384 http://neurology.thelancet.com Vol 7 May 2008

In Context

Profi leKenneth Rockwood: on a mission to save the world?Kenneth Rockwood has dedicated his career to the treatment of elderly patients and the study of age-related diseases such as dementia. He is now a physician at the Queen Elizabeth II Health Sciences Centre and a professor of geriatric medicine and neurology at Dalhousie University in Nova Scotia, Canada, but his route into medicine was not traditional. He started out by studying for a liberal arts degree in politics and French and then landed a job as a civil servant at the Department of Health in Saskatchewan, Canada. He was assigned to work on health-care policy for elderly patients, and through this experience Rockwood found his calling. Inspired by a geriatrician with whom he collaborated, Rockwood returned to college to study geriatric medicine.

The burning desire Rockwood felt as a new medical student has stayed with him ever since. “Geriatrics attracts a sort of missionary cohort”, Rockwood says. Now, when teaching his own medical students, Rockwood tries to instill that same passion. “The major problem facing the western world right now is the care of elderly patients”, he tells them, “[so] geriatrics is a good place to work if you want to save the world.”

Despite this recommendation, many doctors stay away from geriatric medicine, seeing elderly patients as complicated problems they would prefer not to deal with. Elderly patients do not fi t the paradigm in which patients have only one medical disorder at once, explains Rockwood. But that is exactly why he likes geriatric medicine. To Rockwood, elderly patients are not crocks, train-wrecks, goomers (an abbreviation of ‘get out of my emergency room’), or any of the numerous other pejoratives that some doctors use; rather, they are interesting intellectual challenges. He sees geriatrics as being about dealing with complex patients, by breaking down their symptoms into individual treatable parts of the puzzle.

The complexity of symptoms in some elderly patients causes diffi culty not only in the assessment of what is wrong, but also in the assessment of whether treatments are working. Rockwood insists that the key to assessment of the success of treatments is to listen to feedback from patients and their carers. “It seems a simple and inarguable point”, he says. “Everybody knows we should be listening to what patients and carers have to say. But it turns out that [often] we’re not.”

Listening to feedback is just the fi rst step, however. What is really important is conversion of the feedback into usable scientifi c data. For this, Rockwood swears by a technique called goal attainment scaling, which he has used successfully to assess the benefi ts of drugs in

Alzheimer’s disease. The basis of the technique is that, before treatment begins, patients and carers describe their goals; then, during the course of treatment, they assess whether those goals have been met. In the case of Alzheimer’s disease, these goals might be that the patient no longer asks the same question 20 times a day, is not so irritable when the grandchildren visit, or can use the telephone again.

The goals are phrased in the language of patients and carers rather than that of doctors or scientists. But, as Rockwood is quick to point out, assessment of a drug on the basis of such feedback makes no assumptions about the biology behind the disease, and is therefore more scientifi c than is measuring the success of a drug against particular biological criteria. In fact, from listening to feedback from patients, one can learn about the biology of the disease. For example, although Alzheimer’s disease has been thought of mainly as a disease of memory loss, in clinical trials of drugs that are thought to improve memory, Rockwood’s goal attainment scaling approach has indicated that improvement occurred mainly in executive functions of the brain rather than in memory.

Listening to feedback from patients and carers is likely to be valuable for learning about the biology of all dementias and diseases of the mind, reckons Rockwood. “Dementia is a disease where some of the most precious things we need to know about, we’ll never have an animal model for”, he says. “For example, there’ll never be a decent animal model for repetitive questioning and irritability.”

The power of goal attainment scaling to provide biological data appeals to Rockwood’s scientifi c side. He holds a primary research position at Dalhousie University, where he established the Geriatric Medicine Research Unit. However, despite this commitment to medical research, Rockwood classes himself fi rst and foremost as a physician. “I enjoy all aspects of my work”, he says, “but I get a deep satisfaction from the physician aspect.”

Rockwood has treated literally thousands of elderly patients and is a champion of their cause. He is unwilling to accept old age as a cause of confusion, poor balance, or other disorders common in elderly patients. “No-one is ever too old to get out of bed”, he says, “nor too old to stand.” Critics might accuse him of looking too hard for underlying medical causes of disorders of old age. But, he says, better that than to blame old age for symptoms when there could be a treatable cause.

Ruth Williamsruth.williams@absw.org.uk

For an example of Rockwood’s work on goal attainment

scaling see Neurology 2007; 68: 116–21.