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

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Tony L. Teano, MLA

Tony L. Teano, MLA

Communications Specialist
Johns Hopkins University School of Medicine

 

Getty Image: Coronavirus and LungsExciting news!

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

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

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

What have you noticed with frailty and COVID?

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

What do geriatricians need to be aware of?

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

What are the top three COVID concerns everyone should know?

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

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

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

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

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

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

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

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Melissa deCardi Hladek, PhD, CRNP, FNP-BC

Melissa deCardi Hladek, PhD, CRNP, FNP-BC

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

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

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

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

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

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

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

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

References 

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

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

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

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

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