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Towards a self-reported assessment of physical frailty: updates and challenges

Physical frailty is commonly defined by the Physical Frailty Phenotype (Fried et al, 2001), which uses a combination of self-report and objective measures. Physical frailty is a powerful predictor of health outcomes, but it is rarely used outside of research settings because of challenges with implementation. In a busy clinical setting, performing repeated grip strength and timed walking tests is rarely feasible. Self-report questionnaires, in contrast, are easily administered both in the office and even at home for telemedicine visits. Currently, fully self-reported assessments, such as the FRAIL Scale, are not strongly correlated with the PFP (Aguayo et al, 2017).  We therefore set out to develop a self-reported tool that would correlate well with physical frailty, and thus be useful in settings with time and resource constraints.

In our recent study published in the BMC Geriatrics, we tested several possible self-reported frailty phenotypes which included different combinations of questions focused on slowness and weakness (Buta et al, 2022). When we substitute sets of 3 questions for each of the objective measures in the PFP there was substantial agreement between standard and self-reported measures of physical frailty for a 2-level model of frail/non-frail (Kappa=0.76– 0.78). We also found the highest sensitivity (86.4%) and negative predictive value (98.7%) for identifying frail older adults when comparing the standard PFP to a self-reported version that included these 3 slowness- and 3 weakness-related questions. The self-report tool took participants less than 5 minutes to complete.

Table of Physical Frailty Measures/ Criteria Assessed in this Study

We found only fair-to-moderate levels of agreement in a 3-level model that categorized participants as either frail, pre-frail or non-frail. Also, the generalizability of our findings may be limited by the study population of aging registry participants from the Baltimore area. Compared to US national demographics (US Census Bureau), our study population had a higher prevalence of participants who were female; African American; and had completed a bachelor’s degree or higher.

Clinician with hispanic female older adultOur results show the utility as well as the challenges of using self-reported questions to identify a frailty phenotype in clinic. Additional testing in general clinic populations should be done, with refinement of the questionnaire as needed, since a self-reported physical frailty measure with high agreement to the standard phenotype will be a valuable frailty screening assessment in both clinical and telehealth settings. To this end, we have recently published complementary work in a larger epidemiological study that highlights the importance of selecting viable self-report measures: common self-reported disability questions do not appear to serve as strong proxies for the physical frailty phenotype’s performance-based measures (Bandeen-Roche et al, 2023). Additional efforts to simplify the assessment of physical frailty are ongoing (Chen et al, 2023).

The results of this study suggest that a self-report assessment would be valuable as a screening tool if it has low rate of “false negatives”–that is we are unlikely to miss people who would be categorized as frail by the standard phenotype.  In order to optimize clinical intervention early in the course of physical frailty, a sensitive screening tool that is easy to administer followed by targeted objective tests to confirm frailty is an efficient strategy but depends on the effectiveness of the interventions. In Europe, a population wide, app-based frailty screening effort is underway that includes interventional targets following screening and comprehensive evaluation (Subra, 2012). It will be important in the future to follow up this research with high quality intervention studies.

Taking LGBTQ+ Health to Heart: An Interview with Dr. Carl Streed, Jr., on LGBTQ+ Older Adults, Heart Health & Frailty

Hands forming a heart shape with a rainbow flag in the view at the beachFor “Pride Month,” we wanted to focus on Lesbian, Gay, Bisexual, Transgender, and Queer+ older adults’ heart health as a possible risk consideration for frailty.

There is increasing recognition of a multitude of health inequities that exist across many areas of wellness for LGBTQ+ people throughout the lifespan. In addition to age-related changes in cardiovascular risk, older LGBTQ+ adults are at high risk for poor heart health outcomes related to LGBTQ+ specific life stressors and psychosocial, behavioral, and physiologic factors. Further considerations include increased prevalence of diabetes, tobacco abuse, and the use of hormonal therapies in transgender individuals.

Stemming from their lived experiences, or perceived and actual discrimination from present day physicians, many LGBTQ+ older adults mistrust health care providers; consequently, delaying doctor visits may lead to an LGBTQ+ patient being diagnosed when they present with overt clinical disease rather than an early disease stage, where institution of preventative measures may impact patient care.

Last June, the New York Times ran a story titled, “Why L.G.B.T.Q. Adults Are More Vulnerable to Heart Disease” that interviewed several high-profile cardiology researchers and experts on LGBTQ+ health. Among them were Dr. Erin Michos, a current cardiologist at Johns Hopkins Medicine who is also affiliated with the American Heart Association, and Dr. Carl Streed, Jr., who attended medical school at Johns Hopkins University and completed his internal medicine residency at the Johns Hopkins Bayview Medical Center. Dr. Carl Streed, Jr., is now an Assistant Professor at Boston University Chobanian and Avedisian School of Medicine and the Research Lead for the GenderCare Center at Boston Medical Center.

Dr. Carl Streed, Jr., is an Assistant Professor at Boston University Chobanian and Avedisian School of Medicine and the Research Lead for the GenderCare Center at Boston Medical Center.

Dr. Carl Streed, Jr.

For this blog, Dr. Streed kindly answered a few questions on this topic, keeping in mind the context of frailty research.

Tony Teano: With regard to function, how may poor coronary/vascular health lead to frailty?

Dr. Streed: Poor heart health limits the ability to engage in physical activity that reduces the likelihood of frailty. It also limits additional activities, such as community engagement, that are protective against frailty. 

Tony Teano: Within the LGBTQ+ community, are some sexual minorities and gender diverse/expansive people more at risk than others?

Dr. Streed: LGBTQ+ communities are not homogenous and so have significant variation in risk factors for CVD and outcomes. Additionally, persons with multiple marginalized identities can face significant disparities in CVD risk and outcomes (e.g., Black cisgender lesbians, Black transgender women, etc.). There are unique minority stressors that lead to differences in coping mechanisms as well as physiologic changes in response to stress. 

Tony Teano: What are the top few things physicians can do to better evaluate LGBTQ heart health?

Dr. Streed: Improved Sexual Orientation and Gender Identity (SOGI) data collection could help. Also, improved training of clinicians and improved screening of stressors unique to LGBTQ+ persons may make a difference. 

Tony Teano: What interventional steps might LGBTQ+ older adults consider taking above and beyond those for the general population?

Dr. Streed: I would advise to get connected to community, especially through LGBTQ+ community centers. Engagement in any physical activity, especially that which improves daily function can also help, as can getting connected to cessation programs tailored for LGBTQ+ persons if you are still smoking.

Many thanks to Dr. Streed for taking the time to answer these questions. For more information on these matters, please see the following related research and news:

Right now, there is not an abundance of frailty research on LGBTQ+ older adults. However, Johns Hopkins investigators are making strides to contribute to our understanding of aging research among marginalized populations. For example, the JHU Diversity Leadership Council funded a crowd-sourced grant that Frailty Science team member Brian Buta, MHS, pitched earlier this year (about which you may find a related blog here).  Over the spring term, this Diversity Innovation Grant (DIG) helped train 20 research coordinators, scientists, and staff to be more culturally competent at recruiting diverse older study participants. “This is a first step towards improving diversity in aging research at Johns Hopkins, and staff from the Schools of Medicine, Nursing, and Public Health participated in it” said Mr. Buta, adding that the training “covered historical and societal barriers to participating in research among racial/ethnic and sexual and gender minorities. Being aware of such barriers and understanding the importance of treating potential research candidates from these communities with dignity and respect, especially during the recruitment stage, is critical to achieve diverse representation in our research studies, and ultimately, to meet the health needs of those who are most vulnerable.”

The Center on Aging & Health (COAH)’s DIG training builds upon another DIG training from the JHULesbian couple at the beach with Rainbow Flag Division of Geriatric Medicine and Gerontology’s Mosaic Initiative collaboration with Medicine for the Greater Good, “Geriatricians Engaged and Ready for LGBTQ+ Aging, Health & Wellness” (“GEARed”—about which you may learn more here). GEARed trained 18 geriatric faculty and staff in 2022, and the team continues to hold quarterly meetings, and updates are reported at faculty meetings. Also, this year, the JHM Office of Diversity, Inclusion & Health Equity relaunched their “Proud Partner” training—an interactive LGBTQ+ allyship educational offering to improve the ability to interact with and support our LGBTQ+ patients, learners, and co-workers—available to Johns Hopkins faculty and staff through MyLearning in the JHU portal. Moreover, JHU/JHM is taking an active role in transforming LGBTQ+ heath care.

Finally, you may be interested in past COAH & Frailty Science blogs on LGBTQ+ older adults:

Many thanks to Dr. Monica Mukherjee with the Johns Hopkins University Division of Cardiology for providing editorial input for this blog.

Frailty Science Presentations at ICFSR 2023

The 2023 International Conference on Frailty and Sarcopenia Research is coming up soon! This annual conference, which showcases state-of-the-art research on frailty and sarcopenia, will be held in Toulouse, France from March 22nd -24th.  There is also a virtual attendance option. 

We are excited to announce that members of our Frailty Science team will be attending to present talks at symposia and paper sessions during the conference.  Some featured sessions are highlighted here:

  • Dr. Jeremy Walston will moderate the lead symposium, A Road Map for the Development of High Priority Physical Frailty Research.  Dr. Walston will present a talk on Biological Research Priorities; Dr. Qian-Li Xue will present Future Implementation Research Priorities; and Dr. Karen Bandeen-Roche will present Public Health Research Priorities.
  • Dr. Qian-Li Xue will moderate a symposium on Disentangling Relationships among Resilience, Frailty, and Self-Reported Health: Longitudinal Evidence from Community and Clinical Studies of Older Adults. For this session, Brian Buta, MHS, will present Frailty and Self-Reported Health as Surrogate Markers of Physiological Resilience: Findings from the SPRING-RESTORE Study; Dr. Xue will present Physical Frailty, Self-Reported Health and All-Cause Mortality: Implications for Resilience; and Dr. Amal Wanigatunga will present Interactions between Self-Reported Health and Free-Living Movement Patterns on Frailty Incidence.
  •  Dr. Karen Bandeen-Roche will moderate a symposium on the Conceptualization, Ascertainment and Implications of Prefrailty as a Public Health Priority. As part of this session, she will present on Next-generation Prefrailty Assessment in the Physical Frailty Phenotype.
  • Dr. Jenna Mammen will lead a presentation on the Association Between Thyroid Function and Lower Limb Composition in Older Adults: Analysis from the Baltimore Longitudinal Study of Aging.
  • Dr. Megan Huisingh-Scheetz will present on Design, methods and preliminary findings for the EngAGE trial: An exercise and social engagement intervention for multimorbid, homebound African American older adult-care partner dyads delivered over voice-activated technology.

The full conference program is now online, including keynote presentations and poster sessions

We hope those who are interested are able to attend this exciting conference!  Registration is still open, including an option for virtual attendance. 

Please also take a look at our ongoing Frailty Fighters campaign that highlights many of the presenters at this year’s conference. 

Wishing all a great 2023 ICFSR, in person and online! 

#FrailtyFighter 2.0: International Edition–Especially for the ICFSR Congress 2023

We are bringing back our celebrated #FrailtyFighter social media campaign on Twitter!  And we are proud to partner with the International Conference on Frailty and Sarcopenia Research (ICFSR) Congress to highlight global researchers in this space leading up to the ICFSR 2023 Conference in Toulouse, France, from March 22-24 as a key part of this effort. These Tweets will include a visual brief biography about these giants in frailty, sarcopenia, and resiliency research, as well as links to selected publications, and point out when their ICFSR presentation will take place.

“#FrailtyFighter 2.0: International Edition” launched on Monday, February 20, 2023 with content about the conference, to which Johns Hopkins University is sending six researchers to present: Drs. Karen Bandeen-Roche; Jeremy Walston; Jenna Mammen; Amal Wanigatunga; Qian-Li Xue; and Mr. Brian Buta. Also, Dr. Megan Huisingh-Scheetz from the University of Chicago will be presenting at the ICFSR conference; she contributed to Frailty Science’s Clinical Topic: Primary Care content. That brings up the number of Frailty Science team members presenting at ICFSR 2023 to seven!

Over the coming weeks leading up to the conference, we will Tweet about each member of our team presenting at ICFSR 2023 and their research, as well as promote ICFSR 2023 content about leading international frailty researchers, such as Dr. Leocadio Rodríguez Mañas (whom ICFSR will recognize with a Lifetime Achievement Award), and more keynote speakers and presenters.

#FrailtyFighter Prof. Leocadio Rodríguez Mañas, MD, PhD

The #FrailtyFighter social media campaign is a fabulous way to celebrate frailty scientists and their research, and we may continue the series after the ICFSR conference is over to raise awareness of more significant contributions in frailty science, and to recognize up-and-coming junior researchers in the field.

You are invited to participate!

To be considered for this effort, here’s what we need from you:

  •  Name and academic degrees
  •  Brief biography (36 words or fewer)
  • Affiliated institutional logo
  • Current head shot (vertical orientation)

Additionally, it is very nice to have meaningful content to generate more interest in the #FrailtyFighter Tweet about you, such as links to:

  • Recent frailty research
  • Future presentation that includes you
  • Award or honor received
  • News about you on frailty
  • Anything else to related to frailty with which you are involved

We can help draft text for the Tweet itself to accompany the visual art if you like, and you are welcome to prepare draft text (up to 280 characters including links, etc.) if there is a particular angle you would like to promote in messaging.

Submissions are accepted on a rolling basis. 

Please send all content in one email to our communications specialist: tony.teano@jhu.edu

We hope you enjoy the #FrailtyFighter series and consider joining the cause to bring more attention on social media to this critical subspecialty in geriatric research and healthy aging, and your leadership to that purpose.

#FrailtyFighter content requirements

New supplemental award examines mitochondrial function and frailty development among people with and without HIV

MitochondriaThe Johns Hopkins Older Americans Independence Center (OAIC), a long-running NIH funded research program focused on frailty research, was recently awarded a supplemental grant to investigate the intersecting biological pathways that drive early onset of physical frailty in a subset of individuals living with and without HIV through the study of mitochondrial decline. Among people with HIV (PWH), frailty predicts mortality, comorbidities, and hospitalization, and is an important indicator of quality of life. The underlying mechanisms for frailty development are likely multifaceted, due in part to features of biological aging such as mitochondrial decline and chronic inflammation. A major driver of the aging process in PWH is mitochondrial damage, resulting from chronic HIV infection, chronic inflammation, and the effects of some antiretroviral therapies. However, the role of changes in mitochondrial function in the etiology of frailty among PWH remains unclear. Furthermore, each immune cell type may develop different metabolic adaptations in response to stress. The interplay between mitochondrial function and immune activation and senescence in the etiology of frailty development remains unclear.

Dr. Jing Sun is an Assistant Scientist with the Johns Hopkins Bloomberg School of Public Health in Infectious Disease Epidemiology.  Dr. Sun is affiliated with:

Dr. Jing Sun

This supplemental award, led by Dr. Jing Sun (Epidemiology), with mentors and colleagues including Drs. Todd Brown (Endocrinology), Dan Arking (Genetic Medicine), Joseph Margolick (Molecular Microbiology and Immunology), Gregory Kirk (Infectious Disease Medicine), and Jeremy Walston (Geriatric Medicine), will evaluate the association of immune cell type-specific mitochondrial function measurements, including mitochondrial content, membrane potential, and superoxide, with HIV infection and frailty by leveraging longitudinal data, specimens, and infrastructure from two established HIV cohorts: 1) the AIDS Linked to the IntraVenous Experience cohort; and 2) the Multicenter AIDS Cohort Study. These cohorts uniquely include PWH and comparable HIV uninfected adults.

Dr. Sun and the research team will pursue the following aims to accomplish these goals: (1) to characterize immune cell activation and senescence and cell type- specific mitochondrial function, stratified by HIV infection status; and (2) to assess the association between cell type-specific mitochondrial function and frailty during longitudinal follow-up among people with and without HIV. They will apply a novel machine learning approach to characterize the complex and high-dimensional biomarker data in immune aging and mitochondrial function to achieve these aims.  With expertise and resources from the OAIC, the current study will provide new understanding of the interplay between HIV infection, immune aging, and mitochondrial function in the etiology of frailty.

More information is available here: https://reporter.nih.gov/search/47Y0OHlInkKj9BQeZ-vlZQ/project-details/10614117

What Can Digital Health do for Geriatric Oncology? – advancing equity and meaningful use

Frailty, Oncology, and the Geriatric Assessment

Frailty in older adults with cancer is associated with poor outcomes such as mortality (Augustin et al., 2016Soubeyran et al., 2012), functional decline (Hoppe et al., 2013) and toxicity from chemotherapy (Hurria et al., 2011). Major organizations like the American Society of Clinical Oncology recommend using a comprehensive geriatric assessment (CGA) to identify vulnerabilities such as functional impairment, comorbidities, and cognition as well as institute CGA-driven interventions like exercise or nutritional rehabilitation (Mohile et al., 2018) that have been shown to significantly reduce the risk of high-grade toxicity without compromising survival in vulnerable cohorts with geriatric impairments (Mohile et al., 2020).

Importantly, geriatric assessment improves outcomes even when implemented by physicians other than geriatricians (Moreno et al., 2022). However, surveys of oncologists in 2019 (Dale et al., 2021) and again in 2020 (Gajra et al., 2022) show poor uptake of CGA tools by oncologists, with about 50% being aware of national guidelines (Dale et al., 2021) and 40% using a CGA to inform treatment decisions (Gajra et al., 2022). Better solutions are needed now and beyond to ensure the equitable delivery of guideline-based care; Digital Health Technology (DHT) is poised to be that solution in the coming decade.
Digital Health Technologies

According to the FDA, DHTs include computing platforms, connectivity, software, and sensors for health care and related uses. Examples of DHTs range from mobile applications apps for wellness from generally accessible platforms like Headspace – which aims to provide meditation and stress management to users across the globe – to more specialized applications like Cankado, an electronic patient-reported outcome (ePRO) application that facilitates symptom survey collection for both clinicians and researchers in advanced cancer.

Using tablets or computers to facilitate symptom and CGA survey data collection in older adults has proven feasible (McCleary et al., 2013). Thus, DHT provides an opportunity to increase the use of CGA assessments by non-geriatricians and decrease the burden of collecting such data during time-limited clinical visits. DHT-based ePRO collection could even improve longevity in patients with cancer by more rapidly alerting providers to high-risk situations that patients may not recognize as such, as well as improving the response times and rates by clinical staff providing targeted symptom care (Denis et al., 2019). Wireless sensors and wearable devices could provide clinicians and researchers with surrogate markers of frailty (Razjouyan et al., 2018) as well as cognitive impairment (Razjouyan et al., 2020), and other markers of vulnerability such as falls (Warrington et al., 2021). However, much more work needs to be done to realize a comprehensive vision of a usable and feasible “smart medical home” for older adults with cancer and frail older adults generally.

Barriers to Digital Health Adoption

Equally important is the tremendous potential of such tools, in combination with telehealth conferencing applications, to deliver multidisciplinary CGA interventions to underserved and rural populations (DiGiovanni et al., 2020). With Pew Research data showing that in the past decade, the gap in smartphone adoption between adults in their 60s compared to those in their 20s has shrunk, tablet adoption by older adults has grown to 44%, and in 2022 75% of older adults identify themselves as internet users, DHT seems like an obvious choice for many data collection and communication challenges.
However, a “digital divide” by location and aging impedes the adoption and implementation of DHTs in geriatric oncology. Over 30 million Americans do not have broadband infrastructure access, many of whom are located on Tribal lands. Without access to adequate internet, the ability of DHT to facilitate communication between patients and clinicians is vitiated.

 

Age-related changes in visual, motor, and cognitive function also act as barriers to the implementation of technological tools for older adults, in particular the “screen”-based delivery of many DHT applications (Loh et al., 2018). Navigating websites, compactly spaced keyboard buttons, long sets of instructions, and a sense of medical information overload are commonly reported barriers to the adoption of DHTs by this population (Hasnan et al., 2022). When confronted by surveys that are long or include jargon, older patients are therefore at risk of under-reporting due to mental fatigue or cognitive impairment (Kotronoulas et al., 2021).

Most patients and caregivers report low self-perceived electronic health literacy and less confidence in evaluating online health information for cancer decision-making (Verma et al., 2022). There also exists a complex interaction between the older patients’ sense of well-being and their own assessment of their cognitive abilities, which plays a key role in the adoption of wearable use among older adults (Farivar et al., 2020).
Enhancing Digital Health Equity for Older Adults

Interesting design suggestions to optimize uptake and engagement with DHT by older adults include using image or voice prompts, large font sizes, and more pictures/symbols than words for those with literacy issues (Loh et al., 2018). Perceived usefulness could also be improved by providing recommendations of when to visit the ER, medication lists or physical activity reminders, and access to up-to-date, user-friendly cancer disease status and treatment information (Hasnan et al., 2022). Methods incorporating the patient perspective into DHT development through Human-Centered Design is another important concept. By interviewing older users, and examining all aspects of usability, cyclic user testing, and iterative design, developers of DHT can promote applications with better equity and applicability to the diverse components of this heterogeneous population (Harte et al., 2014).

Unobtrusive monitoring is another potential solution, allowing clinicians to obtain patient data without requiring the direct engagement of the participant. This field has been exploring the feasibility of ambient smart sensors that are already integrated with commonly used home items to provide automated measures of health status (Bokharouss et al., 2007Rashidi et al., 2010). Testing such solutions and designing them with the needs and values of the intended population is critical to bridging this divide and developing truly equitable solutions.

One of the goals of geriatric oncology is to enhance older adult clinical trial participation so that we may expand the evidence base in this rapidly evolving field. DHTs again have the potential to act as monitors of patient-centric outcomes and thereby enhance the interpretability and generalizability of clinical treatment trials. DHTs can provide a longitudinal health status assessment by reliably collecting measures of well-being, function, and nutrition in addition to ePROs.

Digital health

The Geriatric Remote Initiative (GeRI), led by myself and mentors from both Drug Development and Gero-Tech at the University of Chicago and supported by the Conquer Cancer Foundation’s Young Investigator Award in Geriatric Oncology, is co-designing a cloud-enabled connected-systems platform with startup Prosilient Systems, composed of a tablet, a wearable, and a scale. There has been some preliminary work on sensor-based assessments of frailty (Blinka et al., 2021Bian et al., 2022). A key feature of this initiative is the participation of key stakeholders, including older patients with cancer, cancer survivors, and caregivers of those with cancer. Thus, our platform will be a novel, technology-based data collection platform, iteratively improved with user feedback and vetted by patients from diverse oncology environments as well as human-centered design specialists able to be adapted and integrated into any geriatric oncology research setting.

Examples of wearable tech for digital health

Excitingly, there are over 100 recruiting Digital Health Studies in Oncology currently registered on ClinicalTrials.gov, ranging from Digital Biomarker discovery to health coaching and symptom management. However, few of these cater to frail adults specifically. As we have seen, barriers to adoption and lack of data supporting DHTs predictive or prognostic capacities in a frail population persist. Such issues need to become a focus of DHT research, given the major effect of frailty on outcomes.

Frailty in LGBTQ+ Adults: notes from a conversation with Dr. Karen Fredriksen-Goldsen

Older adult male holding rainbow flagRecently, I asked Dr. Karen Fredriksen-Goldsen, Professor at the University of Washington School of Social Work and Director of the Goldsen Institute, to share her thoughts about frailty in older LGBTQ+ adults. Dr. Fredriksen-Goldsen is a pioneer in research on LGBTQ+ aging.  She led the nation’s first federally-funded longitudinal study of the health and wellbeing of LGBTQ+ people over the age of 50, “Aging with Pride: National Health, Aging, and Sexuality/Gender Study.” When I brought up the topic of frailty-specific insights in this population, Dr. Fredriksen-Goldsen noted that frailty was a significant problem for LGBTQ+ older adults: 

 

“[Frailty] is an area that really warrants more research and understanding in terms of incidence and prevalence [among LGBTQ+ older adults].”

“We do see higher rates of frailty; I know it is different than disability, but we find disabilities as early as the age of 18 [among lesbian and bisexual women]—that creates vulnerability for frailty.”

 

Research on aging is not the same as a specific attention to frailty, a state of heightened vulnerability to stressors, where studies among LGBTQ+ older adults lag despite a growing body of evidence that the risk factors for frailty are increased in this population. For example,  LGBTQ+ older adults are at increased risks for accelerated aging syndromes and poor health outcomes compared to peers in the general population (Fredriksen-Goldsen et al., 2013; Karen I. Fredriksen-Goldsen, 2017). Trajectories associated with physical and cognitive decline in LGBTQ+ adults are consistent with the consensus on frailty definitions (e.g., Morely et al., 2013), allowing for current frailty research methodologies to be directly employed in future studies in Frailty Science.  Dr. Fredriksen-Goldsen noted that research on LGBTQ+ older adults needs to measure all the factors that mediate frailty in the general population in order to be able to understand the origins of the differences. “[The concept of frailty is] why we have added physical activity [to our research metrics].”

A potentially hidden minority, well-known social determinants of health that can be specific to this this population also contribute to vulnerability (Fredriksen-Goldsen et al., 2011; Fredriksen-Goldsen and Muraco, 2010; see also Healthy People 2020 report on LGBT Health and the AARP’s “Dignity 2022: The Experience of LGBTQ Older Adults”). Dr. Fredriksen-Goldsen observed that much of the general population-based data “doesn’t have good measures” to gather LGBTQ+ status. Even when attempted in surveys assessing same-sex married couples, “research limitations exist,” in this case leaving out data on those who are not married.  Some approaches are not well-informed by the community.

For additional insight, I asked Dr. Jason Flatt, Assistant Professor in the Social and Behavioral Health Program at the University of Nevada-Las Vegas School of Public Health, about the dearth of frailty-specific information on LGBTQ+ elders and he noted: “I haven’t seen much in frailty and LGBTQ broadly, but I think if we look at frailty studies in non-LGBTQ+ we would see disparities for subgroups. Transgender and Bisexual older adults stand out for me.” He encouraged researchers to try and identify such subgroups, suggesting:  “I think you could take indicators from the Behavioral Risk Factor Surveillance System or the National Health Interview Survey.” 

Interestingly, studying frailty in the LGBTQ+ community may also provide insight into mechanism by which to avoid frailty and preserve resilience. Specific generations within the LGBTQ+ older adult cohort are more resilient and aging better than others (Karen I. Fredriksen-Goldsen, 2017“Lessons on Resilience from LGBTQ+ Elders.”).  Interventions are in early days for frailty in general (explore our interventions page for more information); and with the added health challenges and counter-balancing community resources (Fredriksen-Goldsen and Muraco, 2010) that can affect the health-span trajectories of LGBTQ+ older adults, ensuring that the frailty research field includes this aspect of diversity will be of value to all.

I posed these frailty-related questions to Dr. Fredricksen-Goldsen in the Q&A after her webinar Emerging from the Margins: LGBTQ+ Health and Aging” presented to the public by the Center for Aging Population Sciences, University of Texas at Austin, on March 30, 2022. In this talk, Dr. Fredriksen-Goldsen reviewed results on the health, aging, and well-being of LGBTQ+ older adults from “Aging with Pride”–a longitudinal study of 2,450 demographically diverse LGBTQ+ older adults from 2003 to 2010 at 18 partner centers across the nation. Here is a few key take-away points from her talk:

  • Currently, there is approximately 2.7 million LGBTQ+ older adults in the United States; this number is expected to increase to 20 million by 2060.
  • 9 out of 12 Lesbians, Gay men, and Bisexuals had higher rates of a disabling, chronic condition, including stroke, heart attack, and weakened immune system than heterosexuals.
  • Overall, 41% have a disability.
  • Lesbian and Bisexual older women had higher rates of disability, cardiovascular conditions, and physical limitations than Gay and Bisexual older men.
  • Gay and Bisexual older men had greater risk for overall poor health and for living alone compared to Lesbian and Bisexual older women.
  • Lesbian, Gay, and Bisexual older adults have higher rates of disability and mental distress than heterosexual older adults.
  •  Lesbian and Bisexual older women have higher rates of cardiovascular disease and obesity than heterosexual older women.
  • Gay and Bisexual older men are more likely to experience poor physical health and to live alone than heterosexual older men.
  • Transgender older adults have higher rates of disability, depression, and loneliness than non-transgender older adults.
  • Overall, most LGBTQ+ individuals are aging well.

I deeply thank Dr. Fredriksen-Goldsen for entertaining my questions about frailty following this talk, and for sharing her wise insights. The statistics above can be found in fact sheets and other reports online at: www.GoldsenInstiute.org.

Finally, in honor of pride month, we also hope that clinicians working with older adults will consider renewing their engagement with cultural humility vis-a-vis care for their LGBTQ+ older adults, and revisit training in this space. This year, as a first step toward this purpose, Johns Hopkins Medicine’s Division of Geriatric Medicine and Gerontology’s Mosaic Initiative partnered with Medicine for the Greater Good in a project called “Geriatricians Engaged and Ready (“GEARed’) for LGBTQ+ Aging, Health, & Wellness,” which has been training a core of 17 clinicians and one staff member on LGBTQ+ older adult healthcare through free CME courses offered by the Fenway Institute’s National LGBTQIA+ Health Education Center. In addition, GEARed providers received enamel pins, badge reels, and stickers for their clipboards with a logo incorporating the recently updated rainbow pride and Transgender flag colors encircling the statement “You are safe with me.” The hope is that such easily recognizable symbols will help to facilitate both patient interactions and new conversations about LGBTQ+ older adult health among colleagues. GEARed providers can thus become better partners in care to achieve better health outcomes across the institution. Anyone wishing to explore implementing such a program in their practice can contact me.

For more resources on LGBTQ+ Elders and their health needs, see this related blog: Top 10 Recommended Resources About LGBTQ+ Aging & Older Adults

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

 

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

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.

New AI/Technology & Aging Research Collaboratory: Pilot Proposals Due Feb. 18

The recently funded Johns Hopkins Artificial Intelligence and Technology Collaboratory for Aging Research (JH AITC; website) seeks to improve the health and well-being of older adults through novel uses of artificial intelligence and new technologies.  Combatting frailty and its outcomes are important aims of this Collaboratory.   

The JH AITC is funded by a $20M federal grant from the National Institute on Aging (P30AG073105).  It is one of three centers at leading research institutions participating in this innovative Collaboratory: the other two are at the University of Massachusetts and the University of Pennsylvania. 

The scientific vision of the JH AITC is led by experts from the Johns Hopkins University schools of MedicineNursing, the Whiting School of Engineering, and the Carey Business School.  Stakeholders, including older Americans and caregivers, technology developers and innovators, and industry partners, will also play a key role in informing the development of novel and adaptive technologies to improve the health and independence of millions of older Americans.  To propel these efforts, the JH AITC is now offering a call for pilot proposals, including those that are relevant to frailty and resiliency in older adults.   The Requests for Proposals can be found here:

The JH AITC’s tagline provides a concise summary of their role and mission: “Engineering Innovations to Change Aging.”  You can learn more background about this transdisciplinary effort at Johns Hopkins University here.

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.

 

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.

 

Telehealth: remote assessments of physical function and frailty measures

Objective measures of function are critical to both the clinical care of older adults and to research on healthy aging and physical frailty.  While telehealth had already been on the rise in recent years, the COVID-19 pandemic skyrocketed the use of remote and virtual assessments, creating an urgent need to adapt methods for patient care and research data collection to the new environments. Clinicians and investigators, struggling with the need to collect functional information remotely over video conferencing or by telephone, need guidance regarding the safety, feasibility and utility of various options and measures.

With support from the Gerontological Society of America (GSA) Innovation Fund: The Generativity Effect and sponsorship from the GSA Technology and Aging Interest Group, we set out to summarize existing evidence-based recommendations for the safe, accurate administration of objective functional measures during a synchronous, remote visit. We also aimed to summarize alternative subjective assessments that are highly correlated to objective measures but more easily obtained during virtual patient interactions. Our ultimate goal was to develop a set of tip sheets for the administration of functional and frailty assessments during a remote clinical or research visit.

We focused on the components of three commonly-administered objective measures of physical functional and frailty in clinical and research settings: the Short Physical Performance Battery (3-meter or 4-meter usual walk, 5-repeated chair stands, 3 static balance poses), the Timed Up and Go, and the Physical Frailty Phenotype (15-foot usual walk, grip strength).  Our approach included crowdsourcing and literature review on 1) the feasibility, safety, and accuracy of virtual assessments using or adapting these objective measures; 2) the correlation of selected subjective and objective measures of function.

With a collaborating team of interdisciplinary investigators from 10 different U.S. institutions, we completed the literature reviews and summarized our findings.  In brief summary, we found the following:

  • Feasibility, safety, accuracy of virtual assessments: Very limited existing guidelines were uncovered for the administration of virtual functional and frailty measures. Therefore, we created a reference list to guide clinicians and researchers to related expert recommendations on the remote, telehealth administration of assessment and care generally. Important considerations include sensory, cognitive, and physical limitations, as well as adequate physical space and available supervision.
  • Correlation of selected subjective and objective measures of function: Moderate correlations were found between objective performance tests and self-reported measures, except for with grip strength, which had only low correlations with self-reported function. No studies reported extremely high correlations which suggests the different modalities reflect related but distinct domains of function. Small sample sizes / clinical settings can affect generalizability.  Self-reported measures can serve as screening tools for persons at potential risk for functional deficits and when safety concerns preclude virtual objective testing.

Based on these findings, we developed a set of tip sheets that recommend a stepwise approach to the remote / virtual assessment of physical function / frailty for care and/or research purposes. Initial safety screening questions can help identify individuals who may be at the highest risk of injury or who are unlikely to be able to successfully complete the testing during a virtual video call. For this group, we provide a list of subjective functional and frailty questions that have reasonable correlation to act as a surrogate assessment until in-person measures can be safely conducted.  For others, we included a list of supplies needed to carry out testing at home and provided simple instructions for objective measures. The presence of a caregiver or helper on the patient’s or study participant’s end is highly advised.

In conclusion, Telehealth is here to stay. A significant advantage is that the ability to conduct remote visits broadens the reach of geriatric assessment to those who do not have access to local specialized geriatric care, but we need to strengthen our clinical and research methods with additional testing of reliability, reproducibility and safety of remote assessment tools.

We hope you will review the full report and tip sheet that resulted from this work. And we hope that clinicians and researchers will consider standard approaches such as those outlined in the tip sheets in order to help standardize administration protocols and allow better comparison of data across clinical and research samples.

Blog post by Brian Buta, with great thanks to project leader, Megan Huisingh-Scheetz, and to our collaborators and co-authors on this project: Abdulaziz Abaoud, Karen Bandeen-Roche, Margaret Danilovich, John Hall, Erin Harrell, Louise Hawkley, Helen Lach, Michelle Martinchek, Aarti Mathur, Nabiel Mir, Carrie Nieman, Pamela Toto, and Walter Boot.

Middle Aged Couple With Computer Tablet

Johns Hopkins Frailty Science Researchers Contribute to a Global Frailty Seminar Series

Dr. Jeremy Walston and Dr. Karen Bandeen-Roche, Frailty Science’s co-PIs, are participating in a novel Frailty Seminar Series along with other influential aging and frailty researchers from around the world over the coming several months. The highly-informative Frailty Seminar Series is an 11-month program aimed at promoting scientific exchanging and sharing evidence-based practices and research advances about all aspects of frailty around the globe. Continue Reading

Dr. Jeremy Walston and Dr. Karen Bandeen-Roche, Frailty Science’s co-PIs, are participating in a novel Frailty Seminar Series along with other influential aging and frailty researchers from around the world over the coming several months.  The highly-informative Frailty Seminar Series is an 11-month program aimed at promoting scientific exchanging and sharing evidence-based practices and research advances about all aspects of frailty around the globe.

On October 13th, Dr. Jeremy Walston joined Drs. Matteo Cesari (University of Milan, Italy) and Kenneth Rockwood (Dalhousie University, Canada) to present “Frailty as an Outcome of Clinical Trials” as part of this series.   Dr. Cesari spoke to the clinical relevance and scientific relevance of health outcomes pertaining to frailty within the context of aging, and to the importance of frailty definitions and assessment tools.  Dr. Rockwood addressed the complexity of measuring frailty in clinical trials, a summary of mortality risks observed by cardiologists, and characteristics of qualify frailty measures demonstrated through clinical trials. Finally, Dr. Walston discussed the physical frailty phenotype, its biological underpinnings, and the use of both the physical frailty phenotype and the frailty index in clinical trials.  Recommendations were made to target pre-frail groups in clinical study development, and using frailty as a secondary outcome given present FDA targets of primary outcomes in older adult related to physical and cognitive primary outcomes.  

These seminars are recorded.  For your convenience, here are links to the Frailty Seminar Series recordings to date:

All seminars held at Noon ET on the second Wednesday of each month through July, 2022.  The next seminar will be held on December 8th: “Frailty and Vaccine Effectiveness and Response to Infections” with Dr. Melissa Andrew from Dalhousie University, Canada. 

You may be interested to know that Dr. Karen Bandeen-Roche will present “Progression of Physical Frailty and The Risk of All-Cause Mortality” at the session on February 9, 2022.  Without a doubt, her presentation will be thoughtful, insightful, and compelling.  Don’t miss it!

Certificates of attendance are provided.  AMA CMEs are available for those eligible.  You may register for one Frailty seminar or all of them here.  The series is sponsored by the Geriatric Research Education and Clinical Center, and its organizing committee includes scientific leaders from four continents.

Finally, if you are a seeking a postdoc opportunity that explores some of these ideas, take a look at the fabulous T32-funded Translational Aging Research fellowship (PI: Dr. Jeremy Walston) and the Epidemiology and Biostatistics of Aging training program (PI: Dr. Karen Bandeen-Roche) here.

Details about the series, the organizing committee, and the full Frailty Seminar Series presentation schedule appear below:

FSS ScheduleFSS Details & Org Cmte

For World AIDS Day, December 1st: How does one face aging when they never planned to survive? 

Screen Shot 2021-11-23 at 4

The average age of people living with HIV in most care settings in the United States is 50 years of age or older. For many in this group, a diagnosis of HIV may have occurred decades ago and was accompanied, at the time, with the almost certain fate of disability and eventual death.

This led to people living for the day with no ability to contemplate tomorrow, much less, aging with the virus for decades. Living with the clinical consequences of HIV mono therapy and the subsequent resistance to antiretroviral therapy as well as the significant toxicities associated with these older therapies is a double-edged sword.  On the one hand, their lives were saved, and on the other, quality of life and wellness during the aging process were often sacrificed.

This past week, I had the opportunity at the Association of Nurses and AIDS Care Conference to listen to our elders from across the US who are living and aging with HIV. They wanted us to know that while they’re so happy to be alive they often feel that we as a clinical community have been slow to respond to their voices. Not only do many continue to feel isolated because they’ve lost their formative friend group, but some also reported struggling to make new friends as they continued to live.  Social isolation and loneliness heighten the negative impacts of aging through both biological and psychosocial mechanisms. These conditions enhance frailty (see: HIV and Frailty) and likely contribute to earlier transition to long-term care facilities.

Leaving one’s home and transitioning to long-term care is stressful for anyone.  The fear and anxiety of losing autonomy is coupled with concerns of losing dignity from receiving care, meals, and baths from strangers.  This already challenging situation is made worse when living with HIV.  First, the concern of needing to hide your HIV status and the potential for stigma and discrimination by both healthcare workers and other seniors is very real.  Second, long term care facilities are often ill equipped to manage HIV treatment.  Finally, members of the LGBTQ+ community with HIV suffer the potential need to go back into the closet to avoid further discrimination associated with sexual orientation.

There is hope for change, however.  The community aging with HIV is an active group of seniors who are advocating for change around the world.  Here in Baltimore, “Older Women Embracing Life” was founded in 2005 by women living and aging with HIV out of a premise that emotional support enhances quality of life and reduces psychological stress for people with HIV.  Another group called, “Let’s KickASS,” which stands for AIDS Survivor Syndrome, was founded in 2013 by long-term HIV survivors in San Francisco. Both not-for-profit agencies are pillars of the HIV and aging community.  They support members, patients, care givers, long-term care facilities, and others by increasing awareness of the complex nature of HIV and aging.  Their advocacy is essential to highlighting the community’s voice and we must listen.

Researchers focused on aging also have the opportunity to consider people with HIV in their programs.  For example, a program known as Community Aging in Place or CAPABLE, developed by the Johns Hopkins School of Nursing Professor and now Dean of the School of Nursing, Dr. Sarah Szanton, is transforming aging successfully at home. CAPABLE was designed for low-income seniors to improve safe aging in place.  The approach includes a nurse, an occupational therapist, and a handy worker to address both the home environment and uses the strengths of the older adult to improve safety and independence.  This program is now endorsed by the Center for Medicare.  The original work included only a handful of people with HIV and now collaborations are underway to consider the development of CAPABLE-HIV.  This work will focus on how to adapt CAPABLE for people with HIV and determine the unique needs for safe aging in place for this community.  While in the formative stages, we believe this effort will contribute to national efforts to improve aging in place for people with HIV.  The newly formed Center for Infectious Disease and Nursing Innovation (CIDNI) and the long-standing Center for Innovative Care in Aging are partnering to move this effort forward.  Keep watching this space for opportunities to participate in community advisory board discussions.

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.    

Intergenerational African American Family

November 14th is World Diabetes Day

Getty image African American Older Man With Glucometer Kit

Diabetes is extremely common in the older adult population, affecting more than one-quarter of Americans aged 65 and older. In addition, approximately half of older adults have prediabetes; these are individuals are more likely to develop diabetes in the next few years in the absence of appropriate lifestyle interventions. Thus, three-quarters of the older adult population is either at high-risk for diabetes or already has diabetes.

As people with diabetes live longer, there are many geriatric conditions that occur more frequently in people with diabetes compared to those without diabetes, including cognitive impairment, incontinence, falls, and polypharmacy. Our research in the Women’s Health and Aging Studies has found that diabetes is also linked to frailty (Kalyani et al., 2012;  Kalyani et al., 2012). Persons with frailty are much more likely to have diabetes than those who are non-frail or prefrail and they also have dysregulation in hormones of energy metabolism. Previous research has suggested that this relationship is potentially bidirectional: persons with diabetes are more likely to develop frailty, and those who are frail are more likely to develop diabetes. Our studies have also found that higher levels of blood glucose are related to the development of frailty over time, which provides additional insights into potential underlying pathways linking diabetes and frailty.

Physical frailty is defined by unintentional weight loss, low physical activity, exhaustion, slowness, and decreased strength. Emerging data suggest that an accelerated loss of muscle mass, called sarcopenia, may be the key link between diabetes and frailty. Persons with type 2 diabetes (which comprises vast majority of diabetes in older adults) are vulnerable to excessive age-related muscle loss. Although muscle loss can begin in persons with diabetes at younger ages, it occurs more rapidly in older ages, compared to those without diabetes. The loss of skeletal muscle can significantly impact quality of life for people with diabetes and also increase the risk for falls, hospitalization, and mortality.

While diabetes accelerates the process of muscle loss, the mechanisms aren’t fully understood. There are probably multiple mechanisms linking type 2 diabetes and sarcopenia (Kalyani et al., 2014). For example, one of the key roles of insulin is to move glucose from the blood into skeletal muscle tissue where it is necessary for cell function and stimulates protein synthesis. In type 2 diabetes insulin signaling is impaired and insulin is not able to effectively drive glucose into the muscle tissue. This insulin resistance is associated with decreased protein synthesis in the muscle, leading to loss of muscle mass and decreased strength. Insulin resistance is also associated with mitochondrial dysfunction, which results in a decline in skeletal muscle function.

As we celebrate World Diabetes Day this year, we need to recognize that the rapidly increasing number of older adults, and therefore older adults with diabetes, poses a unique challenge to clinicians and researchers. In particular, considerations of the consequences of diabetes beyond the traditional complications such as heart disease and on other morbid conditions such as sarcopenia and frailty, need to be urgently addressed in order to preserve quality of life and reduce mortality for this population.

Advancing the visibility of frailty research: Upcoming spotlight on novel and exciting research questions 

The term “frail” has evolved from a catch-all phrase to describe older persons with a wide range of health conditions to a more refined set of theories and definitions that aim to characterize systemic vulnerability to poor health outcomes. Research on frailty has flourished in recent years, and this growing energy to study and utilize our understanding to best improve the health of older adults sits at a tipping point that we believe can benefit from a targeted focus on existing gaps in our frailty-related knowledge.
To this end, BMC Geriatrics has announced a call for a collection of papers focused on frailty research: https://bmcgeriatr.biomedcentral.com/frailty. Categories include: Epidemiology and Measurement; Frailty Biology; Frailty and Clinical Care; and Interdisciplinary Topics. As noted in a recent editorial, there are four topics  highlighted in hopes of advancing the field toward tackling novel and exciting research questions:
1)    Causes of frailty, distinguishing by primary, biologically-driven causes or secondary disease-driven processes that lead to frailty.
2)    Innovative interventions, including targeting frailty itself as well as approaches for care delivery for frail persons
3)    Biological studies of novel biological mechanisms responsible for the generalized physiological dysregulation associated with frailty, specifically omics-based studies
4)    Integrated solutions beyond clinical medicine for identifying and managing frailty
The call for papers for the Frailty collection is open now; please consider submitting your research!
The full editorial by the collection’s Guest Editors, Prof. Ivan Aprahamian and Dr. Qian-Li Xue, is available here: “Shaping the next steps of research on frailty: challenges and opportunities.”

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.

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.

Understanding the etiology underlying frailty: Making frail older adults less frail 

Why do older adults grow frail? 

Because they grow old–but not only this. We all know, or we recognize as researchers, that some octogenarians thrive, while others ten years younger are highly vulnerable. 

Our field of gerontology often asks a different question: How should an older adult’s frailty influence the care we provide them? That’s important. So also, though, is to treat the frailty itself: truly treat, and not just ameliorate symptoms. This is what any one of us would wish if we were frail—to not be as frail anymore. 

Our group here at Frailty Science has been pursuing the goal of forestalling and turning back frailty for more than two decades. Which brings us back to the question where we began—why do older adults grow frail? If we knew the answer, maybe we could reverse the process: at least, take it a few steps back. The evidence base we have accrued points to a potential answer: People become physically frail because their physiology reaches a pattern and threshold of dysregulation making it impossible to sustain, even qualitatively, its intended functioning. 

You can imagine how thrilled and privileged we felt recently, then, when Nature Aging published a compendium of our work in its inaugural issue. In brief, we hypothesize that frailty results from critical dysregulation in multiple physiological systems—not any systems, but a few specific systems that are central to stress response, musculoskeletal integrity, and energy metabolism. Dynamical systems theory may then provide a useful lens to recognize impending critical transitioning out of qualitatively “normal” physiological functioning, and emergence into a radically different, frail state of functioning. The component systems—stress response and etc.—would be “modules” in the overarching dynamical system, and then their integrity, protocols for interacting with each other, preservation of redundancies against failures, and the like are parameters governing the overarching functioning. Elegant mathematics are available to characterize these parameters: We believe the parameters’ estimation in the context of stressor perturbation hold promise both as biomarkers of frailty and levers to identify intervention points that could indeed turn back frailty—at least, frailty below a severity threshold where intervention remains possible.  

If you’re interested, we hope you’ll check out this work further: 

Nature Aging Article  

Johns Hopkins Press Release