Translating Isaacs

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”.

Why rehabilitation must be part of acute care

Kenneth Rockwood is Professor of Medicine (Geriatric Medicine & Neurology) and consultant geriatrician at Capital Health in Halifax, Nova Scotia, Canada and Honorary Professor of Geriatric Medicine at the University of Manchester.

Many older people leave hospital frailer than when they started. Some of that is preventable, but much of the damage done by acute illness is baked in to how frailty works. Some of it is reparable. That is why rehabilitation must be part of acute care: if we cannot prevent damage, we should at least treat it, especially damage that we inflicted unnecessarily.

The gist of it is easy enough. When frail patients are unwell enough to come to hospital, they typically are not thinking, functioning and moving like they were before they became ill.  That is usually why they come. That, and whatever other symptoms (breathlessness, pain, something red or swollen) signal a problem.  Even when fixing the precipitants, modern care often does nothing to address the worse thinking / mobility / function in which the problems were packaged.  Such complexity of need defines frailty.

Discovering ageing

Kenneth Rockwood is Professor of Medicine (Geriatric Medicine & Neurology) and consultant geriatrician at Capital Health in Halifax, Nova Scotia, Canada and Honorary Professor of Geriatric Medicine at the University of Manchester. Here he reports from the 12th International Conference on Alzheimer’s and Parkinson’s Diseases, held in Nice.

At the March 2015 AD/PD meeting in Nice, the big news, for me anyway, wass that ageing is making its way back into dementia. Sessions such as “Impact of co-morbidities on Alzheimer’s pathogenesis and cognitive function in mouse models” and “Stress and telomere maintenance mechanisms in human life trajectories” elbowed their way into a program with presentations on “the analysis of longitudinal amyloid PET images” and “How do we treat Alzheimer’s disease a decade before dementia?”.

Chinese Geriatric Medicine

Prof Kenneth Rockwood is Director of Geriatric Medicine Research at Dalhousie University, Canada, adjunct Professor of Geriatric Medicine at the University of Manchester and serves on the International Advisory Panel of Age and Ageing journal. 

The Chinese Geriatrics Society met on May 24 2014, brought together for the 7^th National Conference on Prevention and Control of Common Diseases in Elderly People. As a speaker and honorary conference co-chair, I’ve been able to see some of the workings up close.  Geriatrics transcends many aspects of culture, so that much would be familiar to any BGS meeting attendee – and not just the apparently universal audiovisual glitches (I did not go unspared).

Mitigating the effects of severe illness and critical care: lessons for frailty management.

Prof Kenneth Rockwood is Director of Geriatric Medicine Research at Dalhousie University, Canada and serves on the International Advisory Panel of Age and Ageing journal. 

People who are frail have accumulated more health deficits than have others of the same age. Deficit accumulation occurs when damage either goes unremoved (or unavoided) or unrepaired.   That’s why rational management of frailty needs to pay attention both to reducing the exposure to damage, and to increasing its removal or repair.  The same can be brought to mitigating the consequences of acute illness and its treatment. A recent study of patients admitted to an Intensive Care Unit (ICU) shows how.

In the before/after controlled trial of a bundled set of interventions to improve outcomes of critically ill patients (296 aged 19-late 80s, 187 of whom were intubated) Balas et al. were able to reduce delirium duration and mobilize patients early. The study was conducted in several critical care units in a large tertiary care teaching hospital.

Geriatric Medicine and the burden of common sense.

Prof Kenneth Rockwood is Director of Geriatric Medicine Research at Dalhousie University, Canada and serves on the International Advisory Panel of Age and Ageing journal. 

I’ve been teaching geriatric medicine for about 25 years. During that time, my attitude towards the common sense of geriatric medicine has changed. At first, I saw it as a great blessing: it was easy to let people know what they needed to do. Then I began to see it as a challenge: an audience could sit through a diverting 40 minutes, but in the end not be persuaded that they have learned anything. “Nothing to that – it’s all common sense”. Now I see the common sense of what we do as a foe, and one that we should conquer.

Book review : A Life worth living: Albert Camus and the quest for meaning

Professor Kenneth Rockwood reviews an inspirational book about the life and ideology of Albert Camus, the French Nobel award winning author, member of the Resistance and erstwhile philosopher. Professor Rockwood draws parallels from Camus’ life, thoughts and actions that relate to our daily lives, present challenges faced by the NHS and our care of older patients.

• Title: A Life Worth Living: Albert Camus and the quest for meaning.
• Author: Robert Zarestsky.
• Publisher: Harvard University Press
• ISBN: 978-0674724761
• Price: $22.95
• Year of publication: 2013.

The unsurprising flurry of books in the run up to the 100^th anniversary, in 2013, of the birth of Albert Camus, has prompted many claims – notably by French politicians of both the Left and Right – to his legacy. So what about Camus as – if not geriatrician – then gerontologist?

How might health deficits in cells scale up to become clinically visible?

Prof Kenneth Rockwood is Director of Geriatric Medicine Research at Dalhousie University, Canada and serves on the International Advisory Panel of Age and Ageing journal. 

A July Age and Ageing paper on frailty considered how subcellular damage might “scale up” to lead to clinically detectable deficits. In December, a paper from Biogerontology addressed how deficits originate, and how they might scale.  The proposed answer appears to be powerful and offers some insights into how to think about frailty and disease in older adults.

Deficit accumulation as an explanation for ageing and frailty – from the subcellular to the substantial

Prof Kenneth Rockwood is Director of Geriatric Medicine Research at Dalhousie University, Canada and serves on the International Advisory Panel of Age and Ageing journal.

Prof Susan Howlett is  also at Dalhousie, University, Canada in the Department of Pharmacology.

A lot happens at the molecular and cellular levels as we age. A recent review in Cell  identified nine hallmarks of ageing, including genomic instability, mitochondrial dysfunction, cellular senescence and stem cell exhaustion.  These, of course, are intrinsically inter-related; the DNA damage that underlies the hallmark genomic instability accelerates with telomere shortening (another hallmark) and is associated with altered protein homeostasis (another hallmark still). This molecular and cellular deficit accumulation is now widely understood as the basis of how we age.

The Relationship Between Wealth and Frailty

Prof Kenneth Rockwood is Director of Geriatric Medicine Research at Dalhousie University, Canada and serves on the International Advisory Panel of Age and Ageing journal.

It’s never good to be frail, but it’s worse to be frail and poor, or to be frail in a tough environment. That would be one conclusion from a recent analysis of data from middle-aged and older adults in the Study of Health, Ageing and Retirement in Europe (SHARE). This analysis (by our group) showed that the number of health problems people have (the mean deficit count in a frailty index) was strongly and negatively correlated with national wealth (measured by Gross Domestic Product – GDP). In fact, for the 15 countries evaluated, per capita GDP “explained” about 60% of the variance in the national level of frailty.