-frail adults, a substantial body of evidence has provided substantial insight into the epidemiology

and risk factors of cardiovascular disease.55

However, the study of these ‘traditional’ risk factors in frail

populations is providing very interesting paradoxes. For example, recent evidence suggests that

hypertension may be beneficial in frail people older than 85 years 56

. A study showed that the

association between BP and mortality varies by walking speed: among faster walkers, those with

elevated systolic BP (>/= 140 mm Hg) had a greater adjusted risk of mortality compared with those

without, but among slower walkers, neither elevated systolic nor diastolic BP (>/= 90 mm Hg) was

associated with mortality; in participants who did not complete the walk test, elevated BP was strongly

and independently associated with a lower risk of death.57

Low walking speed, inability to walk, or recurrent falling, can all be markers of frailty and underlying

complex systems.58

Another recent study showed that antihypertensive medications were associated

with an increased risk of serious fall injuries, particularly among those with previous fall injuries and

multiple chronic conditions.59

The Leiden 85-plus study has shown that a decreasing trend in systolic blood pressure (SBP) between 85

and 90 years is associated with increased mortality, and that 90-year-olds with SBP of 150 mmHg or less

had increased mortality risk, independent of the SBP trend in preceding years.60

Furthermore, it has

been shown that in patients aged 85 or more with impaired cognitive functioning, higher SBP is

associated with reduced risk of stroke.61

A careful review of the epidemiology suggests that, in the oldest

old, and especially in the frail, hypertension is not an attributable risk factor for stroke, and

hypercholesterolemia has little effect on stroke risk overall.62

Another example in the area of diabetes management are the recently published evidence-informed

guidelines for treating frail older adults with Type 2 Diabetes Mellitus (T2DM),63

which recommend more

liberalised targets (HbA1c ≥ 8%), treatment simplification, and less monitoring. In patients with long-

standing T2DM and at high risk for cardiovascular events, intensive BP control and fibrate therapy in the

presence of controlled low-density lipoprotein cholesterol levels did not produce a measurable effect on

cognitive decline at 40 months of follow-up; furthermore, intensive BP control was associated with

greater decline in total brain volume at 40 months relative to standard therapy.64

Frailty for more Appropriate Prescribing

Frail older people have been grossly underrepresented in clinical trials, and many day-to-day treatment

decisions are still based on evidence extrapolated from more robust patient groups with fewer

physiological deficits.65

There is very limited evidence on the safety and efficacy of medicines in older

adults, particularly in the frail, who often have multiple co-morbidities and functional impairments.66

The risk of adverse drug reactions (ADRs) increases with increasing patient frailty, and since all

physicians are likely to provide care for this group of vulnerable patients, understanding the concept of

frailty may help to optimise medication prescribing for older people. The incorporation of frailty

measures into future clinical studies of drug effects and pharmacokinetics is important if we are to

improve medication use and guide drug doses for fit and frail older people.65

Furthermore,

individualised prescribing could reduce the risk of adverse drug reactions in at-risk frail older patients.67

Specific guidelines for the management of common conditions will be developed tailored to the

biological age or frailty status of older persons 68

.

Frailty as an Indication for Comprehensive Geriatric Assessment (CGA)

Importantly, the emerging evidence base for the frail is not only about reducing interventions (e.g.

saving the patient – and the health care system – from tight blood pressure and glycaemic controls), but

also about proactively intervening. The most notable example is the Cochrane systematic review on

Comprehensive Geriatric Assessment (CGA) for older adults admitted to hospital 69

. This review showed

that CGA (a multidimensional, interdisciplinary diagnostic process to determine the medical,

psychological and functional capabilities of a frail elderly person in order to develop a co-ordinated and

integrated plan for treatment and long-term follow up) increases a patient's likelihood of being alive and

in their own home at up to 12 months 69

.

Conclusion

In clinical care provision, frailty assessment tools are likely to help clinicians assess vulnerability in

specific clinical scenarios. With high degree of probability, there is presently no other area of Medicine

where such an exciting evidence gap has emerged concerning a sizeable and growing sector of the

population, with simultaneous potential to improve patient outcomes, reduce healthcare expenditure in

ineffective (and potentially harmful) interventions, and help focus resources on new, proactive and

effective CGA-based models of specialist care. The frailty paradigm demands an even greater degree of

involvement at the individual patient level, and will pave the way towards a much more personalised

medicine in old age.

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sumj - volume 3 - issue 1

Documents

medical practice2

medical arena

issue of autonomy

acting editor

barr guest editor

rebecca grant year

naomi mcilvenny year

laura fraser year