Simplifying Frailty Assessment in Kidney Transplant Patients: Introducing the Abridged Frailty Phenotype

Image of Human Kidneys by Unknown Author is licensed under Creative Commons BY
Image of Human Kidneys by Unknown Author is licensed under Creative Commons BY

It’s widely known that frailty is associated with poor outcomes in surgical patients including kidney transplant patients. National projections estimate that 16.4% of transplant candidates and 14.3% of recipients are frail (Haugen et al, 2020). Remarkably, transplant centers that measure frailty achieve better pre- and post-operative outcomes (Chen et al, 2022). However, frailty assessments aren’t consistently used at transplant centers for many reasons, with time constraints being a significant barrier (McAdams-DeMarco et al, 2020). Therefore, we sought to create a more condensed frailty assessment that does not compromise on discrimination of clinical outcomes.

In our recent study published in The Journals of Gerontology, we propose a new frailty assessment, the abridged frailty phenotype (Chen et al, 2023). The abridged physical frailty phenotype was developed by simplifying the five physical frailty phenotype components (Fried et al, 2001) in a two-center prospective cohort of 3,220 kidney transplant candidates (Table 1). We found that the physical frailty phenotype and abridged assessment identified 23.8% and 27.4% candidates as frail, respectively. The abridged frailty physical phenotype had substantial agreement (kappa = 0.69, 95% CI: 0.66–0.71) with the physical frailty phenotype and excellent discrimination of it (AUC = 0.861). Among a subset of 20 patients at evaluation, the abridged assessment took 5–7 minutes to complete. The physical frailty phenotype and abridged assessment had similar associations with waitlist mortality (subdistribution hazard ratio [SHR] = 1.62, 95% CI: 1.26–2.08 vs SHR = 1.70, 95% CI: 1.33–2.16) and comparable mortality discrimination, using Harrell’s C-statistic (p = .51).

The results of this study support the use of this novel, validated light-touch frailty phenotype in clinical settings. It offers a cost-effective, objective measure of frailty that is both easier and more efficient to use when compared to the original physical frailty phenotype. Importantly, it maintains high accuracy in identifying frail and non-frail patients. Therefore, transplant departments should consider utilizing the abridged assessment to evaluate frailty in patients when time is limited.

It’s important to note that our aim is not to add yet another frailty assessment to the existing arsenal (Buta et al, 2016). In 2018, the American Society of Transplantation concluded that “a standard, validated measure of frailty is yet to be established” for the field (Kobashigawa et al, 2019). We hope that the abridged physical frailty phenotype can fill this gap and become universally accepted across disciplines. Standardization is essential when we discuss frailty; we must ensure that we are all speaking the same language by using consistent tools for measurement.

In conclusion, the development of the abridged physical frailty phenotype represents a step forward in improving the care and outcomes of our patients. Its simplicity, efficiency and effectiveness make it a valuable addition to the toolkit of providers and researchers alike, paving the way for standardized frailty assessment in the future.

Table 1. Components of the original physical frailty phenotype (PFP) and the abridged physical frailty phenotype.

This work was supported by NIH grant R01AG055781 (PI: McAdams-DeMarco).  Dr. Quint was a visiting scholar at NYU Grossman School of Medicine while working on the publication.

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:

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:

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, 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:

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:

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.

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

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: 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.”

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

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

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

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

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

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

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

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

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

  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


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