Professor Kenneth Rockwood has published more than 300 peer-reviewed scientific publications and seven books, including the seventh edition of the Brocklehurst’s Textbook of Geriatric Medicine & Gerontology. He is the Kathryn Allen Weldon Professor of Alzheimer research at Dalhousie University, and a staff internist and geriatrician at the Capital District Health Authority in Halifax in Canada.
In May 2016 I was honoured to speak about frailty at the Chinese National Geriatrics Conference in Beijing. The audience, not just geriatricians, was people who care for frail older adults. They recognized in geriatric medicine the tools and concepts needed to improve the care of those patients.
For that reason I found myself discussing how best to translate the great Bernard Isaacs’ nicely alliterative phrase “Geriatric Giants. In The Challenge of Geriatric Medicine (Oxford: OUP, 1980) Isaacs elaborates them, also alliteratively, as “instability, immobility, incontinence, intellectual impairment/memory and impaired independence”. These were key ways in which patients and their families understood that “something was wrong”.
Isaacs enhanced the transmissibility of what had taken geriatricians some time to observe, and further time to make common teaching. How are these disease presentations “giants”? A common account is that each is a sensitive but non-specific sign of illness. As argued in a Lancet seminar (2013 381(9868):752-62 they can also be seen as “frailty syndromes”. Here’s how. Past age 20, on average people accumulate deficits at a characteristic rate, doubling about every 15 years (Biogerontology 2016 17(1):199-204). By two doublings (about age 50) deficits are no longer imperceptible. The next two doubling times (between ages 50-80) make clear that as deficits interact, they damage repair mechanisms, thereby increasing their lethality (Physical Rev E 2016; 93(2-1):022309). That lethality is what makes the doubling from ages 80-95 the last for most people.
When enough deficits arise to make a person not just old, but frail, then another way to understand the lethality of deficit accumulation is that some illnesses are severe enough to threaten “whole system” viability. When complex systems fail as a whole, then their high order functions fail first. For humans, our high order functions include upright bipedal ambulation, divided attention, opposable thumbs, and social engagement. Their failure is represented by falls, impaired mobility, delirium and incontinence (and arguably, social abandonment). Hence “frailty syndromes”. It is not simply that these presentations are sensitive but non-specific signs of illness. They reflect multiple, interacting medical and social deficits that increase the risk of adverse health outcomes, including death, dependence and institutionalization.
There is more to Isaacs’ choice of words than alliteration. Giants are large and powerful. If they are to be confronted, they must be taken seriously. For this, recognition is an essential first step. Isaacs’ was a call to action. It countered the passivity, even disgust, of many physicians at the notion of a patient who could not give a history, or sit up in bed, or even maintain control of the bowels. Instead, it reminds us that these are worthy adversaries, threatening the health and lives of the patients entrusted to our care.
This is an abbreviated version of an editorial that will appear in the Chinese Journal of Geriatrics. Used with permission.
Beijing, May 15, 2016.