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Kenneth Rockwood Profile picture
Kenneth Rockwood
@Krockdoc
Newfoundlander. Geriatrician, internist. Big on sharing Comprehensive Geriatric Assessment, individualization, and the joy of geriatrics to enable frailty care.
2 subscribers
Sep 26, 2020 • 7 tweets • 3 min read
Great question. Most key trials preceded the Clinical Frailty Scale. @GrahamEllis247 will know best, but here’s my read. (A 7-part thread; forgive me.) Back in the late ‘70s (when I got into all this) a key question was “who benefits from a Comprehensive Geriatric Assessment?”/2 2/This consumed much effort, and some weird terminology (e.g. “the targeted elderly”). One early line that I resisted was “too frail to benefit”. This struck me as a failing of the measures more than CGA. Fortunately @paulstolee sorted this (early 90s) in his PhD thesis. There/3
May 22, 2020 • 4 tweets • 2 min read
Marshall EG, Clarke B, Burge F, Varatharasan N, Archibald G, Andrew MK. Improving Continuity of Care Reduces Emergency Department Visits by Long-Term Care Residents. J Am Board Fam Med. 2016;29(2):201‐208. @barry86136315 @DrEmilyMarshall CGA The for LTC ref is: Marshall EG, Clarke BS, Varatharasan N, Andrew MK. A Long-Term Care-Comprehensive Geriatric Assessment (LTC-CGA) Tool: Improving Care for Frail Older Adults?. Can Geriatr J. 2015;ncbi.nlm.nih.gov/pmc/articles/P…
May 5, 2020 • 4 tweets • 1 min read
Mad-as-hell must give way to careful analysis. Think about this. In ordinary time disproportionately more older people die in LTC than at home. What fraction of all deaths is that? I don’t know, nor, I’d bet, do many others feeling outrage now. So what to do? We need clear-eyed/2 expert help. My (amateur) guess would ask first about excess mortality, by site. Not all COVID-19 deaths are the same: people can die with it, not just of it. (Think of dying while being cared for till the end vs dying neglected.) Much-needed reform will quickly be obscured if /3
Apr 13, 2020 • 4 tweets • 2 min read
It’s fair to say that I didn’t see its use in a pandemic. Had I done so, I hope that I would’ve tested a guidance for non-frailty experts sooner than the one we’re just trying now. If I’d been asked back then, I suspect I’d say that it beats stratifying risk by age. I recognize/2 that in a pandemic inevitably care will be rationed not by patient preference, but by likelihood of benefit. Some, reckoned as unlikely to benefit will be denied; further, with treatment, some of them possibly could have lived. That’s a hard truth, and not the only one. Even so/3
Apr 11, 2020 • 4 tweets • 1 min read
Great question; requires some detail. People accumulate deficits across their lives. In young people, many disabilities are “single system” eg spinal cord injury, trauma, cancer +/- chemo. There are many exceptions: intellectual disability, autoimmune disorders that show more/2, deficits at any age, ie progressive deficits, “accelerated ageing”. This will be reflected in deficit-associated disabilities, occurring at younger ages. So the first point is that disability means something different in most young people - single system disability shows fewer /3
Jan 24, 2020 • 6 tweets • 2 min read
1/6 Tweetorial Even in peaceful Nova Scotia disputes are not rare, especially in the Emergency Dep't. Here, I've distilled an approach that I've found helpful: I Have Something Interesting To Talk To You About: Speaking To Disagree, Agreeably cgjonline.ca/index.php/cgj/… 2/6 It's not mine: I was taught this decades ago, as a newly minted health policy analyst. It obliges you to address four questions. 1. What is the problem? As with the rest, this should be stated precisely. Stopping to get the words right is calming, clarifying, and empowering.
Dec 27, 2019 • 9 tweets • 2 min read
1/9 A second #ClinicalFrailtyScale tweetorial (tweetegesis?) prompted by three questions from last time: 1. Why include disability when discussing ways in which people can be frail - weren’t the two disentangled long ago? 2. Isn’t frailty a syndrome? 3. Can it be diagnosed? ->2 2/9 Hereabouts, we see deficit accumulation as primary. It’s what happens with age, and how frailty/risk arises. The risk isn’t just of death. Think, say, an injurious fall. It can occur in a fit person. If so, a single-system cause, and/or a big perturbation is most likely.->3
Dec 18, 2019 • 9 tweets • 2 min read
1/9 Was asked good questions re: the Clinical Frailty Scale, so this Tweetorial. Case 1: 84 year old woman; hypertensive, hypothyroid (meds for each) IADLs OK. Walks 5-7 km/day + 15km/week to visit her sister. "Would you still classify her as CFS =3 due to her chronic diseases?" 2/9 She is well with treated co-morbid disease, is physically active daily, and has no function-limiting symptoms; CFS=1, given daily exercise. Few patients aged 75+ are free of any illness: the issue is how much those illnesses bother (symptoms) or limit (function) their lives.
Sep 1, 2019 • 5 tweets • 2 min read
1/5. Against the high ground (more for public health) and the low ground (not my job, Jack) holding the middle is a hard go. But I’m a geriatrician from 🇨🇦; we live in the middle. Granted: Medicine is destroying itself, through often justified true belief in subspecialization, /2 2/4 and through financial self-interest played as sanctimony. But the remedies (a curious mix of nihilism and romance) won’t do, for three reasons. 1) Unless they’re euthanized, a lot of frail old people won’t just die as imagined. 2) Being unwell, they’ll need a lot of skilled/3
Aug 25, 2019 • 4 tweets • 2 min read
Agree. My mother’ s talents extended to fierce copy editing. She passed it on. Successive research trainees have gotten work back from me in a sea of red ink. It’s gone on long enough that I no longer need to explain my advice to “thank Dorothy”. Mom died August 2, aged 91./2 2/4: A private woman, but a dedicated teacher ... I expect she’d excuse me sharing what I learned (vaguely after Dad died, 20 years ago, but with some force now). Speak to whomever is left. Tell them about something you recall of the person who died. It is uncannily comforting./3
Apr 24, 2019 • 4 tweets • 2 min read
The long-run experiment of underpaying geriatricians and making few posts available (in practice plans we’re a drain on the high fliers) means under supply. And an awkward heritage. Now though we must be catalysts and geriatrize routine care. We get this. Others not quite there/2 although it’s fascinating to see how differing ‘ologies are approaching it. Some are rediscovering, others borrowing, some working collaboratively. Many opportunities for good (more sensible, less harmful care) and ill. One ill that stands out is seeing “frailty assessment” as /3
Apr 6, 2019 • 4 tweets • 2 min read
I agree that the FI allows grading the degree of frailty. Don’t know the data showing the FP as “especially useful” in screening, unless you mean its manifestation in @drjohnmorley ‘s FRAIL screen, which doesn’t require instruments. A dilemma in much frailty screening is that /2 2/ it has become uncoupled from frailty assessment. In short, clinicians are acting on the screen only to withhold care. Beyond what won’t be done, there’s not enough information for a care plan. Part of the Clinical Frailty Scale’s popularity ( @GrahamEllis247 )is its head /3
Apr 6, 2019 • 7 tweets • 3 min read
It’s frailty geek territory, but you asked. Prompted by @FrailtyMD @macesari opined on frailty (vs resilience etc). I said his view of frailty needed updating (gave reasons). He replied that I was seeing frailty only as deficit accumulation; otherwise he agreed. Then I agreed/2 2/because frailty is deficit accumulation to me. And to @AMitnitski We measure it by the frailty index (FI). Turns out, the FI is a robust, quantitative method to understand ageing. (I’d say the FI measures “biological age” but that’s its own can of worms -see PMID 27216811.)/3
Jan 12, 2019 • 6 tweets • 1 min read
Thinking a lot these days about what’s needed for better care of an ageing population, in a geriatrician-ambivalent (nice enough, but not essential) setting. I see key challenges. Glad for comments. Much health care planning and info, and innovation, still has a disease focus /2 How to leverage good innovation, but draw to attention that outcomes based on disease are arbitrary for a large fraction of the people we serve, especially the <20% who use >60% of adult, non-obstetrical hospital days. Because the numbers are so large, interests are many, and /3
Dec 12, 2018 • 4 tweets • 1 min read
“Research, suddenly seeing things revealed, just like moments when relationships deepen and transform, is able to bring wonder into our lives.” I only met John twice, but we shared some great correspondence. It began when I took on editing Brocklehurst’s 7th Edition and invited him to update his hypertension chapter. This he did, and then asked about writing another one, on people ageing with intellectual disabilities/3
Dec 2, 2018 • 4 tweets • 2 min read
Agree. “...frailty was not designed to “simply predict”. ... the traditional medical approach is insufficient to address the multiple, heterogeneous, and complex needs of older persons. [Identifying] frailty makes sense only if [it triggers] a comprehensive geriatric assessment/2 ... and the introduction of the patient into an adapted model of care.” Screening frailty for risk is important, but it can distract many non-geriatricians from the real issue. Knowing that the patient is at high risk, and determined to do what they do, what changes? First, /3
Jul 14, 2018 • 5 tweets • 2 min read
1 of 5 Just read @Trisha_the_doc gentle analogy of a wee paper boat. Can manage calm water, but not a storm. Any Newfoundlander gets that rough seas are never too far off. Can’t say when they’ll blow up, or how far from a safe harbour. I like it/2 Does nicely for the frailest. I'd say though likely less so for many with milder frailty. There’s still repair, even if rarely a drydock refit. I nodded at not using “...the word frail at any point in [the] journey, but she knew what we meant, and I think it did help.” I agree /3
May 8, 2018 • 4 tweets • 2 min read
Jay (and I)back for Day Two of the 2018 Hong Kong Health Authority Convention. He’s quoting Canadian Don Melady @geri_EM re: the “silver tsunami”. “Tsunamis come out of the blue. For years we’ve ignored the increasing complexity of who comes to the ED, instead of adapting to it.” Image @POBanerjee “Hospital cultures must change from what their services offer to what people need. For this, we require an evidence base that is rooted in what people need. The Silver Book arose from looking at the variation from what services do, contrasted to what people need.”
May 7, 2018 • 4 tweets • 2 min read
Jay Bannerjee at the Hong Kong Health Authority Conference. Making the point that “safety & quality” is a constant battle. “The quickest way to do ‘the right thing’ is not always the right thing to do. Consider how easy it is to admit a patient vs how hard to send them home.” Image @POBanerjee on how to manage the complexity of frailty in the ED: screen, if +ve Comprehensive Geriatric Assessment; a multidisciplinary team; service coordination +discharge planners with service authority; talk & talk; think differently. The #joyofgeriatrics. (I adlibbed that)
May 7, 2018 • 4 tweets • 1 min read
Frailty index as a predictor of mortality: a systematic review and meta-analysis | Age and Ageing | Oxford Academic …ademic-oup-com.ezproxy.library.dal.ca/ageing/article… "Although the ... studies constructed the FI based on different numbers and types of deficits, in addition to various populations and study settings ... the effect measures were in relatively narrow ranges and may support the robustness of this accumulation deficit frailty model"
Apr 20, 2018 • 5 tweets • 2 min read
@CanGeriSoc Symposium on falls David Hogan: 1) most old people who fall don’t get post-fall follow/up 2) <5% get AGS/BGS guideline care 3)little priority either by pts or by practitioners 4) reflects lack of time, knowledge of resources & evidence, low pt priority, reimbursement @CanGeriSoc Hogan scoping review cont’d: best evidence Close 1999 (60% decrease in falls) Finnish Chaos RCT (30% decrease). Strong studies have strong interventions, targeted to high-risk groups. Descriptive: Australian falls clinics resource intensive, with home exercise program