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

 

Getty Image: Coronavirus and LungsExciting news!

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

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

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

What have you noticed with frailty and COVID?

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

What do geriatricians need to be aware of?

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

What are the top three COVID concerns everyone should know?

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

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

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

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

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

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

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

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

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

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

  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.