The Pulmonary System, Frailty & COVID-19: Q&A’s with Dr. Panagis Galiatsatos
Exciting 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:
- Tips for Managing Long-COVID Symptoms
- The Future of the COVID-19 Pandemic: An Interview with Dr. Panagis Galiatsatos, Part 1
- The Future of the COVID-19 Pandemic: An Interview with Dr. Panagis Galiatsatos, Part 2
- A Covid-19 Update With Dr. Panagis Galiatsatos From Johns Hopkins School Of Medicine
- Covid-19 Story Tip: Panagis Galiatsatos, M.D., M.H.S.: SARS-CoV-2/COVID-19 Tests and How to Use Them
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
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 a
nd 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
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.
<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
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.
The Geriatric Surgery Program at Johns Hopkins
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.
(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
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!
Double Jeopardy for Older Adults of Color: An Urgent Call to Address Frailty in the United States
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
Sarah Szanton, PhD, MSN, RN
FAAN, ANP
Professor
Endowed Professor for Health Equity and Social Justice
Director, Center for Innovative Care in Aging
Roland Thorpe, Jr., PhD
Co-Director DrPH Concentration in Health, Equity, and Social Justice
Professor
Racial inequality that has been embedded in US structures and institutions has been exposed by twin catastrophes of 2020. In the height of the early novel coronavirus pandemic, Black, Latinx, and Native Americans were roughly 5 times as likely to be hospitalized for COVID-19 than their white peers, and Black Americans were twice as likely to die as whites (CDC COVID-19 Hospitalization by Race/Ethnicity, accessed 11/18/20). The killing of George Floyd, Ahmaud Arbery, Breonna Taylor, and others highlight the fact that people of color in the US continue to disproportionately experience police and vigilante violence along with other forms of inequality, including substandard housing, under-resourced schools, and restricted access to living-wage employment.
As one observes that highly publicized disparities in health and safety disproportionately affect young and middle-aged individuals, it can be tempting to predict that inequities lessen or even out in old age. Some have argued this (Meich, 2009). Motivated by studies we have performed as well as others’, we fear that such an approach—whether arising from complacency or misunderstanding—will leave older people of color in America with considerably diminished quality of life and heightened risk of other adverse outcomes. Frailty is a case in point. In a study to evaluate national racial/ethnic prevalence disparities, we found that the odds of frailty among non-Hispanic Black and Hispanic older adults were inflated approximately 1.5 times compared to non-Hispanic White older adults, after adjusting for age, sex, income, BMI, and comorbidity (Usher et al., 2020). Relative to a non-Hispanic white sociodemographic group with 15% prevalence—likely a quite typical group, given an estimated overall national prevalence of 15.3% (Bandeen-Roche et al., 2015)–this translates into prevalence of roughly 21% for non-Hispanic Blacks and Hispanics. We further found that, for Black older adults, relative Black versus white disparities were comparable across income quartiles (and the estimated percentage inflation in frailty odds actually was greatest in the highest income quartile). This means that intersectionality looms large; added risks appear to aggregate when under-represented race/ethnicity and economic disadvantage are taken together.
Disparities in frailty experience may provide a particularly telling case because of implications for other risks as well as for mechanisms leading to the disparity in older age. The studies described above employed physical frailty phenotype (PFP) ascertainment of frailty. Under the PFP paradigm, frailty is hypothesized as a clinically recognizable syndrome arising from critical dysregulation in physiological systems governing energy production and use as well as stress response, resulting in vulnerability to adverse outcomes following stressors (Fried et al., 2001; Bandeen-Roche et al., 2020). With heightened frailty prevalence, older Americans of color or minority ethnicity may disproportionately frequently experience amplified physiological vulnerability together potentially with impaired access to resources by which to compensate, leading to a vulnerability “double-hit” putting them at particularly amplified risk for adverse outcomes. Considering frailty as an outcome of unraveling stress response regulation, moreover, may provide insight into mechanisms leading to such a large race disparity in frailty in late life; stress response stands to be impaired with chronically elevated stress over the life course, and this is exactly what one might hypothesize to follow from the persistent experience of socioeconomic inequities, social injustice, and structural racism. It is the inextricably intertwined historical context and life experiences that many older Black Americans have endured that position their bodies for poor outcomes, such as frailty.
It follows that the need for research to discover the etiology of late life frailty, and then to intervene on or buffer it, is particularly urgent for reducing racial/ethnic disparities in the health and well-being of older Americans. Meanwhile, efforts to buffer the implications of frailty for older Americans need not wait. Interventions with proven effectiveness for reducing stressors in the home environment already exist; CAPABLE, an evidence-based program which provides tailored occupational therapy, nursing, and handy worker services to enhance function of older adults aging at home and prevent costly institutional care, is a strong example of these. Programs and policies to reduce disparities in opportunity to maintain good health also could have high impact. These are needed to address health facilitators that are unavailable to many older adults of color, including ready transportation by which to access health care, high-quality nutrition, and neighborhood environments in which to safely engage in physical activity—all essential to staving off frailty and reducing its impact. If feasibility mandates, these interventions could be targeted—for example, using methods to assess pre-frailty pioneered by our Older Americans Independence Center as well as other groups. Screening to identify pre-frail and frail older Americans of color could not be more timely in the face of the COVID-19 pandemic. We suspect that the etiology underlying frailty intersects considerably with the etiology of susceptibility to the novel coronavirus, and conversely infection may contribute to future frailty. Finally, whether to bolster robustness and resilience in the short term or for protection against future health threats, addressing frailty among older Americans of color is a matter of the highest import for researchers, clinicians, and policymakers alike.
Self-Efficacy as a Tool for Older Adults to Cope with Coronavirus
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:
- 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.
- 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.
- 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.
- 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
“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.
Brain-Related Symptoms of COVID-19 in Frail, Older Adults
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
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.
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.
- 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.
- 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.
- 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.
- 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.
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
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