The Geriatric Surgery Program at Johns Hopkins

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Susan Gearhart, MD

Susan Gearhart, MD

Associate Professor of Surgery
Johns Hopkins University School of Medicine

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

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

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

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

Dr Sally Gearhart in Bayview Geriatric Med Vid

(Click on the image to view the video.)

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

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

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Karen Bandeen Roche, PhD

Karen Bandeen Roche, PhD

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

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

Announcement: Frailty Science 2.0–Website Update

/by
Tony L. Teano, MLA

Tony L. Teano, MLA

Communications Specialist
Johns Hopkins University School of Medicine

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

 

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

 

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

 

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

 

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

Frailty and Cognitive Impairment: Time to Acknowledge and Embrace Heterogeneity

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Qian-Li Xue, PhD

Qian-Li Xue, PhD

Associate Professor of Geriatric Medicine
Johns Hopkins University School of Medicine

Frailty and cognitive impairment, two common geriatric conditions, are known to be associated with late-life vulnerability in older adults (Todd et al., 2013; Cesari et al., 2016; Fried et al. 2001). An estimated 15% of non-nursing home older adults in the United States aged 65 and over are frail (Bandeen-Roche et al., 2015), and about 22% and 9% have mild cognitive impairment and dementia (Katz et al. 2012; Langa et al., 2017). Physical frailty and cognitive impairment often co-exist in older adults. However, there are sizeable subgroups who have one but not the other. According to a recent US population-based study published in the Journal of the American Geriatrics Society by Ge and colleagues (Ge et al., 2020), 67% of frail older adults had cognitive impairment, and 29% of older adults with cognitive impairment were frail. That physical frailty and cognitive impairment may not manifest together is reinforced by clinical encounters with older adults who are physically robust but cognitively frail and vice versa. 

The study by Ge et al. also found that individuals with frailty only (meaning without cognitive impairment) had the highest prevalence of obesity, current smoking, multimorbidity, lung disease, and history of surgery. The group with both cognitive impairment and frailty were the oldest on average and had the highest prevalence of dementia, depression, cardiovascular diseases, and disability. It is also worth noting that the prevalence of dementia in the group with both frailty and cognitive impairment was more than doubled compared to the group with cognitive impairment alone. This latter finding makes it plausible that the comorbid status could result from frailty being a sequela of cognitive impairment beyond a certain severity. Alternatively, the joint versus separate occurrence of frailty and cognitive impairment may signal different etiologies and pathways. Preliminary support of the latter came from a recent longitudinal study showing that people on a trajectory to develop dementia were three times more likely to experience concurrent onset of frailty and cognitive impairment than to develop cognitive impairment first (Chu et al., 2019). Taken together, these findings suggest that the co-occurrence of cognitive impairment and frailty may be driven primarily by neurologic pathologies rather than “normal” cognitive aging or physical impairments. By contrast, the group with cognitive impairment only may represent mostly normal cognitive aging with less disease burden, as shown in the study by Ge et al.

The findings above support the value of assessing frailty and cognitive impairment in tandem in clinical settings in order to achieve greater measurement specificity as well as inform the selection and prioritization of treatment targets. For example, the group with frailty only may benefit from tailoring interventions based on specific disease profiles. In contrast, the group with cognitive impairment only may largely reflect non-pathological cognitive aging given their lower dementia prevalence and multimorbidity burden (cardiovascular diseases in particular), and therefore may benefit from lifestyle interventions. The group with comorbid frailty and cognitive impairment on the other hand may benefit from interventions that target both dementia-related pathologies and vascular risk factors to slow down the progression of dementia and the accompanying diseases. Now is the time to embrace a paradigm shift from pursuing research on frailty and cognitive impairment in silos to an integrative and holistic approach by which precision medicine can succeed in caring for older adults.

World AIDS Day 2020 Reflection–Frailty, Resilience, and Impact.

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Todd Brown, MD, PhD

Todd Brown, MD, PhD

Professor of Medicine, Division of Endocrinology, Diabetes, & Metabolism
Johns Hopkins University School of Medicine

On December 1st 1988, the first World AIDS Day was observed to support people living with HIV (PLWH) and remember those who died during the initial phase of the AIDS epidemic.  Now, 32 years later, HIV has been transformed into a chronic disease with the widespread use of effective combination antiretroviral therapy. The goal of ending the HIV epidemic, while aspirational, is increasingly achievable with the widespread test and treat efforts and very effective prevention strategies.

 With survival of PLWH approaching that of peers without HIV, the HIV population is aging and the majority of PLWH in the US are now over 50 years old. Over the past 10 years, we have seen many reports documenting that aging-related comorbidities occur at an earlier age in PLWH and some have posited that HIV may represent an accelerated aging phenotype, which is driven by chronic immune activation.  There is much work to be done to understand the pathogenesis of comorbid diseases in PLWH and determine the extent to which this is the same or different than people without HIV.  We also need to understand the drivers and manifestations of physical frailty in this vulnerable population.  Here’s a link to an introduction to this area of HIV and Frailty. 

 While potentially vulnerable to the impact of aging-related conditions, older PLWH are also extremely resilient.  They know exactly the devastation that this disease caused and how to face its challenges.  As we face another viral epidemic, I am struck by the perspective of PLWH and their strength in the face of adversity and uncertainty.   The theme for World AIDS Day 2020 is “Ending the HIV/AIDS Epidemic: Resilience and Impact.”   For older PLWH, improving health span is essential, and their resilience forged from their lived experience in the early days of the HIV epidemic will be instrumental to achieve this goal.

#WorldAIDSDay2020

Safer Holiday Plans for Older and Vulnerable People

/by
Tony L. Teano, MLA

Tony L. Teano, MLA

Communications Specialist
Johns Hopkins University School of Medicine

It should come as no surprise that observing the holidays will be different this year.  Here we outline important considerations about holiday gatherings during COVID-19 times, with special consideration to the health of older and more vulnerable relatives and friends.

First, leaders from Johns Hopkins Medicine are urging caution this holiday season.  In a recent memo to faculty, staff, and fellows, they provided the following guidance:

“As you consider participation in various forms of holiday gatherings, please be thoughtful and exercise great care to protect yourself and your loved ones, especially those who are elderly, have underlying medical conditions, or are otherwise more vulnerable to severe consequences from the infection.”

As we approach the Thanksgiving holiday, COVID-19 cases and deaths continue to increase dramatically in the US, and throughout many places worldwide. With winter upon us, everyone is spending more time inside with poor ventilation and dry air—ripe conditions for viral community spread.  At the same time, many people find themselves suffering from Pandemic Fatigue (or COVID-19 Caution Fatigue), and yearning for connection with family and friends.  Though we long to return to normal holiday rituals, it is so important for the health and wellbeing of our older friends and family members that we redouble our resolve to keep ourselves and our loved-ones safe.   Indeed, the Centers for Disease Control (CDC) warns that “small household gatherings are an important contributor to the rise of COVID-19 cases.”  By finding alternative ways to celebrate and reconnect with those dearest to us, we may be able to have safer holiday plans for frail, older, and vulnerable populations.  Below are the CDC’s assessment of lower to higher risk holiday activities:   

Lower Risk: 

  • A small dinner with the people in your household
  • A virtual dinner with family and friends
  • Preparing food for family and neighbors (especially those at higher risk of severe illness from COVID-19 who are physically distancing), and delivering it to them without person-to-person contact
  • Shopping online rather than in person on Black Friday and Cyber Monday
  • Watching sports events, parades and movies at home

Moderate Risk Activities: 

  • A small outdoor dinner with family and friends who live in your community
  • Visiting pumpkin patches or orchards where people are taking COVID-19 safety precautions like using hand sanitizer, wearing masks and maintaining physical distance
  • Small outdoor sports events with safety precautions in place

Higher Risk Activities: 

  • Going shopping in crowded stores just before, on or after Thanksgiving
  • Participating or being a spectator at a crowded race
  • Attending crowded parades
  • Using alcohol or drugs
  • Attending large indoor gatherings with people from outside of your household

As difficult as it may be, there are some individuals whose health conditions should preclude them any gatherings. The CDC advises the following people should not host or attend in-person holiday gatherings outside of their household; including anyone who:

Please see CDC guidelines here to help celebrate Thanksgiving more safely.

Safer Alternative Holiday Planning:

The reality is that socializing during Thanksgiving is likely going to be very limited in real life and may only include those in your household, but the potential for virtual or telephone connection is abundant for almost everyone. This social connection is especially important for our frail and isolated relatives and friends. If you would like to get ideas for hosting a virtual Thanksgiving, you will be pleased to know that the AARP has put together excellent suggestions, which you can find here as well as a “how to” guide, which you can find here.  As noted in a recent NIH Director’s blog, breaking the traditional way we observe Thanksgiving allows the opportunity for something new to emerge and blend in with time-honored traditions.  Here are some ideas to consider:

  • Don’t like Turkey?  Make a dish you love instead! 
  • Love cooking?  Ask for signature dish recipes from you family and friends and share yours! (Here’s a pecan pie recipe my grandmother made every Thanksgiving.)
  • Have you put on your COVID 19lbs?  Mask up and take a Thanksgiving walk and be mindful of nature, and maybe stroll with your pod maintaining physical distance
  • Missing family and friends?  Call them over the weekend on the phone or a video chat service, or write them a note.
  • Need to be more thankful this Thanksgiving?  Start a gratitude journal—it is really good for your outlook and mental health.
  • Want to go somewhere?  Visit a place virtually.  Plenty of venues and museums offer virtual tours these days.  Some of them have programs for children, such as the Baltimore Museum of Art’s opportunity to meet Matisse’s dog, Raoudi, and learn about Matisse’s art.
  • Feeling nostalgic for Thanksgiving pass times?  Fortunately, some aspects of Thanksgiving were pretty much virtual all along.  Here’s the Thanksgiving NFL schedule.  The Macy’s Thanksgiving Day Parade is still happening—which you have probably already virtually attended in the past from the comfort of your own home! In my household, watching “It’s a Wonderful Life” was a given, as well as playing board games.

Perhaps the one thing we can all be grateful for this Thanksgiving is how swiftly coronavirus vaccine research has been progressing, and the hope that this may be the only COVID-19 Thanksgiving we must endure.  We must be grateful for our good health.  And protect it, and the health of those most vulnerable.  Know that we are in solidarity with each other this holiday season in this regard, and that we are in good company in that sense; click here for a message from Dr. Anthony Fauci, world-renowned infections disease expert:  “My Thanksgiving is going to look very different this year.”

Double Jeopardy for Older Adults of Color: An Urgent Call to Address Frailty Disparities in the United States

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Karen Bandeen Roche, PhD
Karen Bandeen Roche, PhD

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

Sarah Szanton, PhD, MSN, RN
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
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.

Overcoming the stress of selecting a frailty assessment instrument: guidance and considerations.

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Brian Buta, MHS

Brian Buta, MHS

Project Administrator, Geriatric Medicine
Johns Hopkins University School of Medicine

Research on frailty has exploded over the past two decades. A quick PubMed search of the term shows an exponential increase in the number of frailty-related publications since the early 2000s. 

NIH Library of Medicine Search on Frailty

But the concept of frailty can be diverse in its underlying theory and measurement.

Different frailty measures can identify different groups of people as frail (Cigolle et al., 2009 ; Xue et al., 2019). And different user scenarios may require different types of measures (Buta et al., 2016; Martin & Brighton, 2008). So how do we move past these challenges?

  • One option: focus on screening for frailty in order to capture vulnerability early, regardless of the measure.
  • Another option: focus on comparing measures to illuminate discrepancies in measurement, and to better inform similarities and differences between measures.
  • Or: prioritize the instrument’s ability to predict poor outcomes… or its construct validity relative to geriatric experience and theory… or its strength as a lever to elucidate and address underlying etiology….

Indeed, these approaches are all important. We need to be able to screen for frailty using existing instruments.  We also need to hone in on what information these different measures – which all fall under a blanket term of “frailty” – are actually telling us about the health of older and vulnerable persons. And for certain studies, we need to know how well frailty will predict adverse health events, while also recognizing the importance of other types of validity (Bandeen-Roche et al., 2020).

In an effort to guide researchers and clinicians who plan to assess frailty, we have posted a new section to FrailtyScience.org: “Frailty Assessment Instruments: Guidance on Selecting a Frailty Instrument.”  We aim to stress the importance of selecting an instrument that best fits the purpose of the research or clinical need.  As noted in this section, “certain measures may be better suited for different purposes.”  For example, a frailty assessment may be utilized as a quick screening instrument (e.g., the FRAIL Scale), or as a method to measure frailty in an electronic medical records system (e.g., the Deficit Accumulation Index), or as an instrument to study physical frailty as distinct from multi-morbidity or disability (e.g., the Physical Frailty Phenotype).

The field continues to lack a consensus operational definition of frailty. But if we can account for the distinct features and uses of different instruments, and if we can use language that better clarifies how frailty is assessed (e.g., physical frailty, deficit accumulation frailty, etc.; Walston et al., 2019), we may be able to improve our ability to prevent and manage health risks for vulnerable older adults across a variety of settings.

Please know that we welcome your thoughts and feedback. You can reach me with comments at bbuta@jhu.edu.

Brian Buta is a project administrator and researcher in the Division of Geriatric Medicine and Gerontology at Johns Hopkins University.  He offers his great thanks to Drs. Karen Bandeen-Roche and Qian-Li Xue for their review and feedback during the writing of this post.

 

 

Healthy Voting is a Sacred Right

/by
Tony L. Teano, MLA

Tony L. Teano, MLA

Communications Specialist
Johns Hopkins University School of Medicine

 

Voting is a sacred rightEveryone in our clinician and researcher community is invited to share vote-by-mail information with their patients and families.  This blog offers a summary of ways to help older people get out their votes as safely as possible in 2020, and it provides a voter’s personal experience on the ease of using a vote-by-mail ballot at a community-based official election ballot drop box.

 

Requesting an absentee ballot and mailing it well before election day, or placing a ballot in a designated drop box offer safe ways to minimize COVID-19 exposure based on guidance from leading experts:

 

 

  • The Bipartisan Policy Center says, “One of the best ways to vote safely is by using a mail ballot. If voting by mail or by absentee is an option for you in your state, doing so may be the best way to keep you and your community safe from COVID-19.” 

 

 

You may also opt to take advantage of voting in person at early voting places or per normal on election day in your state. Although experts believe these methods may carry greater risk for exposure to COVID-19 than voting by mail, there are important ways to decrease that risk if you choose to vote in person.  Please see the Center for Disease Control’s Recommendations for Voters.  

 

Additional information for older adults relevant to voting processes in your area can be found below:

 

  • American Association of Retired People: Resources on all the ways to cast your ballot in the 50 states, Puerto Rico and the District of Columbia; their site is linked to additional AARP information about how to protect your health and vote during the pandemic, as well as additional resources on ballot initiatives that may be of interest to older adults. 

 

  • National Council on Aging: Voting safely and healthy voting are top-of-mind in their nonpartisan resources for the 50 states, the District of Columbia and all U.S. protectorates/territories. 

 

 

PERSONAL EXPERIENCE WITH VOTING BY MAIL OPTIONS IN MARYLAND

 

I tested the sites mentioned above for Maryland’s process, and they were accurate.  Here is the process for Maryland.  At the time of this writing, the voter registration deadline has unfortunately passed—it was October 13th.  But if you are already a registered voter in Maryland, and you want to vote by mail or use a community-based official election ballot drop box, there is still time to do so.  In Maryland, you must request your mail-in ballot by October 20th. 

 

Here’s my personal experience with the process. In September, I requested a mail-in ballot online at the Maryland Board of Elections website.  After I received my mail-in ballot, I looked up all the local issues on my ballot, I carefully followed instructions and filled it out.  Mailing it back is free—it doesn’t require a stamp. But rather than mail it in, I opted to use a community-based official drop box that I found out about at the Maryland Board of Elections website.  I arrived by car at the drop box located at a local high school.  I put on my face mask.  I got out of my car.  I walked to the drop box, and I inserted my ballot.  To make sure it went all the way in, I placed my hand against the ballot box, and I heard my ballot land with a thud.  I looked up and I noticed the security cameras towering above. I felt secure that my ballot would be safe.  Because I touched the box, I used hand sanitizing lotion that I had in my pocket before touching my car door handle. When I arrived home, I washed my hands with soap and water.  The next day, I received an email from the Board of Elections that my ballot was received.  It was that safe and easy!

 

The cumulative effects of this year—civil unrest, economic strife, and the worst pandemic in a century—can make us feel powerless and small and disconnected from our loved-ones, our freedoms, our liberties, and our beloved pursuits of happiness.  Despite the circumstances, now can be a time of empowerment, dignity, and respect for older Americans’ right to vote.  There are very few events that bring us together as Americans: President’s Day; the Fourth of July; Thanksgiving; and Election Day.  I, for one, am glad to have voted and joined the millions of Americans who voted safely—with health in mind.  As they say in these times, “We’re in this together” and “Together apart.”

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

/by
Melissa deCardi Hladek, PhD, CRNP, FNP-BC

Melissa deCardi Hladek, PhD, CRNP, FNP-BC

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

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

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

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

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

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

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

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

References 

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

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

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

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

Motivation Matters: A Socratic Inquiry into Frailty

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Ravi Varadhan, PhD, PhD Varadhan, PhD, PhD

Ravi Varadhan, PhD, PhD Varadhan, PhD, PhD

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

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

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

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

PubMed: A Socratic Inquiry Into the Nature of Frailty

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

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Jeremy Walston, MD

Jeremy Walston, MD

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

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

 

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

 

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

 

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

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

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Jeremy Walston, MD

Jeremy Walston, MD

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

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

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

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

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

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

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

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

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

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

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

May 29, 2020

Welcome to the conversation on Frailty Science.

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Karen Bandeen Roche, PhD
Karen Bandeen Roche, PhD

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

Jeremy Walston, MD
Jeremy Walston, MD

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

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

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

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

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

May 4, 2020