Speaking of Science: From clinical practice to research: changing how we care for people with cardiovascular disease and frailty

Frailty and multimorbidity are key contributions to hospitalisation in this population and are strongly associated with an increased risk of adverse outcomes, including rehospitalisation and mortality.

Proud descendant of the Cabrogal clan of the Darug First Nations people and registered nurse, Dr Julee McDonagh joined NHMRC for Speaking of Science. Watch and listen as she describes her transition from clinician to researcher and provides an overview of her research program into cardiovascular disease and frailty.

Recorded on Tuesday 20 October 2026, 10:00AM–11:00AM AEDT.

Video transcript

0:58 Prue Torrance
Good morning, everyone. I can see people are still joining, but we will make a start.

Thank you all for joining us for our October Speaking of Science webinar.

I'd like to begin by acknowledging the traditional custodians of the lands on which each of us are meeting from today. I would personally like to acknowledge the Ngunnawal people as the traditional custodians at the land where I am today.

I acknowledge and respect their continuing culture and the contributions they make to the life of this nation. I pay my respects to their Elders past, present and emerging and I extend this respect to all Aboriginal and Torres Strait Islander people joining us online today. I encourage you to take a moment and reflect on the land on which you stand or sit today and to recognise and acknowledge the deep contribution that Aboriginal and Torres Strait Islander people have with that land.

My name is Prue Torrence and I am the acting Chief Executive Officer of the National Health and Medical Research Council, NHMRC, and this is our Speaking of Science webinar series. Before we get started with today's presentation, I'd just like to remind you that there will be an opportunity to ask questions of our guest speaker towards the end of today's session, and I encourage you to ask questions. You can answer your questions at any time using the Q&A function within your team's app. We'll remind you of that again later.

Also to let you know that this webinar is being recorded, which also means if you're unable to attend a webinar or if you'd like to go back and rewatch your favourites, you can find them on NHMRC’s website under our Speaking of Science series.

What are our Speaking of Science series? These webinars are an in-conversation series featuring some of Australia's leading voices in health and medical research. Through these online events, we hear from outstanding researchers, consumer advocates and other subject matter experts who share their personal journeys, insights and perspectives on issues that matter to them and the benefits of health and medical research for the community.

The series provides an opportunity to learn from people who are in there shaping Australia's health and medical research landscape and to explore important topics in medicine and healthcare.

It is therefore my pleasure to welcome our guest speaker today, Doctor Julie McDonagh, a proud descendant of the Cabrogal clan of the Darug First Nations people. Julie is a registered nurse with more than a decade of clinical experience in cardiology and is now a Senior Research Fellow in the Centre for Chronic and Complex Care Research, a partnership between the University of Wollongong and Western Sydney Local Health District.

Her research focuses on improving care for older people living with frailty, cardiovascular disease and other complex health conditions.

Julie has led and contributed to a range of clinical research projects, published extensively in her field and secured highly competitive research funding and also serves on a number of advisory boards and committees and that includes alongside her research leadership. She is a member of the NHMRC-MRFF Indigenous Advisory Group and a passionate advocate for better health outcomes for Aboriginal and Torres Islander people.

We're delighted to have her with us today and to share her experiences and her research. Please join me in giving a very warm welcome to Doctor Julie, over to you.

4:12 Dr Julee McDonagh
Thank you very much, Prue for the introduction. As Prue said, I'm Julie McDonagh, and it's a pleasure to be here today and thank you very much for the invitation to come and speak.

I'm really going to just be taking you through a bit of a journey on my research programme, which as mentioned, is really focused on cardiovascular disease and frailty. I'm going to be talking you through some studies that I've done and a bit of an overview of that topic.

Thank you again for having me. I'm working with three screens, so apologies if I'm trying to have a look at a different screen and I've got a camera on another one, but hopefully it won't be too distracting.

I would also like to just do a brief acknowledgement of country. As a proud descendant of the Cabrogal clan of the Darug First Nations people, I really want to respectfully, respectfully acknowledge the Darkinjung people, the traditional owners of the land where I'm currently residing, where I also work and live.

I want to extend that acknowledgement to all traditional owners of the lands that you're all joining from and to any other First Nations people that may be joining the call. I pay my respects to all elders and ancestors, acknowledging the rich culture and connections to the lands, borders, and community, and acknowledge that Aboriginal people never ceded sovereignty.

I just wanted to jump in briefly to start my presentation. I said that I was talking about from clinician to researcher and as mentioned by Prue, I am a registered nurse. It really got me thinking about, well, why do we define a clinician researcher in this country?

Actually there was a 2021 report from the NHMRC that defines a clinician researcher as someone who conducts research and provides direct clinical services in any setting under a formal arrangement, although not necessarily for the same organisation. They also said that they are someone that's eligible to undertake clinical practice in Australia through registration with AHPRA or equivalent.

Interestingly, in a report they published that most clinicians become researchers later on in their career and clinical research pathways designed for medical practitioners are likely not suitable for nurses, midwives and island health professionals who actually make up a significant proportion of Australian clinician researchers.

And it was highlighted in the report that the development of career pathway models for nursing, midwifery and allied health is really identified as a priority for NHMRC.

Just a brief little history about my nurse clinician researcher pathway. I have been registered as a nurse for almost 17 years and as mentioned in my introduction, more than 10 years of that has been working in clinical practice, primarily in cardiology settings, but also including advanced heart failure and transplantation.

I've worked in intensive care and also time as a clinical trials nurse. Early on in my nursing career I went back and did further postgraduate study and within a few years of practising I'd completed a Master of Advanced Nursing and a coursework masters.

Shortly after this, I was seconded to a clinical trials nurse position, so I spent 14 months working in a clinical trials role on a heart failure national clinical trial, which was really amazing, an amazing experience and it really gave me a taste for research.

You know, by the end of almost a year and doing that position, I'd made up my mind that I wanted to do further study and I enrolled in a PhD. It took me quite a few years because I continued working part time as a nurse on the weekends, but I finished that in 2021 and post PHD, I transitioned full time into an academic role alongside.

I don't have a lot of time because those pathways I said it that are a priority for nurses and midwives and allied health don't really exist yet for nurses to hold dual positions unless you literally have two jobs and I don't really have the time with a full time role.

I do fit in some clinical practice where I can in a casual position, but my main role is working in the academic area now and I was very fortunate and in 2025 I commenced my NHMRC Emerging Leader Fellowship, I felt very, and I still do feel very, fortunate with the competitiveness of the Investigator round to be holding one of those fellowships. I'm very grateful.

I found this quote in a news article written by three nurses that really hit home to me, and I just wanted to share it. It says everyday nurses make decisions that shape not only how patients recover, but how they experience illness.

Take patients that recover instant for sepsis, for example. They're often under sedation on a ventilator. Evidence urges daily sedation breaks to prevent delirium, but guidelines rarely acknowledge the fear of suddenly waking up in a maze of tubes.

These moments where protocol clashes with human need make nurses want to be scientists and find better answers.

I really resonated with this quote because it was something that when I was working clinically, I became frustrated with the protocolised habitual practise that often isn't evidence based and I really wanted to understand more about the evidence and how we could improve outcomes and I really wanted to share this from a paper by Braithwaite that healthcare represents a paradox.

While change is everywhere, performance has flatlined. On average only 60% of care we provide alliance with evidence or consensus based guidelines, 30% of the care we provide is waste or low value care and actually 10% of the care we provide causes harm.

This 60/30/10 challenge has persisted for three decades and it's really figures and things like this that drive me to want to keep doing more research to improve outcomes and I think that as nurses, we're really skilled at being able to bring together patient values, applying the best evidence on top of our clinical expertise to really provide that evidence based care.

I want to jump right into my area of interest now, which is cardiovascular disease and frailty.

I'm going to, I'm sure a lot of people already know what cardiovascular disease is, but I'm just going to briefly touch on some figures and stats of cardiovascular disease before moving on to frailty, then talking about the relationship between them together.

Cardiovascular disease globally is the leading cause of death, responsible for a lot of deaths. Primarily the main cardiovascular disease to cause death is heart attack and stroke so actually more than 75% of cardiovascular disease deaths take place in low and middle income countries.

Common types of cardiovascular disease that you may have heard of is coronary heart disease, this is where blood vessels supply in the heart, there's not enough blood supply in the heart and this is causing heart attacks, stroke and cerebrovascular disease, peripheral arterial disease, heart failure, arrhythmias, rheumatic heart disease and congenital heart disease. They're all under the umbrella of cardiovascular disease.

It really is important to try and detect cardiovascular disease, or CVD as I'll refer to it as, we keep moving forward as early as possible so that management can begin.

A lot of CVDs can be prevented by addressing behavioural and environmental risk factors such as tobacco use, dietary factors, obesity, physical inactivity and harmful use of alcohol and air pollution.

Just a snapshot here of the burden of CBD in Australia, it is, the prevalence does increase by age so 26% of older adults aged 75 years and older have some type of CVD and 6.4% of all adults.

Interestingly, 85% of people with CVD also have at least one other chronic condition. CVD in 2024 was responsible for 23% of all deaths, and it's the leading cause of death for males and the second leading cause of death for females.

I want to jump now to talk to you about frailty, something that probably isn't as well known.

We're all familiar with the word frail, but people may not be as familiar with what this means in a clinical setting and what it means for patient outcomes.

The world's population is rapidly ageing. Not only are people living longer, but those admitted to hospital are becoming more complex, with multi morbidity and geriatric syndromes now part of the status quo.

A major geriatric syndrome of concern is frailty, as I said, we're all familiar with this descriptive word, but over the last two decades we've really come to understand more about frailty and its implications for patient management.

Frailty is most commonly described as a clinical state of increased vulnerability to acute stressor events. It causes decline across multiple domains of human functioning.

The word frail originates from an old French term meaning of little resistance. It really is the consequence of cumulative decline in many physiological systems during a lifetime.

We don't know exactly what causes frailty, but it's thought to be a combination of factors that likely contribute to the progression of frailty in that figure there.

Ageing causes genetic pathological changes. It essentially causes the degenerative processes that occur during ageing to be accelerated.

Frailty has been described as the most problematic expression of population ageing and there is no universally accepted definition of what frailty is or the assessment method we should use to determine frailty and I really like this figure here because I think it gives a great overview of exactly what frailty looks like and how vulnerable it can make people.

The green line represents someone who is non frail and when they're faced with a minor stressor event, they only experience a short deterioration before returning to their baseline level of functionality and in contrast, the orange line is someone who's frail and as you can see, they already have a lower level of baseline functionality compared to those who are non frail.

When faced with a minor stressor event such as a urinary tract infection, they experience a prolonged deterioration and rather than returning to their baseline level of functionality, they deteriorate further towards dependence or disability.

This image here also really gives a good picture of the trajectory of frailty so someone with no signs of frailty is considered robust. They're independent and they have high physiological reserve where someone who is pre frail will start to show signs of decline in function and reserve.

When someone becomes frail, they'll have that increased vulnerability and to adverse outcomes and as you can see, when someone then frailty is a pre disability state, so it's something that's potentially reversible.

If someone, or if we can identify someone is frail, we can put in some interventions to try and improve that frailty before they move into the disability stage where reversibility is less likely. Most definitions of frailty syndrome, there's many different definitions, which is part of the problem. There's more than 60 different frailty instruments available, which causes confusion for clinicians because they don't know the best instrument to use.

But really most instruments fit into this, these two different conceptualisations of frailty, so the blue side of the figure is the biological driven frailty definition.

This was developed by Linda Frieden colleagues in 2001 and really was the seminal definition of frailty. It defines frailty as a biological syndrome that causes age related physical decline such as weight loss, low energy and slowed walking speed. This definition focuses on a physical view of frailty.

In contrast, the yellow side of the diagram is deficit driven frailty. This was developed by Kenneth Rockwood and colleagues also in the early 2000s, and this really defines frailty as the result of accumulated deficits across several domains of human functioning.

This conceptualisation takes a multidimensional view of frailty and recognises that it can cause decline across several domains of human functioning, not just physical ones.

As you can see, there are at least cognition, depression, social vulnerability as factors that contribute to frailty. I just wanted to highlight a couple of these very common frailty assessment instruments.

Linda Fried's frailty phenotype that I mentioned, the biological driven frailty, this has five criteria that we assess for people. We have a look at unintentional weight loss, exhaustion, weakness, slowness and low physical activity. It's a combination of measurement of hand grip strength using a dynamometer or a gate speed test so we get someone to walk 5 metres and we time them doing that three times and take the average score.

You can see it's a little bit small, but down the bottom you can see that if someone is negative in all these criteria, they're considered robust or non frail. If they are positive and one to two of the criteria, they're considered pre frail and if they're positive and three or more of this criteria, they're considered frail.

This is really the most commonly used instrument probably still in the clinical practice. It does require a little bit of training and as you can see, it requires some equipment.

Clinicians are very busy. This is sometimes considered that it's a little bit too time consuming to be put into routine practice, but there are ways that we can try and with practice and training we could get this into clinical practice probably still, but we would need to have a look at workflow.

The second one that I mentioned was the deficit driven frailty, although it's also called the frailty index. This one is looking at various deficits and it's the ratio of deficits. The number of deficits isn't fixed and can be altered to suit a certain population and ideally more than 30 deficits should be assessed so the more deficits a person has, the higher degree of frailty.

This is a continuous score and the good thing about this one is that it could be potentially ascertained from medical records using routinely collected data, so it may be more suitable for assessing frailty in large cohorts.

There is a lot of work being done there about electronic frailty indices using a deficit approach and some of that is being looked at to be incorporated into EMR.

This one I just wanted to briefly mention is the clinical frailty scale, so it's really more of a screening tool, but it's very rapid and very, it's used quite frequently. It's requires very little training, there's no special equipment required and it's based on what the person was like two weeks ago.

If we see someone coming to hospital and we want to do a clinical frailty scale, but we'll be asking them to answer the questions from how they felt two weeks before. It doesn't take into account the acute illness episode.

It's a pictorial representation of frailty based on clinical judgement and it's intended to be used after comprehensive clinical assessment and it is already been routinely embedded into electronical medical records across NSW and I think throughout Australia.

I just wanted to give you a real world snapshot of frailty in Western Sydney, where I'm based. This here is just a little snapshot of the Western Sydney Clinical Frailty Registry.

Frail older adults frequently admitted to hospital, and they have very complex care needs, yet we really don't know a lot about their clinical profile, their routine inpatient management or their longitudinal outcomes. The Western Sydney Clinical Frailty Registry is Co led by Professors Caleb Ferguson and Richard Linley.

It's the only frailty registry listed on the Australian Commission on Safety and Qualities Register of clinical Registries and it's been a really great data set for us to be able to have a look at some of the outcomes locally and also, we've published the results of this paper here that you can access through the QR code.

The aim of the registry really was to establish that clinical profile of frail older adults submitted to hospital to determine their inpatient management and long term outcomes. This is a prospective cohort study of adults that are admitted to the rehabilitation and aged care departments that Blacktown and Mount Druitt Hospital.

This is a 572 site District Hospital located in Western Sydney, NSW so we recruit participants while they're inpatients and we follow them up for 12 months. We see the baseline and at 36 and 12 months we follow them up via telephone.

This paper here was published in BMC Geriatrics and it was really, we had a look at some of the 12 month outcomes for the first almost 600 people that have been enrolled into the registry.

The enrolment, the first enrolments of the registry started in 2020 so it's been going for more than five years and it's going to continue for 10 years. In this first 600 patients, the median age of the patients were 82 so it's quite an older cohort, almost 60% of that first 600 patients were female, 71 of this cohort were considered frail according to the Clinical Frailty Scale, which is that pictorial scale I showed you just before and interestingly of this cohort 23% died within 12 months and 56% experienced at least one readmission.

This is a really sick cohort of patients. We also had a look at some of the independent predictors of rehospitalisation and mortality.

Compared to the non frail group, those that were severely frail had an 85% increased risk of rehospitalisation and or death and even those that were mild to moderately frail had a 52% increased risk of death after adjusting for the effects of the other variables.

We now have more than 2000 patients enrolled in this registry. We've got a lot of data here that we can analyse and we'll look forward to analysing the data again in in a larger sample.

The next part of my talk and really highlights the part of my research programme that focuses on frailty and cardiovascular disease, so the two conditions share a bidirectional relationship.

We don't really know why, but each condition, so CVD and frailty can potentially worsen the other. They both share biological mechanisms such as chronic inflammation and oxidative stress and hormonal dysregulation and CBD and frailty both worsen outcomes.

There's a high risk of hospitalisation and mortality so managing and assessing frailty in people with CVD is now recognised as an important priority to prevent decline and associated poor outcomes.

Just some stats here, frailty is highly prevalent in people with CVD, it can be present in around 80% of people with heart failure and 74% of people with aortic stenosis.

Those numbers can change depending on what frailty instrument is used, but it's very highly prevalent in people with cardiovascular disease. To put it into perspective, the general community dwelling older adult population, frailty is present in about 20% of those people, so in those with cardiovascular disease prevalence is markedly higher.

A better analysis of 30 RCTs involving 87,000 people showed that frail individuals had an approximately 2.3 times higher risk of MACH all-cause mortality and hospitalisation.

They also had a 1.7 times higher risk of cardiovascular mortality. Even pre frail individuals demonstrated elevated mortality risk with 57% higher risk of all-cause mortality and a 28% high risk of CV mortality compared to non-frail individuals.

Importantly though, although frailty identifies patients at substantially higher mortality risk, this particular matter analysis found no evidence that frailty reduces the effectiveness of cardiovascular treatments, which is a really important point.

Supporting the provision of guideline directed therapies in frail patients is still warranted and should be practiced, certainly not suggesting that if someone's frail we should be withholding any treatments.

This sum, I'm just moving a little bit on to some of my doctoral work, my PhD really focused more closely on the relationship between heart failure and frailty. More specifically, I had a look about how should we assess frailty in people with heart failure.

Just briefly, heart failure is a very common form of CVD, effects approximately 500,000 Australians and it essentially occurs when the heart is not functioning as it should, so it can't pump or fill with blood effectively.

Prevalence again increases significantly with age, and heart failure really does place a major burden on the healthcare system.

You can see from that image I've included there that bi directional relationship with heart failure and frailty exists with common symptoms and biological mechanisms.

What's the impact of frailty in people with heart failure? I mentioned before that, you know, approximately 80% of people with heart failure could be considered frail. It's a significant predictor of rehospitalisation and mortality. Heart failure and frailty are strongly linked to potential drivers of each other and interestingly, frailty is not only associated with older age, it can also present in middle aged heart failure, younger middle aged heart failure patients, instant studies that are previously done in cohorts where the main age was 53.

26:53
We're still seeing heart frailty present in, you know, 50% of these people and the main age is 53.

The presence of frailty in younger heart failure patients really challenges the idea that frailty is solely a consequence of ageing. Instead, it suggests that frailty may be related to advanced disease processes in these patients, so therefore effectively making it disease related frailty instead of just age related frailty in heart failure.

There's a lack of consensus on the best instrument to use, making the comparison of outcomes between studies difficult.

I'm just going to briefly touch on this. This was the systematic review that I had published as part of my PhD work.

Really, were we interested? There was a lot of research at the time that looked at the impact of frailty in heart failure patients, but there was little information on what assessment instruments we should be using.

When we had a look at this, the Freed phenotype or the frailty phenotype, which was by Linda Freed, the biological definition of frailty was identified as the most commonly used instrument in heart failure research. But there was no robust evidence to say whether this was the most appropriate instrument for this population, and there were no instruments specifically validated for use in patients with heart failure.

I'm just going to touch on this too. An interesting paper is that I also did as part of my PhD, had a look at can we estimate a patient's frailty?

Due to the lack of consensus regarding the optimal instrument for use in a heart failure context and other systems related factors such as lack of education and resources, clinicians are often relying on subjective estimates of frailty such as the end of the bed or eyeball test.

This is really where someone can be deemed frail by a clinician simply by glancing at the patient from the end of the bed so we really wanted to compare this subjective end of the bed assessment to a formal frailty assessment.

Then we had a look, clinicians were asked to rate patients. These were adults aged 18 years and older in and outpatient heart failure clinic or cardiology ward and the clinicians were cardiovascular clinicians, nurses, physicians and allied health professionals.

The clinicians were asked to rate the participants frailty status as either frail, pre frail and non frail which is then compared to their formal frailty assessment using a modified version of that frailty phenotype biological definition.

We had a look at the association between the two using a weighted Kappa statistic and Spearman's correlation coefficient. Really the results we found with the subjective clinician estimates of frailty such as the end of the bed test really did not show strong correlation or agreement with a formal frailty assessment.

It really led us to conclude that the subjective estimates of frailty are not a reliable replacement for assessment using a formal frailty instrument, really underscoring the need for assessment using a valid and reliable instrument.

And, you know, it made us conclude that we really should be using a validated instrument to assess someone's frailty and deciding if they're frail simply based on appearance is not appropriate and could potentially lead to someone being denied appropriate treatment just based on a clinical guesstimation, which is really not appropriate.

I'm just going to briefly touch on this one too in the interest of time, but one of the final studies I did my for my PhD was comparing 6 frailty instruments to have a look at the predictive validity of 6 frailty instruments in adults with heart failure.

The cohort that I had for my PhD unfortunately was a little bit too small to detect meaningful differences in the predictive validity, but I did think it was interesting.

In the bottom right hand corner of this image you can see that the prevalence of frailty using 6 instruments really varied so it went from 33% to 81% depending on the different instrument we used.

The study suggested that some instruments may have better predictive validity, but we really need a larger cohort to confirm this.

And so after several years of my PhD research on how best to assess frailty in people with heart failure, I realised that the conclusion I came to was that there really is no single best instrument we should be using, and the choice of instruments should be guided by clinical expertise and take into account the clinical context.

This really led me to become interested in a different question which I've focused on post PhD. Really, how can we improve frailty in people with CBD?

The good news is there is research out there to show that there is interventions we can put in place to improve frailty.

The evidence in cardiovascular disease specifically is still quite limited, but a lot of the research has been done in older adults and much of the research now really recommends a full pillared approach to managing frailty so focusing on exercise, nutrition, social support networks and medication optimisation.

You can see some suggested intervention in the circles including improving mobility and nutritional intake, maintaining cognition and social networks.

These measures may help or prevent or delay frailty progression in older adults or even may improve or reverse it in some cases.

What treatment works best? As I said, data in CVD is limited. We need more randomised control trials. But a network meta-analysis of 69 RCTs in older adults revealed that physical activity was the most effective type of non-pharmacological intervention to reduce frailty in older adults and resistance training was ranked as the most effective physical activity intervention and reducing frailty.

However, the certainty of evidence for the findings was moderate to very low, so more high quality RCTs are needed.

I just wanted to highlight to you some of the work we've been doing in the heart value population related to management of frailty. I'm fortunate to co-lead the Australian Cardiovascular Alliance Frailty and Heart Failure Clinical.

Really frailty and heart failure has been identified by the Australian Cardiovascular Alliance as a priority area, and we've convened a working group together. I co-lead this clinical theme alongside Professor Caleb Ferguson.

As part of this work we facilitated a national frailty and heart failure workshop. It was in 2023, so a little while ago now, but that work is ongoing and we really wanted to discuss priorities for policy, research, education and practice.

We published this document in Heart Lung Circulation that really highlights key considerations for addressing frailty in people with heart failure.

In November 2023, we convened a panel of research and clinical experts of people from across Australia, including representation from consumers with lived experience. We had clinicians and researchers across a wide range of disciplines and expertise including geriatric medicine, general medicine, cardiology, nursing, nutrition, dietetics, just to name a few.

Representative panel members that joined on the day were asked to present top priorities for clinical practice and research across five broad topic areas, the biology of ageing, routine frailty assessment, cardio geriatric models of care, prehabilitation for frailty and heart failure and multidisciplinary management.

I’m just going to briefly talk you through some of the strategies we discussed.

Again we focused on this four-pillared approach and we talked about the four pillars in the context of heart failure. The first one was exercise so really resistance exercise has been recommended and as I said, it's the most effective intervention from meta-analysis.

Recent research has reported a reduction in frailty and measures of physical function following exercise rehabilitation in patients with heart failure, but we need more evidence.

But we highlighted key points being that an exercise programme with resistance training should be considered for patients with heart failure and frailty.

For all patients with heart failure and frailty, we really need to encourage utilisation of the five Medicare funded appointments so people on a chronic disease management plan can receive five free visits to allied health.

We want to encourage people with heart failure and frailty to use those visits to go and see an exercise physiologist or a physiotherapist to really prescribe some resistance exercise. We highlighted that education regarding exercise prescriptions should be provided to clinicians including nurses and physicians.

This was really because people that are managed in heart failure disease management programmes, often you know, the funding's taken away in allied health specialist clinicians, we don't have enough of them in those programmes.

If we can upskill nurses and other clinicians to also be recommending exercise, then that might help to address this gap and we really highlighted that incorporating resistance exercise into cardiac rehabilitation programmes and improving the accessibility for people with heart failure and frailty.

People with frailty are often not referred to cardiac rehab so we need to think about more creative ways that people with frailty that maybe may not be able to travel in for a hospital cardiac rehab programme can still receive some resistance exercise intervention jumping to nutrition.

We really highlighted the importance of routine screening for malnutrition risk upon hospital admission and acute care settings and period periodically thereafter.

People with frailty or unintentional weight loss should be referred to an accredited dietitian for comprehensive nutrition assessment and individualised medical nutrition therapy.

We highlighted the importance of a food first approach and then consider high energy, high protein supplementation and oral nutritional supplementation should be considered for those who have unintentional weight loss, poor appetite or those that are unable to achieve their energy and protein requirements.

Just a couple of points here on the social support networks. We need further research into effective social support interventions. In places like the UK, they're much more advanced and there's even roles for community link workers and social prescribing, so we need to consider this for people with frailty and heart failure.

Prescribing them to community link workers if available, or social workers for social prescribing.

Medication optimisation is the other pillar. We highlighted that the use of dose administration aids such as blister packs, pill boxes, and reminders can help improve medication persistence and adherence for people with frailty and heart failure.

We also should be considering home medicines reviews for these patients. We need more research to characterise the effects of frailty on medication pharmacokinetics and dynamics. We really don't know enough about this because frail older adults are often excluded from clinical trials.

We need to consider trial designs that will enable the generation of evidence on prescribing and de prescribing drugs in older people with heart failure.

Palliative care considerations. Frailty is increasingly being considered a trigger for palliative care referral. Individuals with heart failure who are frail have a greater number of unmet palliative care needs so shared decision making, communication and advanced care planning should really underpin our intervention planning.

In the interest of time, I won't read all of these out, but this was just in a figure, the key considerations from that paper there for heart failure and frailty.

Across policy practice, education and research so we're really fortunate on the day to have people represented even from basic science all the way through policy practice.

From all these sections here on the diagram, we had representatives in the room, so we really were able to recommend and highlight some important key considerations.

One of the things we did say for assessment of frailty is that we should be routinely including frailty assessment in clinical practice and in clinical trials using both the deficit frailty approach and the biological frailty phenotype just to be able to improve interoperability between trials so we can compare outcomes.

I did just want to also highlight this Australian consensus statement on the prevention and management of frailty. This was published by Professor Ruth Hubbard and her team.

Really a lot of work went into this, so I highly recommend this and it goes through and discusses in more detail for older adults, the community dwelling older adults, the pillars of frailty management. I encourage you to have a read of this.

I wanted to just highlight some patient perspectives of frailty interventions. This paper we published recently in Journal of Cardiac Value Intersections. It's something that I wanted to have a look at for a while.

A lot of trials are focusing on interventions to improve frailty, which is great, but consumers have really been engaged in this research and very few qualitative studies that have a look at frailty, people's perspectives on frailty interventions exist. Well, at the time when I started the study, they didn't there's a few more coming out now, which is great so we convened some people together.

I'm just going to share some of the patient perspectives. We got together 11 people living with heart failure and frailty and also 9 clinicians and the key results from the patients was that they valued interventions that helped them to maintain independence, mobility and quality of life.

Exercise was viewed positively when individualised, flexible and tailored to their symptom burden. Social interaction and emotional support were considered important components alongside physical rehabilitation and participants really highlighted the need for practical nutrition advice and ongoing support.

Flexible, digital and personalised follow up models were preferred and you can access that paper there.

I won't read out all these quotes, but I just feel like it's really, the quotes really speak to themselves.

They were, these were some of our patient participants.

An 80 year old male that we included in the group said that the term frailty from our point of view as medical professionals is different from how most people understand it.

Your understanding or definition of frailty would be different from mine, this person said and when you write your protocols you need to clarify the term frailty is not a good term to use. But there's no other word for it.

Couple of the other quotes up there that you can see.

People really valued social support that they said was more important to them than popping pills.

Social connection was really important and really one of a 73 year old female participant highlighted the need to have consultation with people to find out what works best for them for their exercise.

Any intervention that we put in place, so it was really valuable having to talk to these patients and yeah, wanted to share those.

I also had the pleasure recently, this special issue was published earlier this year. It was great to see Heartland Circulation, which is the society journal for the Cardiac Society of Australia, New Zealand, and I was a guest editor alongside an international team where we really convened an issue about advancing cardio geriatric care and frailty science in CVD.

This issue brought together a lot of great perspectives, and we had a lot of submissions and so I encourage you to go and have a look at this special issue.

There's papers that you know, ranging from food as medicine, assessment of cardiac frailty from a basic science point of view, wearable cardiac devices, frailty and coronary artery disease and AI frailty assessment.

In that special issue, I led the cover editorial, which we highlighted some key priorities for frailty, for the future of frailty and CVD.

I just wanted to read those to you.

We highlighted the importance of understanding the pathophysiology, so elucidating the mechanisms of frailty across the CVD spectrum and identifying pharmacological targets and optimal intervention timing.

Standardisation of assessment, so implementing consistent validated frailty assessment across cardiovascular conditions in both research and practise, embedding frailty in clinical decision making so really integrating frailty is a core risk marker as part of risk stratification, treatment titration and shared decision making.

We really highlighted the importance of designing inclusive trials so conducting adequately powered RCTs that are representative of older, multi morbid and frail populations with patient centred outcomes alongside traditional cardiovascular endpoints.

Implementing scalable models of care so developing and evaluating integrated cardio geriatric path care pathways that combine cardiology, geriatrics, rehabilitation, nutrition and palliative care with protocols for stepped personalised interventions.

And finally, building workforce capacity so expand training and frailty assessment and management across different clinicians, including nurses, physicians and allied health professionals that will really help support implementation.

Just wanted to provide a few little reflections from a clinician researcher, almost five years PhD and some lessons I've learnt along the way.

I've been fortunate now for the last few years to be in research-only fellowship position, by NHMRC, since 2025. Before that I was in a senior research fellow position, which I'm very fortunate to have. But these are some of our reflections after five years post PhD.

The importance of finding a good mentor is really, really important and you know, someone that's different from your supervisor or manager I think can be important too.

Writing grants is really hard, but it does get easier with practice.

Embracing the vulnerability so you know, send that draft to the wider team for feedback even when it feels uncomfortable, it's better to send it and get the feedback rather than holding on to it. Research doesn't happen alone, it really is a team sport.

Something that I've learnt after being full time in research for a few years is that in research, everything is slow so be realistic with timelines.

A simple one but important to always read the author and journal and grant guidelines.

Another bit of advice I have is what data do you have now? You know, we're all searching for funding to try and get our projects done, but what data do you already have access to that you potentially could put a paper out or do a study, some low hanging fruit unfunded work that you could do.

Cohort studies, qualitative work, surveys and pilot work you may be able to do without funding.

Think about the bigger picture so you know what can you put in the pipeline and really think about the logical progression of your programme and your clinical expertise to those clinician researchers of joins is extremely valuable and don't undersell yourself when being asked to join larger research.

Research teams are really important to understand that your clinical expertise is very important and should be considered part of the expertise of the team.

Celebrate the milestones and small achievements, and something that I have learned since being in academia and research is that self-care and family time really is what matters most at the end of the day.

Just wanted to share a picture of some of the wonderful team members I work with. As I said, it really is a team sport.

This photo was taken last year during an orientation of an RCT that I'm leading called the RESIST HF study. This is a study where we're evaluating a home based nurse coordinated resistance exercise programme for people with heart failure to improve frailty.

This work is supported by NSW Health and my Investigator Fellowship. I'm really fortunate to work with such a great team and they inspire me every day.

I'm wrapping up now. I think we're coming to the end of the talk and there's some question time.

To conclude, frailty is not an inevitable part of ageing, as highlighted in this conversation article I co-authored with Professor Caleb Ferguson.

While ageing is inevitable, frailty is not. By recognising frailty early and managing it proactively, we can improve health and function and quality of life for people with cardiovascular disease.

Equally, we need to ensure that older adults are not excluded from research and that we are meaningfully representing older adults in evidence that guides their care.

We need more inclusive research and clinical practice that recognises the needs, experiences and the potential of older adults, including those living with frailty so ultimately, our goal should be simply not to just help people live longer, but to help them live well for longer.

Thank you very much and I'm happy to take any questions.

48:40 Prue Torrance
Great, thank you so much, Julie.

I love that reflections and advice for others piece, and some of those, some of those reflections actually would work regardless of career path as well.

Excellent. It is now time for questions.

I invite people to start formulating your questions and entering them into the Q&A function.

But I might kick off while people are formulating their ideas. I was really intrigued by one of your early statistics, which I believe was from a paper by Geoffrey Braithwaite. About only 60% of care currently aligns with the evidence essentially and this is a big question, but I'm only asking for it from your perspective and experience.

What actually is the role of research then in actually bridging that gap between evidence and practice? If there's already a gap between what we already know, how does research help address that gap?

49:39 Dr Julee McDonagh
Yeah, thank you. That is a big question.

But I think really that Braithwaite paper, he is a real leader in implementation science. I think as researchers, you know, there's often a lot of research waste where we're doing things that maybe have already been done a lot before.

I think the importance of implementation ready trial so studies that, you know, I've done research before that I've been involved in or, you know, I think about research that I'd love to do where, you know, maybe I might employ a new clinician that they currently don't have to help in a heart failure clinic, for example.

But then when the research is over, that funding for that person goes and the programme can't continue. I think we need to be realistic about what we can implement after the work and I know in most grant applications now, we really need to talk about the translation and implementation.

I think as researchers this needs to be front of mind and there is a lot of implementation science frameworks that you can use to try and have a look at, not just the effectiveness, but how it's going to then be translated into clinical practice.

I think this is really important and you know, making sure that our trials are inclusive and representative of the population that it's trying to serve also will really be helping translation once we finish the project too, right.

Perhaps if we also make that, that similar question, but just a little bit more local and personal.

51:02 Prue Torrance
Have you had a wow moment where you've just gone a wow?

You’ve really made a difference to people's live, and can you tell us about that?

51:10 Dr Julee McDonagh
Yeah, well, the study that I mentioned at the end there, the resist HFRCT that I'm undertaking, we're still recruiting participants into that trial and I've got three different sites across NSW that we're recruiting patients.

Part of the trial is it's a home based resistance exercise programme and we have nurses that recruit the patients and also follow them up with weekly telephone support for the first eight weeks of a three month programme.

One of my nurses that I've hired that's doing the recruiting and following up the patients was away and I was covering her while she was gone and doing some of the telephone follow up and I spoke to a patient that was in the trial and the home based resistance exercise programme is quite simple using resistance bands, you know, equipment you can buy from Kmart, there's nothing that's too out there.

This patient though, said from doing the exercises at home, you know, a few times a week, she wasn't able to bring the shopping in beforehand or put the clothes on the line and since just doing those simple exercises at home, she's able to do that again and she was just speaking so highly of the nurse support and the intervention that she had.

For me, you know, we haven't finished that trial yet to see the, the major outcomes, but even feedback like that from people really, you know, makes me remember why I got into research to really help, you know, people and help them to improve their function and have better quality of life.

52:31 Prue Torrance
Right. Just looking to the audience, if you've got any specific questions, we do have a comment so far rather than a question, but it perhaps leaves itself a little bit to a question.

The comment is around Medicare rebates and gaps in fees and specifically around kind of allied health type areas. To what extent do you see some of the issues? Because some of the interventions you've talked about really do rely on these sorts of allied health or nutrition and things like that, the gap in knowledge and education of the community actually feeding into success.

53:15 Dr Julee McDonagh
Yeah, it's a big issue and you know, I did highlight there that a lot of these disease management programmes, the funding's removed and we lose, you know, those allied health specialist clinicians, which is such a shame.

You know, I highlighted one of the strategies for exercise would be to try and upskill others in how to recommend exercise.

But I think more broadly, you know, like you said, the community awareness and public perception of frailty and what we can do to try and improve it I think is really important and there is a lot of work happening.

I shared the Australian consensus guidelines led from the Australian Frailty Network led by Ruth Hubbard and her team.

There's a lot of resources available on, you know, in certain websites now, community facing resources and there's more in development. I think for people that aren't able to access, you know, those types of interventions where they need to see in allied health due to funding or Medicare rebates, having, you know, more community focused resources available.

There might be digital resources or telehealth resources for people to access.

I do think that, you know, the key is also starting these interventions even earlier, not waiting until people are severely frail before we put them in. I think getting that perception out there that we need to be keeping and thinking about those things younger.

Like there's evidence to show, you know, children that are engaged in sport from an early age, you know, the likelihood of becoming frail later is, is less. I think really that public perception about things we can be doing and it was interesting when we published that picture I put there from the conversation article, you know, that was seen by 22,000 people.

I had a lot of people reaching out and saying, you know, these we just talked about the four pillars, you know, having getting on top of nutrition, engaging in exercise, all those things that are quite simple.

But you know, it really resonated with people that we need to be doing those earlier and that article really, you know, got a lot of traction after we published that.

55:09 Prue Torrance
Yeah, and your area of research around frailty means you're dealing a lot with patients with a higher mortality rate or high hospital readmission rate. Does that present particular challenges for you in terms of ensuring there's adequate consumer and community involvement in in the design and conduct of your research?

And what do you see as the both the challenges and the rewards of of that sort of work?

55:36 Dr Julee McDonagh
Yeah, so we’re fortunate where we are in Western Sydney, and I mentioned the Western Sydney Clinical Frailty Registry, we have a consumer advisory group within as part of that registry work.

We engage and talk to them, you know, a few times per year. We have a great frailty clinical nurse specialist regional John, who works with us, who engages really well.

As we all do with the team, with the consumers and you know, when we've wanted to change certain things about the information we're collecting, we've approached the consumer group and they’ve given feedback.

It's interesting, you know, we always talk about and especially in cardiology trials, we're all about wanting to prevent people going to hospital. We want to keep them out of hospital where our frailty consumers told us, well, it's kind of like a car. If my car breaks down, I take it to the mechanic. If something's wrong with me, that's my right to go to hospital.

It's even interesting for something as simple as that. The disconnect is there. People didn't think about hospitalisation necessarily has always been a bad thing for them. They want to maintain brain health and function and they want to see their grandkids on the weekend.

It's really interesting and it is something we do a lot and where we have a great relationship with our consumers and doing that qualitative work I did within heart failure was really informative for the Resist HF trial and we took a lot of that feedback in when we were designing our intervention.

56:53 Prue Torrance
That's fabulous and so perhaps I'll just close with what, what's next for you? What's your next priority, your next focus, your next challenge?

57:03 Dr Julee McDonagh
Yeah. I mean, for me, there's still so much work to do in this intervention space.

But I think, yeah, like we said before about getting the message out there about frailty intervention earlier and that community message I think is really important.

Increasing the accessibility of exercise and things for people with cardiac disease is a passion of mine so I want to keep doing that.

The outcomes from my RCT that I'm running will be really great to see when we can have a look at the results of that.

But yeah, I think for me, just keep going, and keep wanting to hear from patients what's important to them. I think, as you said, the consumer input is really important so for me, I just want to keep working in this space and improving outcomes for people with frailty and CVD.

57:47 Prue Torrance
I mean, I can't believe you're only five years post PhD really, with the amount you've achieved so far so we look forward to continuing to watch your career unfold.

But we are at time now, so I will call us to a close. I'd like to thank you again. It's been a wonderful conversation.

One of the things I value the most about these Speaking of Science series is that opportunity to hear directly from people whose experience and leadership is really making a real difference in the real world.

Clinician researchers are particularly exciting to hear from and really glad you paced those issues about the difference between a nursing clinician researcher and a traditional physician and different pathways.

We need to make sure our system is supporting those pathways, those sorts of US career pathways.

Thank you again for everyone who's attended. Thank you for listening.

I can see there's quite a great deal of support and the reactions for your presentation.

A reminder that you can re watch this or any of our other Speaking of Science series on the NHMRC website and if anyone has a burning question that they think of after they leave, you can contact our Comms and Media team who organise this series.

Thank you everyone, have a great day.

59:06 Dr Julie McDonagh
Thank you.