Remembering Jeremy D. Walston, MD (April 7, 1961—June 10, 2025): Part Two

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The Johns Hopkins Division of Geriatric Medicine and Gerontology will hold a memorial service for Dr. Jeremy D. Walston, their late deputy director, on Tuesday, September 9, 2025 from 3-5pm in the atrium of the Allergy & Asthma Center on the Johns Hopkins Bayview Medical Campus. The service will include recollections and reflections on Jeremy’s life and career and a video slideshow tribute.  Speakers will include Drs. Linda P. Fried, John Burton, Karen Bandeen-Roche, George Kuchel, and Peter Abadir, plus others. No reservations are required.  All are welcome to attend.

Below, we continue sharing personal remembrances of Jeremy that began in Part One of this tribute series.

“What do I say about the most brilliant person I have ever known?  He started out as my boss, then we became friends, and then—as the years passed—I considered him family. Twenty-five plus years working together… he was loved, and I will miss him forever.”

Denise Baldwin, Senior Administrative Coordinator (Retired), Johns Hopkins University, Division of Geriatric Medicine and Gerontology

“I first met Jeremy in the mid-2000s when I started working as a research assistant in the Johns Hopkins Division of Geriatric Medicine and Gerontology. I remember being struck early on by what an exceptional scientist and cutting-edge researcher Jeremy was. As I worked with Jeremy more closely over time as an administrator for the large research programs that he led, I became acutely aware of the kind of leader he was, beyond his scientific brilliance. He was someone who truly cared about and advocated for the faculty, staff, fellows and students he worked with.

Jeremy was an extraordinary colleague and friend to me, as he was to so many. He encouraged me in my own research interests; he gave me life advice; he pointed me in helpful directions when I or my family had medical concerns; he invited me for meals and parties; and I was fortunate enough to travel with him to scientific conferences. Jeremy was a wonderful role model in how he thought about science and the importance of teams and multi-disciplinary connections. He lived with passion and curiosity, and it was always a bright spot in my day when I met with Jeremy.  The world is a dimmer place without him. I know that all I do going forward in my career and life will be inspired by Jeremy and for that I am deeply grateful.”

Brian Buta, MHS, Project Administrator, Division of Geriatric Medicine and Gerontology Johns Hopkins University School of Medicine

“In 2015, I sent Jeremy Walston an email asking if he would be a mentor for my PhD. He replied the same day. Cheerful. Direct. He took my hesitation and replaced it with a quiet sense of belonging. I started showing up every week to the Frailty meetings. Over the years, we wrote papers together, many papers, then NIH grants. Every time I was rejected by the NIH, I turned to him for advice. In his office at Bayview, he would look at me calmly and say, “Try again, and again. You will get funded.” There was no drama in his voice. No performance. Just a man who had seen enough and mentored many. He asked about my family. He called me sometimes on weekends with clinical questions, curious about how cardiology might help us understand aging. With him, failure did not hurt as deeply. It felt like weather. Inconvenient, passing, and above all, expected.

When I passed my thesis defense, he sent a text: “Proud of you.” Three words that now live in my memory with disproportionate weight. From Jeremy I learned that persistence is not about hope. It is about repetition, habit, and accepting random outcomes without complaint. Now, when a junior colleague sends me a manuscript, I remember what he used to say. Be clear. Be useful. Get to the point. I try to answer as he did: without delay, without judgement, and always with care. I still expect to hear from him. That is the trick of death when someone lives that honestly and is dedicated to his work. Borrowing the words of a friend “he spent his time investing in and developing others”. The lessons continue. Write plainly. Try again. Invest in others. A good life, like a good sentence, carries meaning long after the speaker is gone. I will always remember Jeremy, a mentor, a friend, and a steady presence who made the world feel a little kinder, even in its most uncertain moments!”

Dr. Abdulla A. Damluji, Director & Professor, Cardiovascular Center on Aging 
Staff, Interventional Cardiologist, Cleveland Clinic

“I began working for Dr. Walston two years ago. What began as an incredibly nervous new venture for me, quickly became an amazing two years.  Never would I have imagined what an incredible opportunity I had been given.  I quickly learned what a truly kind, selfless, brilliant, funny, humble human being he was; always making me feeling seen, valued, accepted and supported.  I will forever cherish and continue to share my memories of Dr. Walston, and I only wish there could have been more.”

Melanie Davis-Langkam, Senior Administrative Coordinator, Johns Hopkins University Division of Geriatric Medicine and Gerontology

(Note: When Melanie sent the file for the lovely tribute above, it was saved as “WWJWD”—which stands for “What Would Jeremy Walston Do?” Melanie and another fan of Jeremy’s on staff actually made friendship bracelets with this acronym.)

“I first met Jeremy in 2015 while I was a PhD student at the Johns Hopkins School of Nursing. He quickly welcomed me into the Biology of Aging working group meetings, where he modeled a remarkable and enduring example of learned humility. In a space filled with complex, cutting-edge age-related biology, he asked both basic clarifying questions and highly sophisticated ones—showing me that no question is too simple, and that even the most brilliant minds benefit from clear explanations.

Jeremy had a rare gift for distilling complicated biological systems into simple, actionable and translational insights. He continued to invite me into his world of frailty and physical resilience, ultimately inspiring me to join the frailty working group—a community I now consider one of my academic homes. My dissertation came to include frailty measurement, and he went on to co-mentor my postdoctoral training and advise me through my K23 application. My research trajectory—and career as a whole—has been deeply shaped by Jeremy’s influence.

Beyond his mentorship and scientific brilliance, Jeremy was an exceptional human. We shared a love for Puerto Rico and Puerto Rican culture, and a deep commitment to building a more age-friendly, inclusive world—especially for those most marginalized in our society. His light shone brightly, and I can only hope to honor the legacy of mentorship and generosity he gave so freely.”

Dr. Melissa deCardi-Hladek, Center for Equity in Aging, Center on Aging & Health, Johns Hopkins University School of Nursing

“I will miss you, Jeremy. Fond memories of our discussions about growing up in the Midwest, being fathers to two adopted boys of comparable ages, dealing with health challenges, love of geriatrics and aging research, opportunities and rewards of academic leadership, and commitment to mentoring and training the next generation of investigators in aging through the Pepper Center program, Clin-STAR and other vehicles.”

Dr. Thomas Gill, Professor of Medicine (Geriatrics) and Professor of Epidemiology (Chronic Diseases) and Investigative Medicine, Yale School of Medicine

“I was often considered, proudly, as “Jeremy 2” in the Center on Aging & Health’s Frailty and Multisystem Dysregulation Working Group’s Zoom meetings. I’m so grateful to have met Dr. Walston. He inspired me as a researcher and simply as a kind human being. I rarely saw a time in which he wasn’t smiling. When he spoke to me, he spoke to me so kindly. Since I was in North Dakota, Dr. Walston often commiserated with me regarding the winters, since he spent some time in Minnesota. I could easily tell that he loved his work. His life inspires me all the more to continue the work. He will be greatly missed. And his life’s work will continue to be inspiring for aspiring researchers like me. Bless you and your family.”

Dr. Jeremy Holloway, Professor, New Mexico Highlands University

“I am deeply heartbroken to learn about the passing of Jeremy. It’s hard to put into words the sorrow I feel over losing such an extraordinary person.

I had the privilege of working with Jeremy from 2017 to 2020. He was not only one of the most inspiring and visionary leaders I’ve ever worked with in my career, but also one of the kindest human beings I’ve had the honor of knowing. His presence always brought a sense of calm, optimism, and purpose. I can still picture his warm smile and the uplifting energy he carried into every room.

One memory that remains vivid in my heart was during a Friday project meeting at the Bayview campus. Jeremy suddenly lit up with excitement as he started sharing his enthusiastic wish list for the software I was building. His passion was contagious. If I had a time machine, I would revisit that moment just to capture the joy and inspiration in his expression—a perfect reflection of the remarkable leader and human he was.

Jeremy touched many lives with his compassion, integrity, and vision. He will be missed more than words can express, but his legacy will live on in the hearts of everyone he inspired.

My deepest condolences to his loved ones, colleagues, and all who were lucky enough to know him.”

Fatih Karatay, MS, Machine Learning Engineer, Johns Hopkins University Applied Physics Laboratory

“Dr. Walston was always incredibly kind to me and went out of his way to involve me in meaningful work and opportunities. His compassion, humility, and overall attitude toward life have deeply inspired me. I will always cherish the encouragement and generosity he showed me, and I feel honored to have learned from him.”

Ramana Kolady, Host of the Fighting Frailty Podcast, and Medical Student, University of Rochester

“I feel fortunate to have worked for Jeremy for over a decade.  Our standing meetings were the highlight of my week and I fondly remember brainstorming sessions while Jeremy spelled out the plans on a white board.   I will be forever grateful that I was able to support Jeremy’s vision while working on many projects. More importantly, I am grateful for the friendship and support he offered me.  Jeremy was an amazing scientist and boss, and an even better human being.”

Jackie Langdon, MS, Senior Research Program Manager, Johns Hopkins University Division of Geriatric Medicine and Gerontology

“I first met Jeremy as a Hopkins geriatric fellow in 2012. During my fellowship, he was able to find the right balance between providing support for my research endeavors and pushing me to think beyond my usual way of doing things. He had an open-door policy and was always able to find time to meet with me, despite having clinical duties, numerous research grants and projects, plus administrative duties. During our meetings, I never felt rushed or dismissed because he truly listened and chose not to be distracted by e-mails or phone calls. If there was something he did not know the answer to (which was rare!), he was happy to direct me to the right person who could help.

He also embodied work-life balance, leading by example. I was continually amazed that with his busy work schedule, he was always able to find time to attend his children’s school or sporting events. He would often host dinners for our research group, doing much of the cooking himself!

Jeremy has been one of the most “successful” clinician-research mentors I have ever had, with multiple awards, continuous NIH funding, and international acclaim. Despite this, he is also one of the most down-to-earth mentors I have ever had. He has always been willing to share his experiences not only in research but in day-to-day life (usually while enjoying some tasty food!). He has taught me not only the good but also the tough aspects of research and the importance of perseverance. I am forever grateful for his guidance and will strive to continue his legacy.”

Dr. Jessica Lee, Associate Professor, Carmel Bitondo Dyer, MD, Chair in Geriatric and Palliative Medicine, Medical Director, Harris Health LBJ House Call Service

“Like he was to numerous others at Hopkins and around the world, Jeremy was an extraordinary mentor and friend to me. He was the one who recruited me to Hopkins as a geriatrics fellow. I vividly remember that he came to my poster presentation at the 1999 Gerontological Society of America (GSA) annual meeting with an in-depth scientific discussion and convinced me to come back to Hopkins for a second visit after my initial fellowship interview prior to the GSA conference, and the rest is history. After the two-year fellowship training with him with my research conducted in his lab, Jeremy was the one who convinced me to stay on the faculty. He has subsequently provided tremendous mentorship and support for me to set up my own research lab and programs. Jeremy also convinced me to stay despite recruitment effort from other institutions, supported our international geriatrics development efforts towards China and philanthropic work with Milstein family, as well as facilitated the establishment of the Johns Hopkins Center on Aging and Immune Remodeling. In short, my entire 25+-year career at Hopkins owes to Jeremy’s tireless mentorship and support.

Jeremy was also a very close friend of mine. I remember numerous holiday parties and other gatherings in his house. He is an excellent cook. Our friendship goes to our kids. Oliver and Alex played Ping-Pong (table tennis) with my son Evan in his basement many times. Evan and I visited Jeremy after he had surgery and discharged home. I visited Jeremy at Gilchrest for the last time. I went to see him after work on Monday, and he was by himself in the room quietly and comfortably. He knew it was me and squeezed my hand with a smile on his face. While I was there, his friend Connie called him on my cell phone, and Jeremy smiled. Meanwhile, my eyes filled with tears for the entire time. These moments will stay with me for the rest of my life. Evan planned to visit Jeremy the following Saturday. But unfortunately, Jeremy passed away the following day.…  Jeremy will be remembered by me and my family forever!”

Dr. Sean Leng, Professor, Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Division of Geriatric Medicine and Gerontology

“I join my colleagues and scientists around the world in acknowledging Jeremy Walston’s enormous contributions to the field of aging, the study of frailty, and the lives of clinicians, researchers, and patients who will all benefit from his cutting-edge and impactful work. He will be greatly missed, but the foundational discoveries he made and the people he inspired will live on and grow, leaving an enduring positive impact on the health and well-being of many generations to come.”

Dr. Lewis A. Lipsitz, Professor of Medicine, Harvard Medical School

“Some of my memories from AGS meetings as a fellow were to hear career development and mentoring talks by Jeremy Walston – often with his mentors and colleagues from Johns Hopkins. His career trajectory, research ideas and difference that he was making was enviable.  He continued to be a close colleague and friend since then, exchanging research ideas and trends in the field.  Besides being a fan of his work over many years, we recently served together on a Pepper Center EAB and went together to an in-person meeting.  He usually likes to rent a car and gave me a ride to the airport. We drove by the countryside and had some really nice thoughtful conversations about life, family, pandemic recovery, and aging research. It seemed like we connected at a very different level. Looking back, I feel that he must have known about his illness at that time although he did not reveal to me.  I am just so thankful to have known him – my life is richer as a result. 

May his soul rest in peace – his memories are truly a blessing to me.”

Dr. Lona Mody, Professor of Internal Medicine and Epidemiology. University of Michigan, School of Public Health

“Jeremy struck me as an incredibly brilliant, open-minded, generous, and passionate scientist. I will always be grateful to him for inviting my team to participate in the weekly frailty seminars and working groups. He did not even know me and he was that open! If all people—and especially our world leaders—shared Jeremy’s generosity in sharing knowledge, his care for others, and his ability to build communities of collaboration, this world would undoubtedly be a more wonderful place. I am committed to following his example.”

 Dr. Blanca Restrepo, Professor of Epidemiology, University of Texas Health Houston, School of Public Health

“I met Dr. Walston through my work with the Center on Innovative Medicine (CIM) at Bayview starting in 2018. At the time, he and Drs. Hellmann and Abadir were bringing people together around the idea of creating the Hopkins Human Aging Project. That venture was the focus of a CIM retreat at which Jeremy pitched it; his presentation was nothing short of inspirational, visionary, and genius. Jeremy’s sincere commitment to bringing together the great minds and resources at Johns Hopkins as stakeholders to improve health outcomes for older adults permeated the room. Through brilliantly creative innovation that interwove research, education, technology, and patient care, Jeremy saw the potential of connecting the multidisciplinary dots and resources in the region to map out a new landscape for a healthier, longer lifespan.

When I started working more closely with Jeremy through the Johns Hopkins Frailty Science team in 2020, regular program meetings allowed me to learn more about him as a person. Jeremy had a warm, engaging, friendly, and unassuming disposition. In casual conversation, he would mention his spouse and children—whom he adored—and Jeremy shared memories about growing up on the farm in Ohio. One time, he mentioned wrestling pigs. I laughed and asked him how on Earth he went from that to medicine.

Jeremy told me about Lucille Atcherson Curtis, an older lady whom he would help with chores around the house when he returned home from college—raking leaves or putting air conditioning units in the windows, etc.  Jeremy truly liked and admired her.  Mrs. Curtis was a trailblazer—a suffragist and the first female U.S. Foreign Service Officer.  During World War I, Mrs. Curtis drove an ambulance in Paris, France. When she retired, she drove a baby blue Ford Mustang. Over time, Jeremy observed that her health was deteriorating, and that medicine at the time was not helping her age well. By contrast, Jeremy came from a family where good health and longevity were normal, and this difference in health trajectories challenged him to understand and unlock the mechanisms of aging. I believe this story about how one of Jeremy’s early heroes inspired a career in medicine reveals a genuine sense of caring, deep compassion, and steadfast dedication—all of which Jeremy applied to academic medical research and patient care for the rest of his life.

At his core, Jeremy was a kind-hearted humanitarian and a gifted scientist who made a significant, lasting difference in his field.  I am grateful to have known Jeremy and to have supported his amazing work. Like many, I will miss his sparkling eyes, big bright smile, and warm laugh—and his keen mind that was always observing, thinking, and seeing possibilities. Knowing that he mentored the next generation of aging researchers at Johns Hopkins and beyond, combined with his success at creating ambitious yet practical and pragmatic projects, gives me hope that his dream of advancing medicine to extend healthier lifespans will be attainable.”

Anthony L. Teano, MLA, Communications Specialist, Johns Hopkins University School of Medicine, Department of Neurology

We also want to share the following reflection written by Dr. Peter Abadir: Jeremy D. Walston, MD (1961–2025): The Road He Took Made All the Difference (published in the Journal of the American Geriatrics Society).

Thank you for joining us in honoring Jeremy.

Remembering Jeremy D. Walston, MD (April 7, 1961—June 10, 2025): Part One

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The Frailty Science Team profoundly mourns the passing of Dr. Jeremy D. Walston on June 10, 2025. He was 64 years old. Jeremy was an internationally renowned scientist who directed numerous healthy aging research programs at Johns Hopkins; our Frailty Science team was fortunate enough to be one of them. His contributions to the science of frailty and resilience provided critical insights and advancements to frailty assessment, aging-related biology, and clinical translation. He was a gifted program leader who fostered interdisciplinary collaborations and championed early career faculty and students as the next generation of research leaders. In short, he was an outstanding researcher, doctor, mentor, colleague, and friend. We will miss him dearly. We send our deepest condolences to his family. You can read more about his remarkable career and life in recent posts from Johns Hopkins leaders and beyond: Message from Dean DeWeese and President Sowers; Obituary; Baltimore Sun article (2025) ; Baltimore Banner article (2025).

Jeremy is survived by: his spouse Mr. George Lavdas of Baltimore, as well as two sons, Oliver Walston-Lavdas, of Baltimore and Alexander Walston-Lavdas (Willow Washington), of Cocoa, Florida; a sister, Wendy Walston Vaughn (Alan Vaughn), of Pemberville, Ohio; a step-mother, Ellen Walston, of Pemberville; two step-brothers, Brent Sandberg (Kelly), of Perrysburg, Ohio and Justin Sandberg (Melissa), of Pemberville. Jeremy was laid to rest in his hometown, Pemberville, Ohio on June 20th.

Here we are honored to share a handful of personal remembrances and loving vignettes from his colleagues that speak to Jeremy’s vision, dedication, innovation, brilliance, kindness, humanity, warmth, and hope in medicine to improve the lives and health span of older adults.

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“Jeremy was a founding force behind the Biology of Healthy Aging group at Johns Hopkins, and a pioneer in the field of aging biology. His vision, mentorship, and scientific rigor shaped the core of our work and the direction of our field.  As we grieve this tremendous loss, we also take time to celebrate Jeremy’s lasting impact. His commitment to advancing biological discovery, fostering collaboration, and mentoring the next generation of scientists will remain central to our mission.  Let us honor Jeremy’s legacy by continuing to push the boundaries of aging biology, welcoming new members into our research projects, and preserving the collaborative spirit that he championed. We have important work ahead, and we carry it forward, inspired by all that Jeremy built and believed in.”

–Dr. Peter Abadir, Associate Professor of Medicine; Co-Director, Johns Hopkins Older Americans Independence Center

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“Jeremy was extraordinary. He’s well known for being thoroughly gracious, generous, and kind. He shone as a mentor. Sometimes lost in the accolades over his sterling character is that he was a prodigious scholar: His contributions include identifying roles of mitochondrial dysfunction, angiotensin and kynurenine biology, and pro-inflammation underlying frailty, delineating frailty as both a marker and a target for clinical intervention and practice, advancing understanding of implications of stress-response physiology in both frailty and resilience, and delineating opportunities to better older adult health through technology and by addressing psychosocial factors. He was an exceptional program builder, attracting dozens if not hundreds of scholars from a wide array of disciplines to research on older adults.  Above all, Jeremy was one of the best human beings I’ve had the privilege to know. He not only accomplished greatly, and fostered others’ accomplishment—he elevated the lives of everyone with whom he interacted by so doing. My life has been enormously enriched by knowing him.”

–Dr. Karen Bandeen-Roche, Professor of Biostatistics; Co-Director, Johns Hopkins Older Americans Independence Center

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“Jeremy was not only an exceptional scientist and mentor, he was also a pioneer in the field of aging biology and frailty, and a kind and beloved friend to many in our community and beyond. We will never forget his many contributions to our work and our lives, from his time as a valued member of our Division of Geriatric Medicine and Gerontology to his development and leadership of many aging and mentoring scientific programs at Hopkins and nationally.  Here at Hopkins, to name just a few, Jeremy co-directed the Older American Independence Center and the Artificial Intelligence and Technology Collaboratory, and created and led the Human Aging Project. Jeremy also helped build the Clin-Star network, building the field of aging research across the country. Jeremy loved his work and the communities that work built, and he made everything he touched better, as a geriatrician, a professor, a mentor, a researcher, and a friend. We will miss him deeply.”

–Dr. Cynthia Boyd, Professor of Medicine and Division Director, Geriatric Medicine and Gerontology

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“Jeremy was an internationally renowned clinician-scientist in geriatrics. For the last six years, the Center for Innovative Medicine (CIM) has enthusiastically supported Jeremy’s pursuit of the Human Aging Project (HAP), created to more fully understand, delay and prevent the health consequences of aging.  With Jeremy’s leadership and with CIM support, the HAP has become one of the most successful multidisciplinary projects at Johns Hopkins, involving faculty in the Hopkins’ Schools of Medicine, Public Health, Nursing, Engineering, and Business.  The HAP has grown into a $60 million enterprise that funds major initiatives in basic science, clinical research, and artificial intelligence aimed at preserving robust health while aging.  The cohesiveness of the HAP speaks volumes not only to Jeremy’s scientific excellence but also to his many admirable personal qualities.  Because of his humility, generosity of spirit, and impish sense of humor, Jeremy became a treasured friend to us and to so many others. We will miss him terribly.  Each year that I was chairman of the Department, I tried to convey to every new class of interns that Medicine is a jewel; I extended the metaphor to claim it is the joyful and sacred obligation of each person who joins Johns Hopkins to learn how to use a ‘jeweler’s cloth’ and dedicate themselves to adding luster to the gem.  Jeremy’s many distinguished accomplishments have burnished the Johns Hopkins Medical jewel in a spectacular, everlasting, fashion.  We deeply mourn his loss while we celebrate his remarkable work, his legacy and, most of all, his friendship.”

–Dr. David Hellmann, Aliki Perroti Professor of Medicine and Director, Johns Hopkins Center for Innovative Medicine

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“I remember Jeremy sitting down with me to review my manuscripts and grant applications. Line-by-line, with a red pen, he would cut down and simplify my message. Each time, there was the same lesson – focus, in the clearest possible language, on how this research will help improve the lives of older adults. Working with him for seven years, I believe he applied this singular principle at every scale of his work, from drafting the abstract to a first-year geriatrics fellow’s research poster to building entire research programs. I am grateful for my time learning from Jeremy and I know the research community he has built will continue the work to realize his vision.”

–Dr. Thomas Laskow, Assistant Professor of Medicine

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Jeremy Walston was an amazing mentor to fellows and junior faculty. He was a role model for asking curious questions in research, demonstrating how collaborative science can lead to groundbreaking discoveries, and boosting the careers of junior faculty by providing them with career building opportunities. In addition to all of the great work Jeremy did at our institution, nationally, and internationally, he remained approachable and was so present and focused when he met with us during regular mentorship meetings. He would always ask what we needed for our lab projects, our grants, and our overall career development, and would be the first to step up to help find ways to get these resources. Now with mentees of my own, I strive to embody even a few of Jeremy’s qualities to help others experience the constant support, the encouragement during tough times, and to celebrate the successes. Thank you so much, Jeremy.

–Dr. Lolita Nidadavolu, Assistant Professor of Medicine

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I had the honor of knowing Jeremy for almost 20 years as a mentor, colleague, and friend. His kindness and sincerity made everyone he worked with feel valued and critical to his research mission of improving the lives of older adults. He motivated people to go above and beyond the bounds of typical research by providing insights from his personal experiences with the older adults in his life. This commitment left a lasting impact on those who were lucky enough to work with him. As a fellow gardener, I enjoyed his stories about growing up on a farm in Ohio (and he taught me why store-bought tomatoes don’t taste the same as home-grown). His passing leaves a huge hole at JHU and beyond. We will miss him greatly, and his legacy will long be remembered.

–Dr. Jennifer Schrack, Professor of Epidemiology and Director, Johns Hopkins Center on Aging and Health

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Part Two of this tribute series will be published in the coming weeks with information on Jeremy’s memorial service in Baltimore, which is scheduled to be held on September 9 from 3-5pm in the Atrium of the Johns Hopkins Asthma and Allergy Center. The next post will also include more recollections and stories about him. If you would like to submit a brief personal story or recollection about Jeremy, please email tony.teano@jhu.edu by July 31.  Meanwhile, the following links further chronicle Jeremy’s research vision and achievements:

Next Innovative Design, Testing, and Implementation of Frailty Interventions Seminar, June 11 at 9am ET

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The next session of the Seminar Series, Innovative Design, Testing, and Implementation of Frailty Interventions will take place on Wednesday June 11 from 9-10am on Zoom. 

Our June 11th seminar will feature a presentation by Jordan Gunning, PhD, College of Health Solutions at Arizona State University, on “Optimizing healthy aging with personalized lifestyle interventions.”  We hope you can attend this exciting talk!

This series, created by Drs. Xue and Gearhart and sponsored by the Johns Hopkins Older Americans Independence Center, aims to bring together leading experts from around the globe to share insights and advances in frailty intervention and related research and implementation methodologies within clinical and public health settings.

Meeting link: Zoom (https://tinyurl.com/5n8wbfev)

Contact bbuta@jhu.edu

Frailty Science Logos

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The Pulmonary System, Frailty & COVID-19: Q&A’s with Dr. Panagis Galiatsatos

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Tony L. Teano, MLA

Tony L. Teano, MLA

Communications Specialist
Johns Hopkins University School of Medicine

 

Getty Image: Coronavirus and LungsExciting news!

Our website has a new clinical section on Pulmonary Function and Frailty. As the field of Frailty Science is relatively young, research in specific specialties may be scarce—and this is true of the associations between the respiratory system and frailty.

Consequently, we asked one of Johns Hopkins’ top experts in the Division of Pulmonary and Critical Care Medicine to review literature in this space, and compose this new section; we are grateful to Dr. Panagis Galiatsatos, an Assistant Professor in Pulmonary and Critical Care Medicine, for taking up this challenge.

Among other things, Dr. Galiatsatos also serves in the Post-COVID-19 Clinic. So we asked him a few general but important quick questions pertaining to COVID:

What have you noticed with frailty and COVID?

  • “Persons already experiencing frailty have a worse prognosis with COVID.  Long COVID appears to have very similar features to frailty.”

What do geriatricians need to be aware of?

  • “Geriatricians should be aware that the strategy should be 100% to avoid getting COVID.  Vaccines are fine to prevent severe disease, but the focus should be on not catching it.”

What are the top three COVID concerns everyone should know?

  • “(1) Do what you can to not catch this virus, as long-term impact is still unknown.
  • (2) Stay up-to- date with one’s vaccine status, as immunity likely will continue playing a role in mitigating immediate and potential long-term effects.
  • (3) Continue maintaining well any other pre-existing conditions you may have, as COVID tends to cause them to worsen.”

Additionally, here are key takeaways from our new website content on the pulmonary system and frailty, which Dr. Galiatsatos drafted:

  • Around the age of about 35 years, lung function starts to decline as evidenced by physiological factors, such as decreased elasticity and surface area for gas exchange and weakened breathing muscles.
  •  There could be a link between naturally decreased lung reserve capacity and exhaustion in activities of daily living such as walking, and slower gait speed is associated with frailty.
  • Toxic environmental exposures, such as poor air quality or smoking habits, compound any simultaneous decline in the immune system as we age, accelerating a propensity toward frailty because inflammation is more likely to occur.
  • Regarding patients with Chronic Obstructive Pulmonary Disease (COPD): COPD patients who were not clinically frail or pre-frail at baseline had a significantly increased likelihood to meet criteria for frailty in follow up (nearly 3 times as likely). COPD patients who were already frail and pre-frail at baseline had a significantly increased likelihood of death in follow up (nearly 3 time as likely).

You may be interested in Dr. Galiatsatos’ recent interviews about COVID-19:

Finally, did you know that Dr. Galiatsatos hosts weekly “COVID Community Updates”?  To find out more information and their schedule to see if you can particpate, email: mgg@jhmi.edu.

To stay up-to-date on Dr. Galiatsatos’ advice about COVID-19 and pulmonary health, follow him on Twitter @panagis21

Advances in wound care: valsartan nanofilament hydrogel promotes wound healing in a diabetic animal model

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Lolita Nidadavolu, MD, PhD

Lolita Nidadavolu, MD, PhD

Assistant Professor of Geriatric Medicine
Johns Hopkins University School of Medicine

Beyond the substantial financial costs associated with chronic wounds (estimated to be between $28-96 billion dollars in Medicare costs in 2018; Nussbaum et al., 2018), the subsequent chronic inflammation and disability arising from such wounds are significant exacerbating factors that limit health-span in older adults. A recent study from a multidisciplinary wound center demonstrated that frailty prevalence, using the deficit accumulation model, was approximately 75% among their patients and wound healing rate was slower in frail individuals (Espaulella-Ferrer et al., 2021). Wound center clinic visits to manage chronic wounds outside of the hospital setting can also be burdensome given the need for transportation and frequency of visits. Older adults may also have difficulty in mobility or vision impairment that can make home wound care challenging. There remains a great need for novel wound care products that can both expedite healing time and that do not require a complex regimen.

Our study, published in the November/December issue of Wound Repair aValsartan Diabetic Rat Model Imagend Regeneration, seeks to address these concerns (Nidadavolu et al., 2021). Previous work from our group showed that the commonly used blood pressure drug valsartan, which is an inhibitor of the renin-angiotensin system, can significantly increase wound healing in a diabetic pig model when reformulated into a topical cream and applied daily (Abadir et al., 2018). Using nanotechnology, our team has developed valsartan nanofilaments – in other words, nanoscale thread-like structures of valsartan — that self-assemble into a hydrogel. This biodegradable hydrogel allows for long-term and localized release of valsartan directly into the wound bed.

We have tested wound healing with our valsartan nanofilaments in diabetic rat wounds, another frequently used animal model of wound healing. The diabetic rats treated with valsartan nanofilaments demonstrated significantly faster wound healing compared to the placebo group and we observed beneficial changes in critical wound healing-associated cell signaling pathways and mitochondrial energy utilization as illustrated in the figure. This work is an important first step in demonstrating the clinical efficacy of a valsartan hydrogel for faster, more efficient treatment of diabetic wounds. As we prepare for clinical trials, we are excited by the possibilities of using nanotechnology-based drug delivery to improve physical function in frail adults with chronic wounds. Additionally, future studies can examine if pre-treatment of areas at high risk of skin breakdown with valsartan nanofilament hydrogel can prevent the development of diabetic-related wounds in frail adults.

Dr. Judy Kasper: A Remembrance

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Frailty Science Team

Frailty Science Team

 

The sudden passing of Dr. Judy Kasper, a prominent expert in the study of disability in later life and its implications for older adults, their loved ones, and health care policies, struck all who knew her with feelings of sadness and shock.  To celebrate Dr. Kasper as both a stellar scientist and a wonderful colleague and friend, we asked some of her collaborators to reflect on their work with her and the impact she had on their careers and lives.  We have also summarized Dr. Kasper’s important role in facilitating frailty research in the National Health and Aging Trends Study.

 

Dr. Judy Kasper at the Baltimore Museum of Art

<em><strong>Dr. Judy Kasper at the Baltimore Museum of Art</strong></em>

 

Tributes to Dr. Kasper

 

I met Judy in 1992 when she took over as co-PI for the Women’s Health and Aging Study (WHAS). I was at the beginning of my career and the only other social scientist in the research group. Ten years my senior, Judy (unbeknownst to her I suspect) quickly became a role model for me in how to successfully navigate the medical research environment and keep personhood, social structure and environment on the table. Judy was my sounding board and reality check. Two of my earliest first-authored papers were executed under Judy’s support and guidance. Social scientists think differently, I won’t say better, but work touched by Judy was and is indeed better. Judy was creative and accomplished – for example, co-writing much of the WHAS “purple book” monograph and expanding the WHAS footprint by establishing the Caregiving Study focused on the care receivers, a novelty at the time. Our collegial relationship continued well beyond the active collaborations, developing into a cherished friendship. I will forever miss our annual extended lunches and summer gourmet potluck dinners at the Bolton Hill Tennis and Swim Club, where all the people and surroundings would fade into the background as we caught up on our academic lives and the life events and accomplishments of our children.

 

                    — Eleanor Simonsick, PhD, Intramural Research Program, National Institute on Aging

 

 

Like Eleanor, I met Judy in 1992 as a fellow member of the WHAS team. I have been privileged to collaborate with her ever since, including in WHAS but also extending to the National Health and Aging Trends Study (NHATS) and National Study of Caregiving (NSOC). We were finalizing an NSOC paper when Judy passed away so sadly and far too soon last summer.

 

Judy’s advancement of scholarship on disability, long-term and end-of-life care, and caregiving was truly monumental. Her leadership of the NHATS and NSOC leaves a particularly enduring legacy of this. Anyone visiting the websites for these studies will quickly see: These studies achieve the highest standard of rigorous design and implementation, thorough documentation, and effectiveness of data sharing. They will advance science—and commensurately, health and functioning of older adults and their caregivers—for years to come. In her own work Judy was the model of a public health scientist—her research thoughtfully grounded in theory as befits the social scientist she was, but always addressing matters of practical import for both individuals and populations. It addressed the identification and forestallment of disability before it becomes severely disabling, documented the caregiver experience so that policies to maximize their efforts may be developed, and identified disparities and other major factors determining access to health services. I’ll remember Judy, most of all, as an ideal colleague—one unblinking in her appraisal of a work’s scientific method and practical import but also fiercely and generously supportive of her trainees, ready with a laugh, and open to ideas contrasting with her own. She provided me with a role model of female leadership that was strong but also comfortable in one’s skin: This affected me more than she likely knew. I dearly miss her.

 

                     — Karen Bandeen-Roche, PhD, Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health

 

 

I had the tremendous fortune to meet Judy in 1999 as 1st year doctoral student during a “meet and greet” doctoral seminar at which she talked about her career and research in aging and disability. Judy was involved at that time in a variety of survey-based projects, including a Commonwealth-Fund supported survey to understand the experiences of older adults with disabilities living in 6 states who were dually enrolled in both Medicare and Medicaid.  She was also wrapping up her work in co-leading the Women’s Health and Aging Study and its ancillary survey of family and other unpaid caregivers. 

 

Hearing Judy talk about her work was transformative for me. I had up to that point only worked with administrative claims data and the business side of health care. Judy’s talk revealed for me the importance of understanding what matters to people in their experience of health care. In particular I was struck by the need to understand the impact of living with disability as well as the consequences of disability and care delivery for their family members. Judy revealed the power of survey-based research as a way to understand individuals’ lived experiences. Hearing about Judy’s work led me to switch directions and she became my dissertation advisor. Judy’s commitment to strong social science and survey methods and her respect for the research process influenced my decision to pursue a career in academics. We went on to be close collaborators on a host of NIH and foundation-funded initiatives and over time in jointly mentoring doctoral students and junior investigators. Losing Judy has been tremendously difficult not only because of our strong collaboration and her professional mentorship but her friendship and wisdom. Her legacy will live on through the strength of the National Health and Aging Trends platform and her numerous mentees who are leading research, policy, and practice initiatives in aging and disability.

 

                    — Jennifer Wolff, PhD, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health

 

 

I first encountered Judy when I was a doctoral student at the Johns Hopkins Bloomberg School of Public health over a decade ago. She gave a talk at the Center on Aging and Health on her plans for NHATS, specifically its design and development. As someone who was studying late life mobility as a contributing factor to disability, I was very interested in, and motivated by, her talk. Several years later after I returned to JHSPH as faculty, Judy approached me about implementing objective physical activity assessment (accelerometry) into NHATS to better understand how physical activity contributes to the disablement process. I was honored and excited to become an NHATS co-investigator and contribute to its mission of improving life for older adults. Throughout the design and implementation process, I enjoyed working with Judy and learned a lot from her mentorship. She was intelligent, kind, and fun and becoming Co-PI of NHATS and Judy’s colleague has been a highlight in my career. Taking over for Judy has been bittersweet, but I am committed to continuing her vision for NHATS, and to looking for ways to expand and advance our understanding of disability in late life.

 

                    — Jennifer Schrack, PhD, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health

 

 

A Brief Summary of Dr. Kasper’s Impact on Frailty Research

 

Among the many accomplishments in her renowned scientific career, Dr. Kasper served as Principal Investigator for both the National Health and Aging Trends Study (NHATS) and the National Study of Caregiving (NSOC). Over the past decade, hundreds of publications have resulted from the comprehensive and rigorously collected data in these studies. Led by Dr. Karen Bandeen-Roche, members of our Frailty Science team had the privilege to closely collaborate with Dr. Kasper to operationalize a measure of physical frailty in NHATS. This work led to the highly cited paper, “Frailty in Older Adults: A Nationally Representative Profile in the United States”, published in the Journal of Gerontology: Medical Sciences in 2015; Dr. Kasper was the senior author. This publication established a nationally representative prevalence for physical frailty in the US and also highlighted the notable race and income disparities, and regional differences, in frailty prevalence among the older non-nursing home population.  It also laid the ground work for numerous frailty-related studies that have followed in recent years, including research on the associations of frailty and mortality, cognitive impairment, psychosocial factors, and health disparities, among others. A full list of publications to date is available on the NHATS website using the keyword, Frailty: https://www.nhats.org/publications/search.  We are deeply grateful for our partnership with Dr. Kasper, for her scientific excellence and collegiality, and for the legacy of research on frailty and aging that endures from her vision and leadership.

 

Virtual Event: Honoring the Life & Legacy of Judy Kasper

 

The Johns Hopkins Bloomberg School of Public Health will hold a virtual event to honor the life and legacy of Dr. Kasper on Tuesday, January 18, 2022 from 12-1pm ET; details here.

 

Family Caregiving: An Essential Resource for Older Adults

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David L. Roth, PhD

David L. Roth, PhD

Core Faculty, Center on Aging and Health
Professor of Geriatric Medicine

It is estimated that somewhere between 18 million (Schulz & Eden, 2016) and 53 million (AARP, 2020) Americans provide care to an older adult with a disability who needs some type of help with basic living needs.  This care can include help with grooming, bathing, or dressing; assistance with mobility or preparing meals, or help with managing finances or medical appointments.  Most older adults with dementia, limited physical capabilities, or major sensory problems depend on family members or close friends for this kind help on a regular basis.

Substantial research over the past 30+ years has examined the health and well-being of family caregivers.  Many of these studies have been inspired by a stress process model of caregiving (Pearlin et al., 1990), which emphasizes that caregiving can lead to both primary stressors that are directly associated with care delivery and secondary stressors that are indirect consequences of caregiving, such as reduced opportunities for leisure activities.  This model is frequently invoked as part of an advisory narrative – that the stress of caregiving can be substantial and can lead to health problems for the caregivers (Pinquart & Sörensen, 2003).

More recently, however, researchers have countered this stress process narrative with alternative perspectives that emphasize the potential health benefits of prosocial helping behaviors.  Research on volunteerism and social support has shown that people who help others are generally healthier themselves (Brown and Brown, 2015; Okun et al., 2013), remaining more active in their lives and finding purpose in the positive influences they have on others.  Perhaps caregiving can also have this beneficial effect, much like volunteering within one’s own family or social circle.

These competing narratives may both be true to some extent.  Most caregivers do report positive benefits associated with their caregiving experiences (Roth et al., 2015), but a small minority of caregivers also find the stress of caregiving to be quite high.  A prominent early study concluded that the stress of caregiving may even be associated with higher mortality rates for caregivers (Schulz and Beach, 1999), but at least eight subsequent studies, with larger samples and longer follow-up periods, have found just the opposite pattern — that caregivers live longer or have lower mortality rates than several non-caregiving comparison samples (Roth et al., 2015; Mehri et al., 2021).  In one follow-up study, caregivers were found to have higher rates of depressive symptoms than non-caregivers, but lived longer anyway (Roth et al., 2018), suggesting the caregivers benefitted from a resilience to stress due to their prosocial helping activities, similar to resilience benefits of older adults who are active in volunteer organizations.

Caregiving, therefore, can be stressful, but that stress is usually not dangerous or leading to life-threatening illnesses.  Caregiving, like parenting, is a normal and usually healthy relationship within families – sometimes stressful, but more often rewarding and fulfilling, and something that should be encouraged.  More evidence is needed to understand how frailty might impact caregiving burden (Ringer et al., 2017), but even for highly vulnerable “frail” persons, the benefits of providing support may likely outweigh any detrimental effects.

The real threat to the caregiving resource for older adults in the years to come is a looming shortage in number of traditional family caregivers.  In the past, older adults have typically depended on spouses or adult children for this type of care, but, because marriage rates and birth rates have steadily declined over the past several decades, there are now fewer spouses and fewer adult children available to take on these roles.  Caregiving networks, organized through faith-based groups and other community organizations, may be part of the solution.  We should all start looking around for family members and friends whom we can help, even if they might be outside of our own traditional nuclear families.  If anything, the research convincingly shows that this type of helping behavior is not only good for those who are receiving care, but also for the helper as well.    

Intergenerational African American Family

The Geriatric Surgery Program at Johns Hopkins

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Susan Gearhart, MD

Susan Gearhart, MD

Associate Professor of Surgery
Johns Hopkins University School of Medicine

Johns Hopkins Bayview Medical Center (JHBMC) annually performs surgical procedures on more than 600 patients over the age of 65, with nearly one-third of these patients identified as frail and at high-risk for adverse outcomes.  It is currently the goal of JHBMC to be the national leader in discovering how to bring our older patients through surgery safely, preserve quality of life, and return them to their loved ones as soon as possible.

The first step in mitigating the impact of frailty on surgical outcomes is being able to recognize who is vulnerable. JHBMC has been a leader in the affirmation and implementation of best practice guidelines put forth by the American College of Surgeons and the American Geriatric Society for the care of the older surgical patient. JHBMC participated in a national survey to examine what resources were most needed for the care of the older frail surgical patient. In addition, JHBMC along with seven other institutions was asked to examine best methods for implementation of a Geriatric Surgery Care Pathway that incorporates the best practices outlined by these societies. This project included setting both national standards and individual pathways for the perioperative care of the vulnerable older adult patient and ultimately, designating hospitals that participate in these pathways as “Centers of Excellence.”

Effective care pathways are not new to the care of surgical patients at JHBMC. In 2015, JHBMC implemented an Enhanced Recovery Pathway (ERP) for patients undergoing major abdominal surgery.  Surgical outcomes for major abdominal procedures following the implementation of our ERP have resulted in a significant reduction in length of stay (2 days), a 50% reduction in hospital-acquired complication, and a 9% increase in patient satisfaction following major abdominal procedures (Sateri et al., 2017).  In 2018, JHBMC implemented a multidisciplinary, hospital-wide, Geriatric Surgery Pathway, and Figure 1 below is a schematic of our pathway.  We recently examined our outcomes from the past 3 years following implementation.  We have seen a significant (over 70%) reduction in discharge to skilled nursing facilities following surgery and a 30% reduction in postoperative complications (Mostales et al., 2021; see page S205).

The following short video provides an overview of the surgical care experience at JHBMC.

Dr Sally Gearhart in Bayview Geriatric Med Vid

(Click on the image to view the video.)

To learn more about surgery in frail older patients, please see the Clinical Topics section on Surgery and Frailty.

Announcement: Frailty Science 2.0–Website Update

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Tony L. Teano, MLA

Tony L. Teano, MLA

Communications Specialist
Johns Hopkins University School of Medicine

As you may have noticed, our website has a fabulous new look and feel, as well as several new, interesting features! 

 

  • The Johns Hopkins Fighting Frailty Podcast: Intended for patients, caregivers, physicians, researchers, and the interested public alike, this new series explores areas of frailty science research and practice.  The first podcast features Dr. Jeremy Walston, who gives an overview of the biological and physiological aspects of frail, vulnerable persons—including the age-related biology, cellular changes and inflammatory pathways, glucose metabolism and mitochondrial dysregulation, as well as weakened stress response systems.   Dr. Walston addresses a broad range of questions from a basic definition of frailty to the consequences of COVID-19.  For instance, Dr. Walston explains how grip strength, unintentional weight loss, walking speed, low activity, and fatigue assessment can combine in an aggregate measure of pre-frailty and frailty.  Beyond that, Dr. Walston suggests how physical activity and a high-quality protein diet can slow the progress towards frailty, and maintain robustness. He also mentions scientific research on the horizon that may help fight frailty on the cellular level.  The podcast’s next installment features Dr. Melissa Hladek, who discusses self-efficacy and frailty. Student/volunteer with Frailty Science, Mr. Ramana Kolady, hosts the series. You can listen here.   

 

  • The Sheldon Gottlieb, MD, Photography Gallery:  There’s more to  Sheldon Gottlieb, MD, than meets the eye.  Known for his compassion as a cardiologist with a special interest in caring for those living with diabetes and heart failure, Dr. Gottlieb has provided excellent care for Johns Hopkins’ patients for more than 30 years.  He truly enjoys getting to know patients and their stories, and he treasures them.  One of the ways he has captured his appreciation for people who entrust him with their care is to see them not only through the lens of a watchful physician, but also through the camera’s lens as an excellent amateur photographer.  For those of you who have visited the third floor of the Mason F. Lord Building at the Johns Hopkins Bayview Medical Campus, you may have noticed an exhibit with his images: “An Appreciation of Caring” features roughly a dozen images in both inpatient and outpatient settings, collectively revealing the depth of the doctor/patient relationship.  Dr. Gottlieb plans to publish an art photography book one day; until then, we are pleased and grateful that he has allowed us to feature a sampling of his remarkable images on our website for your enjoyment and reflective contemplation.  Visit the gallery here. 

 

  • Curated Searchable Library:  As you may know, the field of Frailty Science is relatively young, emerging only a few decades ago. In an effort to promote sentinel publications and studies on the subject, we have compiled a well-curated searchable Frailty Research Library.  Explore the science here.  

 

Moreover, returning visitors to our website will see a wonderful new homepage that is easy to navigate.  It succinctly promotes the latest content: featured clinical topics; a research spotlight; the latest blog topic; the Fighting Frailty podcast; the Gottlieb gallery; and our Twitter feed.  The user-friendly “Frailty Science 2.0” website is a significant upgrade.  Please tell us what you think and what you’d like to see more of! 

Self-Efficacy as a Tool for Older Adults to Cope with Coronavirus

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Melissa deCardi Hladek, PhD, CRNP, FNP-BC

Melissa deCardi Hladek, PhD, CRNP, FNP-BC

Assistant Professor, Department of Nursing Faculty Johns Hopkins School of Nursing

JS is a 72 year-old caregiver to her 75 year-old husband with advanced heart failure.  She usually brings him in to clinic every 3 months.  In April, she was able to conduct a telemedicine visit with the heart failure clinic. She said her grand-daughter had face-timed with her from out of state and talked her through using the computer to connect to the electronic record, but she had to search for her glasses to read the weight chart to the provider, as she could not scan and upload it. And she got flustered manipulating the camera to show his degree of edema. She requested refills but, she expressed a sincere fear of going to the pharmacy to pick-up the medications, where there may be sick people.  JS is not alone in the adaptations she is making or the stress she feels from having to do so.  Even formerly routine activities of daily living like grocery shopping feel oddly intense, full of new rules and routines. This is not normal time; this is pandemic time, and the impacts on health are likely to be significant even in those who never get COVID-19.

How do we as clinicians help older adults manage the stress arising from this pandemic?  Researchers have shown that improving “self-efficacy” may help. Self-efficacy is confidence to perform well at specific tasks or in specific domains (Bandura, 2001). No one has any experience mastering the adaptations to stay-at-home orders, but it is not surprising that people with better personal resources and confidence are more likely to successfully solve new problems.  Self-efficacy has been studied extensively as a mechanism to improve health outcomes and well-being (Marks et al., 2005). For example, Lorig and colleagues designed a self-management program for those with chronic disease built on self-efficacy principles and showed 6 month improvements in exercise, well-being, fatigue, pain and provider communication (Lorig et al., 1999). In a sample of 831 participants who completed the Lorig self-management program, there was a 2-year reduction healthcare utilization and health distress (Lorig et al., 2001). Unfortunately, at the same time that disruptions are requiring high levels of self-efficacy, the social isolation, financial stresses, lack of access to fresh food and medicine and exercise, are all working against the easy adaptation to new conditions.

There are four ways clinicians can work with patients to build more self-efficacy:

  1. Personal Mastery.  Past experiences influence confidence to perform the same task successfully today. One such task is coping with sorrow and stress.  Clinicians can reflect on the past with patients, help them recall their prior positive ways of coping and apply them to today’s situation. In addition, a sense of mastery can be built for a new task by finding parallels with old tasks. Ms. Julia has always been a strong advocate for her husband. She asks questions, takes notes, brings everything in a binder with her to the clinic. Reminding her that she figured out what was needed in clinic and that next time she will know what she needs for the telemedicine visit reassured her. We planned another visit in a short time interval so that she could practice.   Everyone has mastery in their lives. Find it, remember it and apply it now.
  2. Positive Modeling. This is the observation of how other people have performed a task well. This is particularly difficult for older adults who are frequently further isolated during the stay-at-home conditions by their lack of facility with the technology that would allow them to stay connected to their social network. It is exactly the ability to master technology that is the skill which they need help (and coaching will help)!  But people stayed in touch before there were iPads, or even phones. My teenager got a letter, on real stationary, from a friend the other day, and felt so connected by that, she even wrote back! JS and her husband have an active local church group, and talking about those friends she realized that many might be able to help her figure out how to go to the pharmacy and grocery store safely. Modeling expands personal mastery through social learning.
  3. Coaching.  Coaches inspire and encourage and for older adults trying to use technology, some of the best coaches will be from younger generations, just as JS’s grand-daughter who helped her, with the added benefit of decreasing the social isolation during the coaching session. This coaching can go both ways in such situations. The act of coaching will also improve self-efficacy and reinforce the sense of self-mastery discussed above.  Although knowledge about coronavirus is evolving, the stress induced by the presence of a pandemic- the social isolation, the financial strain, the health fears- are not new and many older adults will have guidance to offer younger family members coping with losses like sports seasons and school graduations, the social fun of being a kid. Asking older adults about their families and experiences can help them recognize the support they have to offer as well as receive.
  4. Listening to the Body. The body itself provides feedback via the stress response networks, reflecting the confidence a person has to positively address a stress experience.  Sometimes simply acknowledging the body’s own contribution to emotions and self-efficacy is enough to release the physical sensation (like stomach pain) and move on.  Tools to help acknowledge and integrate the body’s sensations include a good cry, sleep, meditation and prayer, journaling, talking it out and exercise.

Improving self-efficacy will look different for each person. And this pandemic is not fair. Structural changes are needed to address all the inequities and challenges of this pandemic that are not impacted by our individual or collective agency and ability to cope.

The good news is that increasing self-efficacy is possible at any age. Spending a little time during clinical visits acknowledging each patients’ strengths and masteries and help identify sources for modeling and coaching, can go a long way toward improving well-being and maintaining health status for older adults during this crisis.

Melissa deCardi Hladek is an Assistant Professor at Johns Hopkins University who studies stress and resilience in the context of aging.

References 

Bandura, A. (2001). Social cognitive theory: an agentic perspective. Annual Review of Psychology, 52, 1–26. 

Lorig, K. R., Ritter, P., Stewart, A. L., Sobel, D. S., Brown, B. W., Bandura, A., Gonzalez, V. M., Laurent, D. D., & Holman, H. R. (2001). Chronic disease self-management program: 2-year health status and health care utilization outcomes. Medical Care, 39(11), 1217–1223. 

Lorig, K. R., Sobel, D. S., Stewart, A. L., Brown, B. W., Bandura, A., Ritter, P., Gonzalez, V. M., Laurent, D. D., & Holman, H. R. (1999). Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Medical Care, 37(1), 5–14. 

Marks, R., Allegrante, J. P., & Lorig, K. (2005). A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: implications for health education practice (part II). Health Promotion Practice, 6(2), 148–156. 

Motivation Matters: A Socratic Inquiry into Frailty

/by
Ravi Varadhan, PhD, PhD Varadhan, PhD, PhD

Ravi Varadhan, PhD, PhD Varadhan, PhD, PhD

“The unexamined life is not worth living,” with these famous words which define the essence of the human endeavor, Socrates launched an intellectual revolution in ancient Greece. He urged his disciples and his critics to carefully examine their implicit assumptions and beliefs with regards to any given ethical, moral or political stance. He often exposed the fallacies and contradictions in the commonly held views by subjecting them to the “Socratic” scrutiny.

Even after 2500 years, the Socratic dialectic method is still the gold standard means of generating knowledge. In modern day science (defined broadly to include all branches of knowledge), the Socratic dialectic method is employed implicitly by means of peer-reviewed publications and various other modes of interactions between thinkers. There is no place for unexamined opinions and hypotheses in the arena of science.

Since my own scientific interest lies in elucidating the physiological basis of frailty, I imagined a dialogue between Socrates and myself where the great master is relentlessly probing me to better understand what frailty is! This is the genesis of the idea for my JAGS article. I went back to Plato’s dialogues to see whether Socrates had anything to say about aging. There is not much in the Platonic literature on aging. It is only in The Republic, the magnum opus of Plato, that there is a reasonably lengthy discussion of aging between Socrates and Cephalus, who was a rich merchant of Athens.

Therefore, I decided to model my fictitious dialogue on the interchange between Cephalus and Socrates. Due to word limitations imposed by the journal, I could achieve neither the depth that is the hallmark of a Socratic dialogue nor the breadth that was needed in order to address the many critical issues in frailty science. In spite of its brevity and lack of depth, I hope you will find the paper stimulating.    

PubMed: A Socratic Inquiry Into the Nature of Frailty

Brain-Related Symptoms of COVID-19 in Frail, Older Adults

/by
Jeremy Walston, MD

Jeremy Walston, MD

Raymond and Anna Lublin Professor of Geriatric Medicine
Johns Hopkins University School of Medicine
Co-Director, Johns Hopkins Older Americans Independence Center

Please note: this post serves an addendum to the previous blog, Accelerated Frailty and COVID-19.  Colleagues from Johns Hopkins University recently published an important paper (Bullen et al., 2020) the demonstrated that COVID-19 can infect brain cells.  The study points out that neurons also have the ACE 2 receptor on their surface, necessary to transfer COVID-19 into a cell.  

 

These findings provide a potentially important explanation for some of the more common brain-related symptoms of COVID-19 infections that we see in frail, older adults.  For example, several of the patients that I treated on the COVID-19 inpatient unit back in April had florid delirium and visual hallucinations with minimal signs of COVID pneumonia during the first few days of their hospitalization. 

 

Although the cytokine storm could be a contributor to these symptoms, direct infection of brain cells might also be contributing to abnormal central nervous system discharges, consistent with hallucinations and delirium.  In addition, it is possible that central mechanisms that drive thirst and hunger could be directly impacted by the virus, leading to the marked anorexia and adipsia that I described in the earlier blog. 

 

Reference: Bullen CK, Hogberg HT, Bahadirli-Talbott A, et al. Infectability of human BrainSphere neurons suggests neurotropism of SARS-CoV-2 [published online ahead of print, 2020 Jun 26]. ALTEX. 2020;10.14573/altex.2006111. doi:10.14573/altex.2006111

Accelerated Frailty and COVID-19: Musings from the COVID Unit at Hopkins Bayview

/by
Jeremy Walston, MD

Jeremy Walston, MD

Raymond and Anna Lublin Professor of Geriatric Medicine
Johns Hopkins University School of Medicine
Co-Director, Johns Hopkins Older Americans Independence Center

Over the past two months, I’ve worked on several occasions as the attending physician on a non-ICU COVID unit at Hopkins Bayview where I treated several older adult patients.  Although many of them had some level of COVID-related pneumonia, many others presented to the hospital in unexpected ways.  One of the more common ‘alternative’ presentations that I observed was one that looks like accelerated frailty with none of the other common signs or symptoms of COVID.  The following clinical presentation represents an amalgam of several patients who presented in this way, and a few thoughts on how COVID infections could provide researchers and clinicians alike important insights into frailty, its etiologies and its potential treatments. 

The Clinical Case:   A new 83 year old patient was admitted to the non ICU COVID unit after several hours in the emergency room.  She was in quite good health in the week before she was admitted and was cooking and cleaning and participating in all of the household chores according to her daughter.  A couple of days before she was admitted, she started to complain about how tired she was.  A day before her hospital admission, she didn’t help get the breakfast dishes cleaned from the table, and went to rest in the bedroom.  She slept most of the day and didn’t eat or drink much.  The following day, she was still quite fatigued, didn’t help with usual household chores, and didn’t eat or drink at all.   That evening, the family found her alert but too weak to get up from a chair in her bedroom and called 911. 

During her emergency room evaluation, she was found to have no cough and no fever.  However, she did have very low blood pressure with evidence of dehydration on her lab values and profound muscular weakness.   A few opacities on a routine chest x-ray triggered a COVID test, which turned out to be positive.  On admission, she was profoundly weak and fatigued, with absolutely no interest in drinking or eating.  After about three weeks in the hospital and two negative COVID tests, she started sipping water and nutritional supplements, and regained enough strength to go to a rehabilitation facility for further care.

Strikingly, the patient never had any signs or symptoms of COVID pneumonia beyond a few modest changes in her chest x-ray.  Instead, she had presented with an accelerated version of the classic signs and symptoms of physical frailty including weakness and fatigue.  Given the emerging evidence that marked inflammatory pathway activation drives much of the pathophysiology observed in COVID infections, these frailty-like signs and symptoms may well be driven by inflammatory cytokines.  Indeed, the clinical observations that I made in several older patients during my shifts on the COVID unit are quite similar to what we have found in frailty research over many years.  Such observations, and many more coming in now, may well provide us with some important insights as we look to better understand frailty and how best to treat it.  Stay tuned for more on this topic in the coming weeks and months. 

Dr. Jeremy Walston is a Geriatrician and Professor of Geriatric Medicine in the Johns Hopkins University School of Medicine.

Frail Older Patients in the Emergency Department: Considerations during the COVID-19 Pandemic.

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Consider the following hypothetical scenario from the experiences of an emergency medicine physician: An 84-year-old man is transferred to the emergency department (ED) from a skilled nursing facility (SNF) following three days of mild shortness of breath and non-productive cough. His past medical history includes mild dementia, COPD on home oxygen (4 liters per minute), and atrial fibrillation on anticoagulation and hypertension. The emergency medicine providers have no advanced care directives from the patient’s SNF. On arrival, the patient is awake and alert with a slight increase in work of breathing. The patient’s triage vital signs show a slightly elevated temperature, respiratory rate and heart rate which together with oxygen readings are consistent with a likely respiratory infection; blood pressure of 115/80 is within the range considered normal. His pulmonary exam demonstrates bilateral wheezing. In the Spring of 2020, the above patient commonly presents to the emergency department (ED) where a concern for COVID-19 is at the top of the list of possible problems.

Similar to the patient in this scenario, older adults with these complaints present considerable challenges to emergency medicine providers (EMP) compared to their younger counterparts.

  1. The first, and perhaps most obvious, is that older adults with multiple co-morbidities have the highest mortality rate with COVID-19. For this reason, the suspicion needs to be high for coronavirus, however, classic and more common disease processes such as COPD exacerbations, coronary artery disease, bacterial infections and metabolic derangements need to be concomitantly considered.
  2. The second challenge is that many of these patients can present more subtly than younger adults. Older adults are less likely to mount a classic fever, and those with cognitive or sensory deficits may not be able to communicate their symptomatology as clearly. Fortunately, the nation’s ED have developed fairly low threshold screening protocols to ensure maximum sensitivity in identifying older adults with potential COVID-19.
  3. A third, true challenge that has developed in emergency medicine revolves around airway management. Currently, professional society recommendations and many hospital policies call for limited or no use of non-invasive ventilation (such as BiPap) due to the risk for aerosolization of viral particles. For this reason, early endotracheal intubation has been the practice in many COVID-19 patients. The patient in the above story, in pre-COVID-19 times, would clearly have been a candidate for non-invasive ventilation such as BiPap or even continuing to observe on a small increase in home oxygen requirements. In current day, intubation is likely to be considered much, much earlier to prevent rapid decompensation. However, EMPs recognize that patients such as this, who are intubated, have significant morbidity and mortality, simply associated with the procedure and ICU course it will bring even, or perhaps especially, if the problem is not COVID-19 infection. Moreover, invasive and aggressive interventions such as those associated with ICU level care can be further complicated by these patient’s underlying co-morbidities, potential cognitive impairment and frequent polypharmacy.  Hence, EMPs really struggle with the decision to intubate frail older adults, more so than ever, in the COVID-19 era.
  4. Finally, allocation of resources must be considered with such a widespread pandemic. More widespread and rapid testing of frail older adults including in the ED, as well as obtaining early prognostic markers, may be of greater benefit to this population compared to younger patients. However, given the severity of the disease in the older adult population, scarcity of some life-saving resource shortages would likely disproportionally impact older adults seen in the ED. Although workgroups and policies are being discussed and developed regarding resource allocation, this area remains uncharted territory.

The presence of frailty is elevated in older adults in the ED (See Clinical Topics: Emergency Medicine).  Having a framework or understanding of a patient’s frailty could help EMP as they face these novel challenges in the COVID-19 era.  For example, a frailty alert developed in the outpatient setting or based on rapid ER screening may help triage frail older adults appropriately, guide treatment decision, plan resource needs sooner and ultimately have the potential to improve the care provided to these patients during these unprecedented times. Innovative approaches are needed in order to better care for these vulnerable older ED patients.

May 29, 2020

Welcome to the conversation on Frailty Science.

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Karen Bandeen Roche, PhD
Karen Bandeen Roche, PhD

Frank Hurley and Catharine Dorrier Chair of Biostatistics
Johns Hopkins Bloomberg School of Public Health
Co-Director, Johns Hopkins Older Americans Independence Center

Jeremy Walston, MD
Jeremy Walston, MD

Raymond and Anna Lublin Professor of Geriatric Medicine
Johns Hopkins University School of Medicine
Co-Director, Johns Hopkins Older Americans Independence Center

Welcome to the Frailty Science blog!  Whether you are a researcher, clinician, student, policy maker, advocate, older adult, or caregiver—we hope you will find something interesting or useful on the site.  We aim to provide a gateway to information for those seeking to learn more about frailty, vulnerability and resiliency in older adults. We hope you will enjoy checking in for the latest frailty-related findings, evidence-based reporting on research and clinical topics, best-practice recommendations from national and international organizations, and guidance on frailty assessment instruments.

This blog will be one of our website’s avenues to facilitate communication across the community of scientists and clinicians interested in understanding frailty and resilience in aging. Our Older Americans Independence Center, a federally funded research center at Johns Hopkins University, has rigorously studied frailty for nearly two decades. We aim to advance understanding of frailty-related biology, measurement, clinical practice, and public health implications for our aging society.  Significant new research findings from this center and our outstanding group of collaborators will be featured regularly. Leaders in the field from around the world will also be invited to provide commentary on important work and present a global picture of frailty.

In addition to providing regularly occurring commentary on findings, we also aim through our blog to highlight areas we consider to have knowledge gaps or points of confusion. Addressing frailty and promoting resilience stand to benefit older adults—but there remains a great need for randomized controlled evidence in order to establish the effectiveness of intervention strategies. How frailty and resilience should be measured, and even what one means by these terms, remain under debate. There is a growing literature investigating the cellular, physiological, social and environmental underpinnings of frailty—but the specific pathways remain to be elucidated. We see these areas and more as in critical need of discovery, and our blog will address them in greater depth in the coming months.

Most urgently, as the COVID-19 crisis is upon us, insights into the pathways resulting in aging-related vulnerability and frailty may be the same that illuminate what it is that triggers catastrophic responses to COVID-19 infection, and others like it. Our blog’s mission is to speed the way to achieving the promise frailty researchers of diverse opinions all seek—to add quality years to life by delaying frailty onset, promoting resilience, and developing best-practice guidelines for clinical management in the face of frailty. At the least, we hope you will enjoy the conversation.

May 4, 2020