Forest Before Trees: A Reflection on "Most Cardiology Is Geriatric Cardiology"
The Sentence That Should Disturb Every Physician
A recent Medscape conversation between two respected geriatric cardiologists, John Dodson and Ashok Krishnaswami, walks through the now-standard toolkit of the field: assess frailty with gait speed, grip strength, or the Rockwood Clinical Frailty Scale; screen cognition with the Mini-Cog, escalate to MoCA if needed; address polypharmacy by deprescribing drugs that impair function; de-escalate beta-blocker doses when fatigue and bradycardia appear. Each recommendation is sound. And yet the sequence itself — frailty, then cognition, then polypharmacy, presented as three stations on a checklist — is precisely where my discomfort begins.
Not because cardiology is wrong to care about the mind. Because the mind is treated as one more item on the list, alongside gait speed and grip strength, rather than as the ground from which many of these items grow.
Why This Is Not a Cardiology Problem — It Is a Whole-Organism Problem
The heart gets the spotlight in cardiology clinics for an obvious reason: it is the organ the specialty is built around. But frailty itself does not originate in the heart, or in the muscles, or in the brain as separate malfunctioning parts. It is, as I've argued throughout my work on the connective tissue continuum, a property of one interconnected structural-regulatory field that runs through and links every organ — a field sustained by shared hematopoietic and stromal cell lineages, common inflammatory signaling, and a single mechanostat governing how the whole body senses and responds to load. When that field loses coherence, it does not fail in one place. It fails everywhere at once, in different accents.
This is why gait speed, cognitive slowing, and drug intolerance so often arrive together in the same patient. They are not three unrelated problems that happen to coincide with age. They are three readouts of a single narrowing of systemic reserve — three different instruments in an orchestra that has lost its conductor.
The Brain Is Not a Fourth Checklist Item — It Is Often the Root
Here is where the transcript's instinct, though well-intentioned, still fragments what should be seen whole. Cognition is discussed as a screening target — Mini-Cog, MoCA, referral to memory clinic — parallel to frailty and polypharmacy, as if the brain were simply one more organ to check on the way through a busy visit.
But a great deal of what cardiologists call frailty has its roots in the brain, specifically in the failure of neurovascular coupling and glymphatic clearance. The precise regulation of cerebral blood flow in response to neural activity is one of the most sensitive functions in the aging body, and its disruption directly drives cognitive decline and executive dysfunction. When the perivascular matrices around the brain stiffen and basement membranes thicken with age, the glymphatic system — the brain's overnight waste-clearance mechanism — becomes a bottleneck rather than a channel. This is not a separate lesion. It is the same connective-tissue failure pattern seen in the aging heart and kidney, now expressed as slowed processing, executive dysfunction, and gait disturbance together, because frontal networks and brainstem-cerebellar control circuits share the same vulnerable vascular field.
In plain terms: the unsteady gait a cardiologist notices at the office door and the "slight" cognitive fog a family member mentions in passing may not be two findings. They may be one finding, seen twice, through two different windows.
Wellspan, Not the Checklist, Is the Actual Aim
This is why I keep returning to wellspan as the organizing question rather than any single domain score. Wellspan is not "years lived free of disease" — that is healthspan, and it quietly excludes the millions of older adults already living with chronic conditions who still want a full life. Wellspan asks a different question: how long does a person remain recognizably themselves, with preserved identity, coherence, and capacity to participate in their own life, regardless of diagnosis?
Measured this way, gait speed, cognitive screening, and polypharmacy stop being three separate boxes on a form and become three windows into the same underlying variable — the width of a person's remaining adaptive range, their homeokinesis. A physician who screens for all three but never asks what they jointly reveal about the patient's overall coherence has counted the trees and missed the forest.
The Radical Possibility: Polypharmacy That Never Needed to Emerge
This brings me to the sharpest question buried inside that dialogue, one the speakers touch but do not fully unfold: what if the polypharmacy problem itself is often a downstream artifact of fragmented, organ-by-organ care — and what if better root-level, whole-system attention could prevent much of it from ever accumulating?
Consider how polypharmacy typically forms. A patient develops hypertension; a drug is added. Then dyslipidemia; another drug. Then mild cognitive symptoms attributed to "normal aging"; perhaps a symptomatic add-on. Then a fall, attributed to age; perhaps another prescription to manage a consequence rather than a cause. Each addition treats a downstream expression of the same underlying narrowing of the connective-tissue and neurovascular field, without anyone asking whether these are really four separate diseases or four faces of one system losing coherence. By the time a geriatric cardiologist finally reviews the list and starts the difficult work of deprescribing, the patient may be carrying eight medications for what began as a single systemic drift.
If, instead, the first clinical encounter had asked a forest-level question — what is happening to this person's whole structural-regulatory field, and what is the earliest, most proportionate way to support it — several of those prescriptions might never have been needed in the first place. This is precisely the logic behind what I call the Principle of Disease Optimality: every disease unfolds along a potential optimal path, one that minimizes the cost of recovery while maximizing functional outcome, and the physician's task is to guide the system toward that path early, not to arrive after fragmentation has already occurred and call the cleanup "deprescribing". Polypharmacy reduction, in this view, should not be viewed only as a late-stage correction. It should be recognized as a symptom of how fragmented our earlier attention already was — and its best treatment is often prevention of the fragmentation itself, not skillful subtraction after the fact.
What Changes in Practice
None of this argues against the specific tools Dodson and Krishnaswami describe — gait speed, Rockwood scores, Mini-Cog, careful beta-blocker titration are all genuinely useful, fast, and validated. The argument is about what happens afterthe screening: whether the clinician stops at three separate scores, or asks what single narrowing of coherence is generating all three signals in this particular patient, at this particular moment.
In practice, this means:
Treating a slow gait and a foggy memory in the same visit as possibly one signal, not two, and asking whether both trace back to the same vascular or inflammatory field before assuming two unrelated problems.
Asking, before adding any new medication, whether the symptom being treated is itself downstream of an earlier medication or an earlier untreated systemic drift — tracing the chain backward rather than only forward.
Reframing the goal of every visit, briefly, around wellspan: not "which numbers are still abnormal" but "how much of this person's coherence, autonomy, and recognizable self can we still protect, and what is the least disruptive way to protect it."
The One Tree That Matters Above All Others
But if I have to leave the reader with a single instruction, it is this: whichever tree you examine first — the heart, the gait, the lab value, the medication list — look through it toward the same ultimate target. Help this patient remain mentally present, coherent, and themselves for as long as life continues, ideally up to the last exhale.
This is not a sentimental addendum to clinical practice. It is the actual measure of success. A cardiologist can normalize every biomarker, titrate every dose with precision, and still fail the patient completely if, in the process, the person's clarity, autonomy, and sense of self are allowed to erode unnoticed. Wellspan does not end at some arbitrary point before death — it is designed to be pursued as close to the very last day as the body allows, so that the person inhabiting the years we have added is still recognizably present in them, still deciding, still connected, still themselves. The task of medicine at the end is not to abandon this pursuit but to accompany it — guiding the patient with clarity, compassion, and coherence right up to the boundary of life, rather than surrendering the mind to entropy while the body is kept technically alive.
This reframes every tree in the forest. Gait speed matters not primarily because falls are dangerous, but because mobility sustains the social participation and independence that keep a person's identity intact. Polypharmacy matters not primarily because drug interactions are risky, but because a foggy, over-medicated mind cannot fully inhabit its own remaining days. Even beta-blocker titration, that small and unglamorous adjustment mentioned almost in passing in the transcript, matters because a patient who is fatigued and bradycardic is a patient less able to think clearly, converse fully, and remain present to the people who love them.
Most cardiology may indeed be geriatric cardiology, as the interview's title claims. But geriatric cardiology, practiced well, cannot be organ-specific screening with a longer list. It has to be the discipline of seeing the whole field first — heart, brain, muscle, and matrix as one continuum — and then asking, of every single intervention: does this help the person in front of me stay mentally themselves, present and coherent, for as long as they have left? That is the forest. Every tree we tend should be judged by whether it serves that forest, right up to the final breath.
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