Andrea Wershof Schwartz

The Identification of Frailty: A Systematic Literature Review

An operational definition of frailty is important for clinical care, research, and policy planning. The literature on the clinical definitions, screening tools, and severity measures of frailty were systematically reviewed as part of the Canadian Initiative on Frailty and Aging. Searches of MEDLINE from 1997 to 2009 were conducted, and reference lists of retrieved articles were pearled, to identify articles published in English and French on the identification of frailty in community‐dwelling people aged 65 and older. Two independent reviewers extracted descriptive information on study populations, frailty criteria, and outcomes from the selected papers, and quality rankings were assigned. Of 4,334 articles retrieved from the searches and 70 articles retrieved from the pearling, 22 met study inclusion criteria. In the 22 articles, physical function, gait speed, and cognition were the most commonly used identifying components of frailty, and death, disability, and institutionalization were common outcomes. The prevalence of frailty ranged from 5% to 58%. Despite significant work over the past decade, a clear consensus definition of frailty does not emerge from the literature. The definition and outcomes that best suit the unique needs of the researchers, clinicians, or policy‐makers conducting the screening determine the choice of a screening tool for frailty. Important areas for further research include whether disability should be considered a component or an outcome of frailty. In addition, the role of cognitive and mood elements in the frailty construct requires further clarification.

Evaluating the impact of the humanities in medical education.

The inclusion of the humanities in medical education may offer significant potential benefits to individual future physicians and to the medical community as a whole. Debate remains, however, about the definition and precise role of the humanities in medical education, whether at the premedical, medical school, or postgraduate level. Recent trends have revealed an increasing presence of the humanities in medical training. This article reviews the literature on the impact of humanities education on the performance of medical students and residents and the challenges posed by the evaluation of the impact of humanities in medical education. Students who major in the humanities as college students perform just as well, if not better, than their peers with science backgrounds during medical school and in residency on objective measures of achievement such as National Board of Medical Examiners scores and academic grades. Although many humanities electives and courses are offered in premedical and medical school curricula, measuring and quantifying their impact has proven challenging because the courses are diverse in content and goals. Many of the published studies involve self-selected groups of students and seek to measure subjective outcomes which are difficult to measure, such as increases in empathy, professionalism, and self-care. Further research is needed to define the optimal role for humanities education in medical training; in particular, more quantitative studies are needed to examine the impact that it may have on physician performance beyond medical school and residency. Medical educators must consider what potential benefits humanities education can contribute to medical education, how its impact can be measured, and what ultimate outcomes we hope to achieve.

Bisphenol A in thermal paper receipts: an opportunity for evidence-based prevention.

The recent report by Taylor et al. (2011) on the pharmacokinetics of bisphenol A (BPA) emphasizes the similarities between humans, monkeys, and mice in the metabolism of this ubiquitous and potentially toxic synthetic chemical. The authors suggested that human exposure to BPA may be “much higher than previously assumed.” They observed that a potentially important nonfood source of exposure to BPA may be the thermal paper used in cash register receipts. BPA is found in receipt paper (Mendum et al. 2010) and appears to transfer readily from receipts to skin (Biedermann et al. 2010) and to be absorbed transdermally (Zalko et al. 2011). Retail workers, who likely have more frequent exposure to cash receipts containing BPA than other Americans, have been found to have elevated levels of urinary BPA (Lunder et al. 2010). BPA has been shown to be capable of crossing the placenta (Balakrishnan et al. 2010) and to be toxic during early mammalian development (vom Saal and Hughes 2005). This toxicity is relevant to humans, given the similarities in BPA metabolism observed across species by Taylor et al. (2011). Prenatal exposure of human infants to BPA has been associated with behavioral anomalies (Braun et al. 2009). There is a sense of deja vu about this story: In the 1970s polychlorinated biphenyls (PCBs) were widely used in carbonless copy paper (Erickson and Kaley 2011). PCBs were shown to be absorbed through the skin (Carpenter 2006), and prenatal exposures to PCBs were subsequently shown to cause irreversible brain injury to developing fetuses, which resulted in permanent loss of IQ (intelligence quotient) and alterations in behavior (Jacobson and Jacobson 1997). This exposure ended when the manufacture of PCBs was banned in the United States in 1976. The research of Taylor et al. (2011) contributes to our understanding of the potential harms to the developing fetus from BPA. These findings underscore the need to develop a new U.S. chemical policy that would require toxicological testing of widely used chemicals already on the market and premarket safety testing of all proposed new chemicals (Landrigan and Goldman 2011). The time to presume that chemicals are safe until they are proven beyond all doubt to cause injury to America’s children is past. While research into the effects of exposure to BPA continues, we have an opportunity to act today on the basis of the available evidence to remove BPA from thermal paper, as we strive to protect the health and future intelligence of America’s children.

Disparities in pneumococcal and influenza immunization among older adults in Israel: A cross-sectional analysis of socio-demographic barriers to vaccination☆

OBJECTIVE Vaccinations against influenza and pneumonia reduce morbidity and mortality among older adults. We examined vaccination rates among Israels diverse geriatric population to determine socio-demographic barriers to vaccination. METHODS This study is a quantitative data analysis with a cross-sectional design, comprising 136,944 patients aged 65 and older enrolled during 2008-2009 in the Maccabi Healthcare Services, one of Israels four sick funds (preferred provider organizations). We conducted multivariable logistic regression analyses to determine the association between vaccination status and socio-demographic characteristics, including age, gender, rural residency, socio-economic status, region of origin, immigrant status, and Holocaust survivorship. We controlled for potential confounders, including comorbidities, primary care visits and hospitalizations, as well as the physicians gender and region of origin. RESULTS Overall, vaccination rates were 72% for pneumonia and 59% for influenza. The strongest socio-demographic barriers to vaccination included female gender, rural residency, low socio-economic status, recent immigration, and being from or having a physician from the Former Soviet Union. CONCLUSION Efforts to further explore barriers to influenza and pneumococcal vaccination and interventions to reduce disparities in vaccination rates should focus on the sub-groups identified in this paper, with careful thought being given as to how to overcome these barriers.

What Van Halen Can Teach Us About the Care of Older Patients

Van Halen, the American hard rock band, dominated the music scene of the 1980s, becoming known not only for their dramatic pyrotechnics and dance moves but also for their particular pickiness when it came to preparing their dressing rooms. Their lengthy 1982 contract rider contained a stipulation that, in addition to towels and chips, a bowl of M&Ms be provided for the band—with the brown M&Ms picked out. This unusual request was the pretext for several cancelled performances—if the band discovered on arrival that there were indeed brown M&Ms in their dressing room snack bowl, they would refuse to play the show.1 As a geriatrician, my curiosity was piqued by the explanation cited for this strange behavior in a story reported on NPR: Van Halen apparently used the brown M&Ms as evidence of attention to detail on the part of the concert venue. If the venue staff had not noticed this small detail buried in the rider, the band could not trust that the complex music system and stage had been set up correctly, that the elaborate pyrotechnics would function safely. The presence of the brown M&Ms called into doubt the stability and safety of the entire concert setup. This tale from the entertainment industry resonates in the work we do as physicians caring for older adults: what are the analogous brown M&Ms we can notice when it comes to the care of frail patients with complex conditions? What are the details that, when amiss, can alert us to the risk level or stability of our patients and cause us to worry about the patient’s resilience to physiologic stress? Unlike Van Halen, when we notice these brown M&Ms we cannot cancel the show; we must use these warning signs as a reminder to check the functioning of the whole system in these high-risk patients and help support them. A physician assessing an older adult with multiple medical problems may be tempted to address issues one at a time, medical problem by medical problem, a process that can be exhausting and overwhelming for both patient and physician. Three simple geriatric assessment tools can help us pay closer attention to identify the “brown M&Ms”—the details that should prompt us to look further into the overall function and frailty of our older patients and take steps to minimize their risk for adverse outcomes. First, when our patients enter the examination room, we can watch how they walk. Gait speed is an important predictor of mortality2 and is one of the most frequently used criteria to identify frailty.3 When we notice a patient walking slowly, it can prompt us to focus on their arthritic knees or proximal muscle strength, asking whether they require better pain control, physical therapy, or an assistive device; their balance, considering whether they would benefit from vitamin D or B12 supplementation or a home safety assessment to install grab bars in their shower; and overall fall risk, prompting an evaluation of medications that could be deprescribed or fall risk factors that could be mitigated such as orthostatic hypotension or vision or hearing impairment.4 Second, as part of our physical examination, we can observe our patients performing the “sock-on, sock-off” test.5 If we notice our patients wearing slip-on shoes year round, or having difficulty donning socks—a task that requires balance, vision, dexterity, joint flexibility, and muscle strength—we have a second warning sign that they may be in danger of losing their independence and their ability to dress and care for themselves. A simple sock donner from an occupational therapist, a home health aide for a few hours a week, or a referral to local elder services might be the intervention that helps keep that older adult living independently. The third of the brown M&Ms involves paying attention to patients’ toenails, a part of the examination not typically at the top of a busy internist’s list. As geriatrician Juergen Bludau instructed in Atul Gawande’s Being Mortal, for an older patient, “you must always examine the feet.”6(p40) I have been surprised many times in my career thus far by the disconnect between how a patient is dressed and how their feet may look. Even if they have no difficulty taking off their socks and shoes, the dexterity required to cut one’s own toenails may prove more challenging. I ask my students, if you were injured and could not reach your toenails to cut them, what would you do? Ask a friend or family member, they suggest, see a podiatrist or get a pedicure. When our patients’ toenails are long but they have not been able to do one of these things, we worry about the patients’ support network, caregiver burnout or inability to attend to details, or whether they have the executive function or financial resources to seek the support they need, let alone manage their medications or other instrumental activities of daily living. Unkempt feet prompt a podiatry referral, as well as a closer look at the patient’s overall functional status and support system, and perhaps involvement of social work or local elder services. When clinicians notice the presence of any of these 3 subtle signs in a patient’s examination, slow gait, difficulty donning socks, or unkempt toenails, we can use them as Van Halen did the brown M&Ms: as reminders to take a look at the stability and resilience of the whole system, the whole person. When we notice these feaPERSPECTIVE