Submitted by lac59 on Wed, 16/09/2026 - 08:58
Dr Nicholas Evans is a stroke specialist at the University of Cambridge. In this blog he reveals why frailty is a better measure than age when it comes to stroke medicine and the interventions we could offer with better patient assessment regardless of their age.
None of us are getting any younger. Not only is this true at an individual level, but it’s also the case globally. The World Health Organisation reports that by 2030, one in six people in the world will be aged 60 years or over. In the UK, the number of people over 85 is expected to double to 3.6 million by 2049. By 2080, it is predicted people aged 65 and over will outnumber those aged under 18 worldwide.
Age may well be just a number, but it is a number that often comes with a range of consequences. We recognise that health conditions and disability become more common as we get older, as does the likelihood of frailty. Frailty – a word often used in a pejorative sense and frequently misunderstood – is a clinical term that refers to how well the body has aged and how effectively it is able to withstand and recover from illness. Essentially, an individual living with frailty will get sick more often, more severely, for longer, and is less likely to make a full recovery. Consequently, frailty is often considered to reflect someone’s ‘biological age’ and serves as a measure of how resilient their body is to injury and illness.
Why is this important? Whilst we see that frailty becomes more common with age, we should recognise that frailty is not inevitable as we get older. We see this in our own experiences with friends or family members who seem “young for their age.” For example, how many of us would say that David Attenborough seems 100?
This difference between someone’s chronological age – measured simply by the number of birthdays they’ve had – and their biological age takes on an increased importance in the ageing population. Although we cannot do anything to reverse the number of times we have been around the sun, preventing or reversing frailty is possible.
Although many proponents of longevity advocate for increasing lifespan, arguably a more pressing concern is ‘healthspan;’ the number of years someone lives in good health, free of significant illness and disability. As many people argue, what is the point of living longer if those extra years are of low quality? Indeed, concerningly in the UK, the age at which significant illness and disability develops has fallen in recent years. Consequently, we need to prioritise how we maximise quality of life before we start increasing quantity of life.
Why focus on frailty and biological age in cerebrovascular and cardiovascular disease?
My group’s research focuses on how changes within blood vessels – particularly atherosclerosis, the hardening of arteries as we age – relate to frailty. We investigate how these processes of ageing affect the brain and make it more vulnerable to injury, such as stroke, and how frailty influences the effectiveness of treatment and rehabilitation. We are bringing our translational geroscience from the lab out to patients, asking: what is the bigger picture in individuals with frailty? What links the vulnerable blood vessels, vulnerable brain, and vulnerable individual?
Why focus on this area? In addition to the importance of addressing the global health concerns, this topic is vitally important to patients and their families. Through our conversations with the public and individuals affected by stroke, we have heard how keen people are to be treated as individuals and not defined by their age. People want to know not only how to live into older age, but how to live well.
As a stroke doctor, one of the biggest challenges I face is the uncertainty about how best to treat older individuals with stroke. This is because older individuals have frequently been excluded from the research on which our practice is based. Consequently, the group that attend hospital most frequently are the group being most underserved by research, with consequent negative impacts on their care.
Why some of our oldest patients miss out on clot removal
This detrimental impact on care is particularly true at the earliest stage of stroke. The last decade has seen the development of one of the most powerful interventions in modern medicine: a procedure called ‘mechanical thrombectomy’ that can remove a blood clot within the brain and reverse the effects of a stroke. This intervention, along with clot-busting treatments to dissolve the blood clots (‘thrombolysis’), means that many individuals who would previously have been left severely disabled or died following a big stroke are potentially able to return to independence within days of their stroke.
When I first started work as a doctor, people aged over 80 years were not eligible for thrombolysis. As evidence increased that it was safe and effective at older age, this cut-off was removed. Mechanical thrombectomy does not have an explicit age cut-off, but some of the eligibility criteria means that older people are less likely to receive it. For both treatments, older individuals remain less likely to receive them due to perceived concerns about limited benefit and increased risk.
Our research has shown that it is frailty, rather than age, that affects outcome after stroke, including how well people respond to these acute treatments. This has been important to ensure older people are not denied beneficial treatment, simply because they are chronologically old. It is important that frailty – the individual’s biological age – is considered rather than their chronological age in order to provide personalised and more precise care.
Importantly, our recent work has shown that whilst frailty is associated with increased mortality and some attenuation in the benefit from treatment, such treatments are not futile. This is important for pushing back at treatment nihilism (the perception that treatment won’t make a difference or that the risks are too high) for older people that is still pervasive within clinical practice. Our results show this is not the case: there are still people with a degree of frailty who stand to benefit, without an increased risk from receiving these treatments.
Returning to what the public and stroke survivors tell us, a consistent message is that older people with frailty still wish to be given a chance to benefit from these acute treatments. We heard that whilst many people recognise that they are frailer than when they were younger – and so may have some reduction in the benefit from treatment – the fact there remains some benefit from treatment may make the difference between getting home versus living with extensive disability that requires institutional care.
As one person told us: “I don’t expect a miracle, but I don’t want to be written off.”
Our findings, and the wider work of the group, is shifting the perception and improving care through better tailored clinical decision-making for the individual based on their biological rather than chronological age.
There is a lot of work still to do. Through our research, we are starting to understand the key processes linking frailty, vascular ageing, and brain disease. For example, inflammation affects both blood vessels and the brain in individuals with frailty priming the body for injury. With better understanding of the process, we could find better treatments for inflammation, and this could reduce the impact from stroke.
Furthermore, frailty may mean that a range of treatments used to treat vascular risk factors, such as high blood pressure and diabetes, become less effective. Rather than continuing such ineffective treatments on their own, combining them with anti-frailty therapies, could treat both vascular risk factors and frailty at the same time. This may hold promise for reducing the risk of heart attacks and strokes in this vulnerable population.
In addition to improving treatments and rehabilitation for stroke survivors living with frailty, we are working to develop interventions to reduce the impact of frailty on blood vessels and brain health. Rather than waiting for a stroke or dementia to happen, why not target frailty at an earlier stage and lessen its impact to prevent serious cardiovascular and neurological disease in the most at-risk groups? Prevention is better than cure.
This work, with interdisciplinary links across the Department of Clinical Neurosciences and the Victor Phillip Dahdaleh Heart and Lung Research Institute, holds great promise in ensuring brain and cardiovascular health as we get older, and that we can enjoy older age, rather than be defined by it.
