GERIATRIC SYNDROMES

To the Editor: We read with interest about the development of geriatric syndromes as a bedrock for further advances of the discipline of geriatric medicine.1 As the authors point out, key to this is the development of conceptual models that might link the syndromes to each other, and especially to the vulnerability state known as frailty. The authors usefully summarize some models, including a figure that shows an evolution from a linear model of risk factors leading to advanced disease to an interactive concentric model from which clinical phenotypes might emerge.1 As helpful as these qualitative figures are, it is also useful to remember that conceptual models can arise from quantitative studies. From the simple idea that the more things a person has wrong with him or her, the more likely her or she is to be frail have arisen several quantitative estimates.2 For example, people accumulate things wrong with them (deficits) at a characteristic rate,3 even though approximately one-third of older adults show improvements in health status over short-term intervals.4 Those who accumulate deficits at a faster rate are more likely to die.5 It appears that exactly which deficits people accumulate might not be as important as the number that they accumulate, at least in terms of their vulnerability to adverse outcomes,6 a key item in defining frailty.7 Of potential clinical importance is the observation that there appears to be a fixed upper limit to frailty. From any set of things that people might have wrong with them, they cannot accumulate more than two-thirds of those potential deficits.8 Each of these items can be summarized in a mathematical model that shows good fit (r2>0.95) with observed data.4,9 In his accompanying editorial, Dr. Hazzard rightly endorsed the authors calling to attention the implications of shared pathophysiological features converging along final common paths to vulnerability, decline and death.10 He wondered whether to give the authors an A or an A+ on their 2007 report card. We suggest that geriatric medicine might withhold its highest ranking until we can better measure what is measurable and make measurable what is still conceptual. This is especially so for describing the complex phenomena that make geriatric medicine both a challenge and a joy. Conflict of Interest: The editor in chief has determined there are no conflicts of interest relevant to this paper. Author Contributions: Both authors contributed to this letter. Sponsors' Role: There were no sponsors involved.

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