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Geriatric Health and Well-being

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SARA LOMAX-REESE: So today we are with the Einstein docs.  It is that time again and we are fortunate to be looking at geriatric health and well being on today's program.  We have as usual, our favorite family medicine doc, Dr. Donee Patterson.


LOMAX-REESE: Welcome and we have in the house Dr. Andy Rosenzweig who is part of the Department of Medicine's Geriatric Division; welcome to the program Dr. Rosenzweig.

ANDY ROSENZWEIG, MD: Thank you so much for having me.

LOMAX-REESE: A very youthful looking Dr.  Rosenzweig from the Geriatric Division.  We are going to delve into these issues that are so important because our population is aging.  We know that the baby boomers are now hitting the age of 65 plus and that is going to have a huge impact on our healthcare system, on everything really.  A little bit later we are going to be talking with State Senator Vincent Hughes, regarding the affordable care act and we will weave that all into this conversation as well so stay tuned for that at about 12:30.  Dr. Donee, why don't you, as you usually do, lay the foundation, the groundwork for what we are going to be exploring today in terms of geriatric care.

PATTERSON: We picked this topic today just because our geriatric population is definitely growing and with that comes some very serious medical issues.  You can be totally healthy in your geriatric years, but if you do have medical problems, we want people to know what to do.  A lot of times people don’t' realize that there are actually people who specialize in geriatric medicine and we want to delve into that and explain that a little bit more and talk about issues that are predominate in this population, like falls or getting ready to get your living will together or differences in medications, so really important topics.

LOMAX-REESE: Excellent.  Why don't we define geriatric care, first and foremost, Dr. Rosenzweig?

ROSENZWEIG: Well the first thing to realize about geriatrics is that it doesn't specifically refer to age alone.  So Medicare defines the geriatric patient as anyone age 65 or older, but the way we look at it is anyone who has a complex combination of medical issues that are significant enough to affect quality of life; affect function and affect independence in the home.  These will reach a point that go beyond just the medical issues, it becomes psychosocial issues, care giver issues, financial issues.  All of these weave together to create a war state for the patient if they are not all addressed.  So the internist or generalist might just handle the list of medical issues, we take a 360 degree approach and factor all of these issues in when we take care of a patient.

LOMAX-REESE: So would an internist refer to a geriatric expert?  Is that usually the way someone gets to a geriatric expert?

ROSENZWEIG: A lot of time, yes.  We function primarily in a primary care arena but as a subspecialist, we also do a lot of both inpatient and outpatient consultative work.  Some people transition from an internist and then say all right I think it is now time to have a geriatrician be my primary doctor.  Some people say I want to keep the internist I've been with for 20 years but I am going to see this specialist periodically for some of these "geriatric" issues; things that Dr. Donee had mentioned, cognitive or memory changes with aging, fall prevention, osteoporosis.

LOMAX-REESE: I know you want to get in Dr. Donee, but I am curious why you need to have a particular expertise in…I mean what is so different over the age of 65 or in that part of your life span that you would need a specialist as opposed to somebody that maybe has been caring for you since you were 50?

PATTERSON: I kind of wanted to clarify that a little bit.  You don't have to transition to a geriatrician, you really don't.  You can stay with your internist if you are comfortable; they know your medical problems; absolutely no problem.  There is a difference between chronologic age, so the age you actually are and your medical or physiologic age.  A lot of times people are very sick and that comes with some more psychosocial issues, it may be dementia and you need some more social service input, then you might transition to a geriatrician who has some different resources for you to be able to help you transition into a more complicated medical time of your life.

LOMAX-REESE: Dr. Rosenzweig?

ROSENZWEIG: I would agree with that wholeheartedly.  I don't think anything takes the place of a great and trusting relationship with an internist who knows you well.  In geriatrics, we do a lot of extra training to understand what normal aging is; the biologic changes that are going to happen to all of us so we can better distinguished when there is abnormal or pathophysiologic changes with aging and those subtleties are things that we can probably see earlier and then address more effectively.

PATTERSON: So someone may have a parent who doesn't have a doctor or their doctor has moved on somewhere, so you are left with taking care of your parent.  You are thinking, do I take him to my own doctor?  That may be a time to consider taking him to a geriatrician if they have a lot of medical issues.  Certainly, there are 70, 80 year olds who are in great health and they may not need those extra services, they can go as well, but really, those people who have those extra issues you may consider transitioning him to a geriatrician.

LOMAX-REESE: so let's talk a little bit about those specific illnesses that may require that kind of coordinated care of a geriatrician and some of the things that are on a list that was given to me are things like sleep issues.  To me some of these things are quality of life issues; sleep issues; bladder issues.  There are other kind of specific things depression and anxiety; elder abuse was on this list.  Of course some of the medical issues like hypertension but I thought one of the most interesting ones was the fact that you may be taking so many different medications that there might be contraindications.  Talk to us about it and I will give this to you Dr. Rosenzweig, some of the specific things that need to be addressed or considered when seeking a geriatrician.

ROSENZWEIG: In regards to the polypharmacy?

LOMAX-REESE: Yes, in regards to some of the specific illnesses.

ROSENZWEIG: So we look at polypharmacy or taking more medications that might be necessary as a geriatric syndrome as serious as dementia or osteoporosis or some of the other issues you mentioned.  When you get above appropriately five prescribed medications, the risk of a drug/drug interaction approaches 100% and it grow exponentially.  As we get older, not only are there issues with drug/drug interactions but the older population is much more susceptible to the side effects that occur with all medications.  When I talk about medications, we should note that this includes not only the prescribed medications but complimentary or alternative medications, supplements, herbals, over the counter.  I will tell you what we consider in geriatrics to be public enemy number one is Benadryl.  Something that anyone can get very easily over the counter is just fraught with side effects as well as drug/drug interactions.  

LOMAX-REESE: Is Benadryl fraught with side effects in and of itself or when it is mixed with other things?

ROSENZWEIG: In and of itself in a lot of people.  It is used by people who are having allergic reactions or itching for whatever reason or trouble sleeping.  The class of medications it has can cause confusion, constipation, urinary retention…

PATTERSON: Excessive drowsiness.  I do want to say Benadryl does have its place in medicine.  We are not putting down any particular medicine but definitely in this population it really does have some side effects that you need to really watch out for.

ROSENZWEIG: We always tell people to bring everything, a brown bag visit when they come to the doctor so we can see not only the prescribed medications, but also the over the counters they are using. You would be surprised some of the errors you can uncover.  For example, husband and wife are co-horting all their medications together and there may be confusion who's taking what, bottles can get mixed up and it's just a good opportunity to lay everything out and then you may be able to get rid of a lot of them.  A lot of times people have a tendency to prescribe a drug to treat a side effect of another drug and it's that prescribing cascade that we often see.  A geriatrician is someone is likely to pick that up as opposed to adding more medications for these symptoms, be able to actually take away stuff and the patients feel better.

PATTERSON: And with that said, you also, if you go to other specialists, a cardiologist, a neurologist, a urologist, if they ever add anything, you definitely want to make sure that your primary care doctor or geriatrician knows about that and make sure we communicate and we actually have those updated medical lists.

LOMAX-REESE: It just seems like we live in a country and it gets agitated or aggravated as we get older that is very prescription heavy.  For everything you have, there is a pill that you can take to address it.  You see it on TV, whether it is Viagra or whatever, the restless leg syndrome, everything has a medication that is associated with it and I can easily see how, if you are seeing multiple specialists how you could be on five plus medications because that is just kind of the culture that we live in.

PATTERSON: I read a statistic that 50% of the time you visit a doctor you leave a prescription in hand and that is probably true for many reasons.  One is when a person comes to you they have often tried several homeopathic or stretching type exercises, they often tried those things at home so when they are coming to you they are looking for something different, but I never want this show to be about medication.  We are not pushing any particular medication but you are absolutely right, we have to retrain ourselves as consumers, as patients, even for myself, that it is not always a medication.  Sometimes people come in with flu like symptoms and they want antibiotics.  Well the flu is a virus and antibiotics are antibacterials and so it is really hard to train people that you don't actually need a medicine for this, you have to let time heal itself, drink lots of fluids and eat healthy.

LOMAX-REESE: Get plenty of rest.

PATTERSON: Exactly, so it is hard to explain that to people.  They are upset with you when they don't leave with a prescription, even if it is a prescription for cough medicine that they can get over the counter; they want a prescription.  I often try to explain to my patients; this is something that time has to run its course, if it gets worse come back.  When you sit down and talk to someone I that fashion, they tend to get it but we have to retain ourselves as patients.

LOMAX-REESE: Dr. Rosenzweig?

ROSENZWEIG: I think the prescribers play a big role in that as well.  Number one, we want to satisfy our patients, we want to satisfy our customers and if we feel that pressure that they want to leave with something that will "fix" or quickly eradicate what is going on, we are likely to be influenced.  Also, it takes me 30 seconds to write a prescription; it might take me ten minutes to explain life style and exercise changes to help through someone's illness and in this day and age where there is more and more pressure to see more patients in less time, some doctors might also say, alright let me just write this script and be done with it.  That is not good and I don't prescribe that but that is the nature….

LOMAX-REESE: It is multifactorial.  There is definitely responsibly on the individual's part and I think there is responsibility on the heathcare system provider's standpoint.  I want to talk a little bit about keys or strategies for healthy aging. I want to talk a little bit about keys or strategies for healthy aging. So what should people who are 35 or 45 now be doing to make sure that at 75 or 85 they are as healthy as they can possibly be?   Dr. Donee, do you want to start?

PATTERSON: Sure, one thing I wanted to make sure I emphasize, we always talk about diet and exercise, but it is so very important.  To continue to make sure your muscles are strengthened, your back muscles are strong, you are taking care of your bones, you are exercising, eating high plant and fruit diets.  All those things are very important as we age because our blood vessels inside can get clogged and our muscles can get weak.  I don’t think people realize how important falls are for the geriatric population.  It was actually surprising to me when I was in training to find out that when people fall, then actually have a higher risk of dying much sooner.  Their quality of life and their life expectancy decreases dramatically.  We have to think about fall prevention which in the early years, as you are saying, leads to strengthened muscles as a young adult, but we really have to pay attention to falls in the geriatric population.  There are things that you can do; inspect your home; decrease clutter; get rid of throw rugs; put bath mats down, secure bath mats, install guardrails in your bathroom or guardrails up the stairs, very, very important things.

LOMAX-REESE: Dr. Rosenzweig?

ROSENZWEIG: In terms of healthy aging, things that you would do earlier in life in addition to what Donee said, a few things I would mention.  Number one, we talked about exercising our muscles for strength and endurance, balance.  I would encourage everyone to exercise your brain as a muscle as aggressively as any of these other muscle groups and this can start in the earlier decades and it should carry through.  You need to stay stimulated socially and mentally.  That is not just watching TV, that’s reading, doing crossword puzzles, socializing is probably the best way to exercise your brain, both in early  years and later years.  Think of your brain as any other muscle that needs exercise.  For the younger decades that you mentioned, I would also just comment on routine healthcare maintenance that can begin in those ages.  We don’t have time to get into it all, but time appropriate mammograms, pap smears, colonoscopies, bone scans, and so forth are the best ways to prevent the kind of life threatening conditions that can affect you in elder years.

LOMAX-REESE: We are going to have to take a quick break.  That is Dr. A R and we are talking with Dr. Donee Patterson, both of them are from the Einstein HealthCare Network and we are talking about elder care and healthy aging and geriatric issues.  If you have a question or comment, feel free to give us a call.  We will take it on the other side of the break.  215-634-8064 or toll free 866-361-0900.  Don’t go away.

LOMAX-REESE: And we are back.  You are listening to HealthQuest Live on 900 am WURD on air, on line and in the community.  We are talking today about geriatric care; geriatric issues and how to stay healthy as we age.  We are talking with Dr.  Andy Rosenzweig in the Department of Medicine in the Geriatric Division at Einstein and Dr. Donee Patterson who is a family medicine physician with Einstein Department of Medicine.  Dr. Rosenzweig one of the things I think is most closely associated with aging and one of the illnesses and concerns that people have with aging is dementia and Alzheimer's.  We get a lot of information about Alzheimer's and I wanted to see if you could talk to us about dementia and its relationship to Alzheimer's or Alzheimer's relationship with dementia and just what we as listeners need to understand about this very important issue.

ROSENZWEIG: Sure, I would be happy to.  The first thing to recognize is that as we get older we all will incur some memory issues.  It is usually some subtle short term mental issues, word finding, where did I put my keys, what did I come into this room for.  Not all age related memory issues are dementia so I don’t want anyone out there to worry about that.  We define dementia as issues with short term memory and some other domain of cognition or thinking, the combination of which is significant enough to affect function.  Like I said, we are all going to have some memory issues as we get older and the wheels may not turn quite as smoothly as we get older, but we don’t diagnose it as dementia until it has become significant enough to affect a person’s ability to do their activities of daily living, function and quality of life.  Alzheimer's disease is far and away the most common type of dementia.  It would probably be about 80% - 85% of all dementia cases would turn out to be Alzheimer's type dementia. 

PATTERSON: There are some other things; for example, depression really does in some cases mask dementia because they are so depressed that they can’t remember things or they are feeling really down or they are feeling withdrawn and there are some things that mask dementia.  It is something you definitely need to talk to your doctor and medication sometimes can make you foggy or make you dizzy.  It is definitely to bring to your doctor and don’t stay away; don’t be afraid to come in had ask us.

LOMAX-REESE: Is there a diagnostic tool for dementia?  Is there a way to make a concrete diagnoses and then what happens? Are there medications?  You mentioned socialization and other kinds of things as a preventive measure, but at what point are you beyond the scope of prevention?

ROSENZWEIG: By far and away the diagnoses is still clinical based on the constellation of symptoms and what we get in the history and physical exam.  There are some imaging studies that are still in the research phase now that they are correlating the degree of abnormality seen on the PET scan that might correlate with dementia but that is nothing that we are using on a clinical day to day basis.  There are no blood tests that can diagnose dementia either.  The medications we have out there that are FDA approved for different types of dementia specific Alzheimer's type, none of it makes it go away or reverse what is going on.  The only thing that they are truly affective at is slowing down the rate of progression.

LOMAX-REESE: So does that mean that when you are diagnosed really is important in terms of slowing down the progression because then you can get on some type of medication?

PATTERSON: Absolutely.


PATTERSON: Also, you asked about tools.  There are things that doctors use.  There are questionnaires that have been fortified and tested and those questionnaires may include a depression scale, an alcohol scale, because a lot of times alcohol abuse can mask the disease and there are some questions and drawings your doctor may institute while you are that the office and they really are value tests to us because we studied them and they help us to know if you have some of those early symptoms of dementia.

LOMAX-REESE: We are going to go to the phones; if you have a question you can give us a call, 215-634-8064 or toll free 866-361-0900.   We've got Gina from North Philly; welcome to the show Gina.

GINA:  Good afternoon everyone.

PATTERSON: Good afternoon.

ROSENZWEIG: Good afternoon.

GINA: I don't even know how to put a label on this but I wouldn't say it is mental illness or anything like that but I think there is also an issue of aloneness amongst a lot of seniors.  I'm in my early 60s and I am the only remaining sibling in my family and all my immediate family is gone.  I have a circle of nice friends but I am also in the crooks of time to straighten out family business.  A lot of issues my last sibling left and I don't even know where to turn, I need grief counseling and all of that but I really don't know where to turn.

PATTERSON: I think this would be a great time to reach out to your doctor.  Without knowing much more it sounds like you may have some level of depression and loneliness is a part of that.  I find and I'm sure Dr. Rosenzweig can attest, as patients get older they see a lot of their loved ones passing away; a lot of their friends are passing away and they feel left behind.  That comes often with some mood changes and depression.  I would reach out to your doctor and if your doctor doesn't have the resources, you might want to reach out to someone like a geriatrician like Dr. Rosenzweig to help you piece together some of those issues.

LOMAX-REESE: What about the Philadelphia Corporation for the Aging or those kinds of … Center in the Park…those kinds of resources that are specifically geared towards people who are in that age category?  Dr. Rosenzweig?

ROSENZWEIG: PCA is just one of many amazing organizations that provide so much for individuals in Gina's position and in older patients in general.  The issue is what is that connecting step that gets you to that individual.  I would suggest finding a geriatrician who is usually in close contact with the geriatric social worker and who could very, very easily get you connected to all these resources.

GINA: I really appreciate that because I never thought of PCA. It is a moment of enlightenment for me.  So thank you so very much.

LOMAX-REESE: And Gina, one other thing, I think the idea of grief counseling is a great one.  

GINA: I need it badly.

LOMAX-REESE: I have a dear friend whose brother was killed and she has been going to grief counseling and it has provided a tremendous to her.  She is in New York.  I can find out from her what resource she is going to and see if there is one in Philly and maybe you can leave your information with my producer Eric and I can share that if I find it.

GINA: Thank you so much.

PATTERSON: We wish you well.

GINA: Thank you.

LOMAX-REESE: We are going to go to Sage from University City; welcome to the program Sage.

SAGE: I am so thrilled to get to talk to the brightest person I can hear on the radio, whose a female.  Let me get right to it; I am a senior citizen and everybody is deceased and I'm clinically diagnosed with depression but I was overwhelmed I lost my sister August 4th and I reached out to an article in a newspaper called  Hold that Thought. Prior to that I was affiliated with something called Eat the Blues these are all affiliated with Center in the Park and I would like to share that information with your listeners.  Both times I had a therapist come….they come to your home with hour sessions that are recorded.  I don't know if people of our orientation or culture, I'm trying to find the right words, are aware of how comforting therapy can be and I find it to be…I'm excited every time I visit.  I go tomorrow, I call ahead of time and here's a way to share, it doesn’t have to be a personal friend or someone.

PATTERSON: That is awesome Ms. Sage, thank you for sharing that.

LOMAX-REESE: Thank you for sharing the fact that these are resources that are available in the community.  I think that both Sage and the previous caller are speaking to this kind of social isolation and the depression that just comes when family and friends transition and you just feel this sense of loneliness and I'm curious, if you guys have relationships with some of these institutions like Center in the Park and PCA and I'm sure there are even more that are maybe culturally appropriate that can be connected up with the patients.

ROSENZWEIG: Most definitely.  Any division of geriatrics and most internal and family medicine groups these days have all of these organizations on a very short list to reach out to.  We understand that this population is going through a number of major life stressors that both of our callers mentioned, from losing loved ones, losing friends.  Suddenly it may not be so easy to get out of the house and go to socialize or run errands or do things that used to be so simple.  Maybe driving isn't as accessible or taking public transportation as it used to be.  All these things add up and people are changing the way they have lived for years; suddenly things they used to do so independently require so much effort.  Late onset depression we deal with all of the time.

LOMAX-REESE: We kind of have to wrap things up but I want to see if you can both give one take away. I think one thing that I am hearing is that we as a society have to be much more inclusive and loving and nurturing of our elderly and not be such a youth focused society; one takeaway for our listeners in terms of healthy aging.

PATTERSON: I want to encourage the listeners to reach out to their elderly neighbors and family members.  If they need rides to their doctors or if they appear depressed, try to reach out to them and get them some help.  We want to definitely emphasize that a living will is something that you don't wait until someone has dementia to get in place.  A living will is your opinion about how you want your medical care and financial care to be handled if there is a catastrophic event.  You want to make sure that you have appointed a person that you trust and that you have written down your wishes for yourself while you still have your mind intact.  We want to emphasize that point.  It doesn’t have to be this major thing that you have to spend a lot of money for or to get a lawyer.

LOMAX-REESE: Dr. Rosenzweig?

ROSENZWEIG:  I think what I would like to mention is that the resources are out there, plain and simply, especially in Philadelphia County.  There are tons of groups that recognize the issues related to older adults; the changes that occur and the best way to deal with them.  It is just a matter of taking the initiative and figuring out how to access those resources.  So reaching out to your doctor, getting on the computer and looking up these issues, it is very accessible.  Nearly every university or hospital system in the area has a division of geriatrics or division of case management or social work who can get you the resources you need.  They are there; I can guarantee they will be more effective than any pill or prescription we can do in giving you a higher quality of life and they are there to be utilized.

LOMAX-REESE: I want to thank you both for spending time with us today to talk about this very important issues that we will all have to confront if we have the good fortune of living long enough.  Dr. Donee there is a gift card in the offing for our listeners.

PATTERSON: As usual we have a gift card we are offering, a $25 gift card to the local ShopRite and if you go to the Einstein Facebook page, you can answer very simple questions and quality for this gift card.  We encourage you to go there and give us any comments that you have about the show or any future topics that you are interested in.  If you are interested in a primary care doctor or a geriatrician, you can call 1-800 EINSTEIN. 

LOMAX-REESE: Thank you both very much for your time today.

PATTERSON: Thank you.

ROSENZWEIG: Thank you.


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