Episode 29: Geriatrics: Aging of the Body and Mind

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Episode Summary:

There is much you can do to watch out for, minimize, and manage the physical and mental changes that accompany aging.  Among other things, learn how deep sleep, Tai Chi, and social engagement (appropriately socially distanced social engagement of course!) may reduce risks of dementia and other age-related health issues.

Episode Guest:

Vittoria Gassman, M.D., Medical Director, Jewish Senior Services; Clinical Assistant Professor of Medicine, Quinnipiac University School of Medicine, HaM.D.en, Connecticut.

During This Episode We Discuss:

  • Healthy aging.
  • How to help those in your life at a more advanced age.
  • We review Geriatrics.
  • Who should have the care of a Geriatric specialist?
  • Common concerns and conditions associated with advancing age.
  • Retirement, loss, and change.
  • Tips for aging well.
  • The major risks associated with advanced age.
  • Strategies to prevent and minimize risks.
  • Tai Chi anyone?
  • Care for those of advanced age.
  • Recognizing dementia in your family member.
  • Advanced care recommendations, advice for nursing homes, assisted living.

Quotes (Tweetables):

“ Most of the patients I see as outpatients in the office are well into their 80’s, if somebody’s getting frail and there is a concern regarding dementia in the ’70s, then that person could definitely seek consultation, and in the nursing home where I work, the average age is 90, the mean age, so half the patients are over 90 and half of the patients are under.”

“Nursing home criteria are pretty definite, if your need help with 3 or more basic activities of daily living, That’s walking, bathing, toileting, dressing, those kinds of things.”

Vittoria Gassman, M.D.

Recommended Resources:

Episode Transcript: 

Dr Pelman(01:25):

On this episode of The Original Guide to Men’s Health, we’ll be reviewing the aging male with Dr. Vittoria Gassman. Dr. Gassman is the medical director of Jewish Senior Services Institute on aging. She is a clinical assistant professor, at the Quinnipiac School of Medicine, Hamden, Connecticut, Dr. Gassman received her medical doctorate at New York University and completed her residency also at NYU. She’s also certified in Geriatric Medicine. Welcome Dr. Gassman.

Dr. Gassman (01:59):

Thank you for inviting me to be with you

Dr Pelman (02:03):

To have a discussion about something that is relevant as we move through life, meaning as we age. And I think I’d like to start with just a review of what is a geriatrician. What is different about seeing a geriatric specialist than your primary care physician?

Dr Gassman (02:23):

Geriatrics is a fairly new specialty. Gerontology refers to non-physician specialists who study the aging process and older people and society. But geriatrics is the medical specialty that focuses on people as they get older. 

Dr Pelman (02:47):

So when we look at an aging population and they have a primary care physician, when would they transition or should they transition to a geriatric specialist?

Dr Gassman (03:00):

It would be ideal if they could transition, if everyone could transition at a certain point, but there aren’t enough geriatricians in the country. So we tried to educate primary care physicians and other specialists and teach them a little bit about geriatrics so that they can continue to help their patients. We mostly work as consultants in the hospital or in the outpatient setting. And if there’s a concern, for example, about dementia, we often get consultations and a referral for a patient for that. And we try to look at the whole individual, the medications, talk to them about their psychosocial wellbeing, physical exam, which includes walking and how they get around, et cetera, it’s time consuming. But if there are concerns that somebody is not doing well as they’re aging, it can be a very helpful thing to do,

Dr Pelman (04:14):

What age would you generally say, the population that would be seen by a geriatric specialist by a geriatrician? Would somebody in their sixties or seventies, seventies to eighties, or eighties to you know; or is it just really, how is that individual doing? I mean, what age group do you recommend people start moving over? 

Dr Gassman (04:34):

It’s gotten older and older. I think most of the patients I see as outpatients in my office are well into their eighties. If somebody’s getting frail and there’s a concern about dementia, seventies, then that person could definitely seek consultation. The average age is 90, the mean age. So half patients are over 90 half are under. 

Dr Pelman (05:09):

Interesting, the aging process is somewhat subtle. Sometimes people sometimes have things that make it more dramatic, but what would you recommend to the population that begins aging, say later sixties to seventies, that they should start being aware of, and if they’re not seeing a geriatrician, at least to make certain that they bring up to their primary care physician?

Dr Gassman (05:33):

Functional abilities are really important. We study what are called the activities of daily living. So if a person is having trouble walking, if they’re having falls, if there are hygiene problems, people aren’t bathing, those kinds of things definitely could seek some geriatric specialist help. But I think in general, there’s still a lot of things we don’t know, but exercise and physical function are really important. We try to emphasize that with patients because many of the geriatric syndromes such as falls seem to be consequences of diminishing strength or balance and problems with the activities of daily living. 

Dr Pelman (06:36):

So people should not get sedentary, to try to keep moving, keep exercising in some form, maintaining some musculoskeletal fitness, some muscle density range of motion, and that starts early and you just have to continue it.

Dr Gassman (06:51):

I’m a big fan of Tai Chi, as well as other types of exercise. I have attended Tai Chi classes myself, and I’m currently looking for a class, but it’s a very interesting way to work on your balance. And it’s the only exercise that has been proven over and over to decrease the risk of falls, even better than working with a physical therapist.

Dr Pelman (07:27):

So that can be an interesting thing to do for people that helps with the balance and, you know, transition from people playing sports to some seniors continue, but say a senior who golfs or plays tennis, but then loses some of the ability to do that as well. You would want them to move to something where they continue to be active and work on balance and movement skills. And you’re saying Tai Chi is nice.

Dr Gassman (07:54):

And walking is good. Many people give up walking, but it’s a great form of exercise. Doesn’t have to be fast, but walking every day definitely maintains some form of physical functioning and muscle strength. 

Dr Pelman (08:14):

Yeah. Do you have people walk with hand weights or anything to maintain some upper body strength when they do that? Or is that a separate, would you recommend a separate exercise set?

Dr Gassman (08:23):

We usually recommend a second set of exercises for that, but if people are quite fit and they want to use hand weights, that’s perfect.

Dr Pelman (08:34):

It Is. This would be a daily outing?

Dr Gassman (08:37):

Yes. The government has recommended, you know, all different things, from three times a week to five days a week, but maybe a majority of the days in the week, people should be out there doing something. 

Dr Pelman (08:54):

Then moving from exercise, to just being aware of things that are subtle, that change in eyesight, hearing, that becomes an issue, particularly hearing loss for seniors.

Dr Gassman (09:08):

Yes, that’s very important. Hearing loss is widespread in the aging population and we expect there’s going to be more of it because the baby boomer generation did have the delight and unfortunate consequences of listening to too much rock music and blasted their hearing functions. So, I know many older people resist getting hearing aids. They resist getting tested. It’s a stigma that’s been around for a long time. Probably starting when the hearing aids were very bulky and not nice to look at, but hearing aids now are tiny. They can’t even be seen. And hearing loss is associated with developing dementia. Nobody wants to have dementia or any cognitive loss and hearing loss is definitely involved in that process so that can help motivate people to go get a hearing test and then hearing aids if they need them. The other problem with hearing devices is they’re very expensive and Medicare doesn’t typically provide them. Some of the Medicare Managed Plans, the Advantage Medicare plans will cover it. And that’s a great thing because they can cost many thousands of dollars.

Dr Pelman (10:50):

The acuity of a hearing does fall off over time. So you would start with getting a hearing test, which is fairly easy to do on a range, but it’s just making somebody aware that they need to be checked.

Dr Gassman (11:06):

 The primary care physician should be doing what’s called a whisper test. They stand a few feet away from the patient and they cover their mouth and, and whisper numbers. Or somebody could do that with their spouse and check each year separately. But if you can’t hear whispered numbers from two or three feet away, there may be a problem. 

(2) Whisper Test – YouTube

Dr Pelman (11:33):

If somebody requires a hearing aid, is that good for life? Or do you need to upgrade continuously as hearing changes or worsens?

Dr Gassman (11:40):

Yeah. I may be able to make adjustments as hearing worsens, but they don’t typically need many new hearing aids. Of course, they’re very small. They do get lost, but apart from that, you may not need multiple sets of them as, as hearing worsens as people age. 

Dr Pelman (12:05):

And then you mentioned mental status changes. And of course we talk about people aging and just having normal loss of some memory. What distinguishes somebody who’s truly getting dementia? And then in dementia is a spectrum Alzheimer’s versus other forms of dementia. Go into a little bit about that because that compromises a significant portion of people’s health if they do develop that.

*Episode 42 The Aging Brain: Normal Aging, Dementia and Alzheimer’s

Dr Gassman (12:37):

We know that dementia increases with age, more than 50% of people in their nineties do have some degree of dementia and we’re still not completely sure what can prevent it. There’s some hope that a healthy diet and more physical exercise may prevent it, but there’s nothing very obvious in terms of medication or vitamins. Nothing’s been shown to really work in terms of medication. Many people start having problems with memory, especially with remembering names and associating faces to names. That’s not thought to be all that significant, it’s quite universal, but missing a few names here. And there is not really a warning sign, but when somebody starts to have problems in multiple areas of their life, for example, at home, in terms of their family relationships and or at work, completing their work tasks, that already is a big red flag. And that person certainly needs that dementia evaluation.

Dr Gassman (14:10):

Most of the dementia in this country is Alzheimer’s disease. It hasn’t been clear to the public. And I hear this question all the time. What’s the difference between dementia and Alzheimer’s? I’m not sure which word is scarier, but they’re both pretty scary. But in the United States, approximately 75% of dementia is Alzheimers disease. And the rest are comprised of things like vascular dementia, which means an accumulation of small strokes or TIA*, does seem to rob the patient of their memory and other faculties and some more rare variants, such as Lewy Body Dementia*, which is very associated with Parkinson’s disease and some or others. But the vast majority is Alzheimers and it’s very gradual and insidious. And I find that most people, and especially the families, don’t recognize it as it gets worse and worse. I did a lot of primary care myself over the years, and I can honestly say that I missed it many, many times in my practice.

*A transient ischemic attack (TIA), sometimes called a mini-stroke, is a sudden, short-lived neurological condition. It is caused by a small, temporary blockage in one of the blood vessels that carries blood to the brain.

*Lewy body dementia, also known as dementia with Lewy bodies, is the second most common type of progressive dementia after Alzheimer’s disease. Protein deposits, called Lewy bodies, develop in nerve cells in the brain regions involved in thinking, memory and movement (motor control). Lewy body dementia causes a progressive decline in mental abilities.

Dr Gassman (15:43):

And I think the issue for families and primary care doctors is that when you have a lot of contact with the person, it’s hard to see the changes. You know, it may feel that it’s just the patient’s personality or they’re just getting more stubborn or that they’ve always been like that. And now it’s more so, but this disease, it takes over the brain very slowly and sometimes an outside consultant can see it. A geriatrician or a neurologist can more quickly put their finger on it. Unfortunately, we’ve spent a lot of time in this country researching dementia, and we haven’t gotten very far unfortunately. We do have some medications, but they’re not very helpful. They seem to stabilize the patient at the level they’re at. But I think scientists have been working on a hypothesis about a cause of Alzheimer’s disease, which is called the amyloid hypothesis.

Dr Gassman (17:00):

There’s this substance in the brain called amyloid and all the treatments in terms of medication have been focused on this and then the last year or so, there’s been a lot of rethinking. And it seems now that the amyloid is not the cause of dementia, but it’s something that happens along with it or as a byproduct of the disease. Luckily there is a lot of research going on. I really recommend the Alzheimer’s Association* website, which has a lot of helpful information, very accessible to families and patients, et cetera. And there’s a lot to learn about this. It’s fascinating. 

*Alzheimer’s Association | Alzheimer’s Disease & Dementia Help

Dr Pelman (17:58):

And unfortunately it’s still just dementia in general. And trying to be healthy, we know that good sleep has a significant impact on the development of dementia. So, you know, sleep specialists, making certain that you don’t have sleep apnea* seems to be at least one of the issues involved in the onset of dementia.

*Episode 19: Sleep Health and Sleep Apnea

*Sleep apnea affects the body by interfering with sleep. You might choke, snort, or snore while you sleep. Obstructive sleep apnea affects the body by increasing the risk for adverse clinical outcomes ranging from decreased daytime alertness and quality of life to cardiovascular morbidities and mortality to increased risk for hospitalization.

Dr Gassman (18:22):

Yes, I agree with that. There’s even some very interesting research about that, that I think it’s mostly been done in animals, but there are some small studies in humans showing that there may be a whole new organ in our brains that is responsible for draining out of the brain toxic byproducts of metabolism, including the amyloid, et cetera. That seems to function best when somebody is in the deep sleep stage, and REM it’s an important sleep stage, but it’s like sleep. And that’s when you have dreams, but everybody cycle through various stages of sleep, three or four or five kinds every night and deep sleep may turn out to be a key time when our brains get rid of toxins. And that’s just very fascinating to me. You know, I mainly work in a nursing home and very few people in the nursing home get a good night’s sleep. We try to work on things like decreasing the sound, having the lights low, trying to get people, good sunlight exposure in the daytime that can help with sleep. But most of them have very fragmented sleep patterns. I know you’re a urologist. So, you know, bladder spasms and having to urinate every two hours all night long, it’s very disruptive to sleep.

Dr Pelman(20:09):

Yes, it’s one of the major issues we see. I always try to make certain that the issues with nighttime urination or nocturia is something that is looked into as there are many other reasons besides just bladder, prostate issues, people who have sleep apnea for instance, will get up thinking they need to urinate. And it’s really they’re awake because of air hunger. Sometimes they have mobilization of fluid just due to physiological issues and you know, some of it’s reversible. So it’s a great point you make, and it is something robs people of valuable sleep time and should be looked into, but it isn’t always, it isn’t always bladder prostate for looking at the population that needs to control cholesterol, blood pressure that certainly prevents some of that microvascular disease you were talking about that can lead to dementia. So just good health and taking care of those issues as well can help.

Dr Gassman (21:10):

Yes, blood pressure control, cholesterol, diabetes, all the traditional cardiovascular risk factors are probably implicated in the development of alzheimer’s. So making sure your blood pressure is at a good level, keeping your cholesterol well controlled and really working on the diabetes can help postpone or prevent dementia too.

Dr Pelman (21:43):

If we look at the opportunity to look at a different spectrum of the mental issues, meaning depression, certainly as people age and lose function, perhaps can’t work anymore. Maybe lose a spouse. You see a spectrum of issues

Episode 16. Mental Health: Part 1—General Depression; Part 2—Deeper Depression, Suicide and Suicide Prevention.

Dr Gassman (22:02):

Depression is really widespread in this society. And I think you’re right. You talked about losing the spouse and losing the job or the functional role in society. That’s very important. I think especially men who retire, I think do have a hard time adjusting to that retirement. If they haven’t made some preparations ahead of time, you know, thinking ahead of time what you’re gonna do with all that free time can be really helpful. And we do see some men who really get into their hobbies, develop new hobbies, take up bridge or other games. And all that is very healthy. Men are much less likely than women to lose their spouse because men still have a shorter life expectancy at every age. So women are much more likely to live without a partner for many years. And we see that in the nursing home, most men, even over 85, about a third of them are still married, which is much better than for women.

Dr Gassman (23:30):

Three quarters of them are widowed over 85. So that partnership, that companionship is so important. You know, there’s not too much you can do at the end of life about that, but having some other social contacts is really important. People who do volunteering or some participation in the community, they really get a benefit from that. It’s not just “they’re helping others.” It’s good for them. And it can even be phoned volunteering, you know, having a phone pal who you call once a week. That can be a great activity, even if somebody is at home, but you know, in the real world where all of that is really important at my nursing home, we’re lucky we have what’s called the work center. It’s a, most nursing homes don’t have this, although they could try and create a similar thing, and some definitely do, but it’s basically clerical work.

Dr Gassman (24:39):

And many residents of the nursing home will come and work there morning and afternoon, five days a week, except for holidays. And it’s a social activity. So that’s nice, people talk and make jokes with each other and it’s friendly. But I think underneath that is this hidden sense of having a purpose. It’s very important to people. And you know, if a man has been deeply engaged in his career or his job, that finding some way to recreate that in retirement and then all day, which I think is, is just critical. I have patients who get an infection and I asked them to stay in their room for a few days and take medication. And the first question they asked me, they say, but doctor, can I go to work tomorrow? And you know, even if they have a fever and they want to get back to their usual routine and that’s a very important human trait, we want to feel like we have a purpose. 

Dr Pelman (25:54):

And that’s something that if somebody is listening and they have a parent who maybe is becoming more socially isolated, that’s as difficult as somebody who becomes sedentary. So they need to make sure they become engaged in some sort of activity, some sort of social event you’ve brought up in the nursing home. So let’s move a little bit into as people age, when they want to transition from independent living or maybe independent living into a different living situation. When does that occur or how do you advise patients regarding that? Or they say, “well, we’ve been living in our own house. We’re thinking of going into an assisted living situation or an independent condo with assisted living, possibly nursing home attached to it.” What do you advise people? 

Dr Gassman (26:41):

Unfortunately our health system in the country is very fragmented and it’s really up to individuals and their families to find what the resources are near them. Assisted living was meant to be for pretty independent, healthy seniors, but they have much more for people who are frailer, not quite as into and needing more help. Nursing home’s criteria are pretty definite. The criteria to get into a nursing home is if you need help with three or more basic activities of daily living. So that’s walking, bathing, toileting, dressing, those kinds of things. And if you need help with three or more of those, you probably can be in a nursing home. And along with those functional problems, obviously comes the medical issues that create those problems with function. So a patient might have heart failure, diabetes. They may have a few falls and a hip fracture because of that. But to get into a nursing home in general, the criteria are functional problems in three or more basic activities of daily living.

Dr Pelman (28:12):

And we were doing this recording in the time of COVID-19. And obviously people are worried about transmission of it, whether it’s this virus or something that comes along, or even flu during normal flu season through a nursing home. So that’s something. You’re a medical director of a nursing home, and you have a nursing home population. You want a nursing home that is well supervised and has plans for taking care of issues like this.

Dr Gassman (28:40):

Right? It’s been terrifying in the state of Connecticut. I don’t think we’re doing too badly, but we are scrambling to keep the vulnerable older people safe. One thing is there is a new model for nursing homes called the Small House Model. Have you ever heard of that? 

Dr Pelman

No.

Dr Gassman

 So it’s been around for a while, I believe on the west coast, and somewhat in the Midwest, they are building new nursing homes on this model. And our nursing home in Connecticut is built on the Small House Model. And it’s been great for decreasing the transmission of infections. We’ve been in the building three years and we’ve seen it with the flu and hopefully we’re going to see it with the COVID-19. Basically there is no giant dining area for everybody to go to. And there are no long halls with the nursing station in the middle, and it looks like a hospital. Rather, it’s the whole home that is built, broken up into a 14 person unit.

Dr Gassman (30:03):

They call them houses and there’s a door in a doorbell for each one. And then there’s 14 people with private rooms and baths and some common areas like a kitchen, which looks like a nice suburban kitchen and the dining room, dining area, a living room, and a porch for fresh air. It’s been very helpful for isolating people who are sick in their rooms and decreasing the risk of infection going all over the building. So I’m grateful that we have that and your listeners, if they’re looking for a nursing home or even in assisted living, the new ones seem to be built on this model.

Dr Pelman (30:55):

It looks like it’s a more successful model and hopefully newer homes will be following that pattern. So any resources that you would refer people to? That they could find online that you would tell them that they, if they want more information, as far as aging?

Dr Gassman (31:13):

Number one is the Alzheimer’s Association. They can go with their different chapters in every state and different regional associations. And there is a lot of really good information there about aging and dementia. And the other resource I’ll mention is the American Geriatrics Society.* They have information for the public and for patients also all different topics about healthy aging and about diseases as well. And I think those are very good sources. There are so many on social media, and the internet is just wonderful, but there is so much potential with that. But there is a lot of misinformation, and not good sources that you can trust. And I hope the public will, you know, keep challenging and checking out the sources that they’re using and making sure that they’re reliable and consistent.

*Alzheimer’s Association | Alzheimer’s Disease & Dementia Help

*Home | HealthInAging.org: Powered by professionals at the American Geriatrics Society, this website provides expert health information for older adults and caregivers about critical issues we all face as we age.

Dr Pelman (32:26):

Just summing up, staying healthy as we age. It sounds like we should continue to be active and not be sedentary and active. Not only physically, but mentally and socially engaged.

Dr Gassman (32:39):

Yeah, I think you’ve got it. Absolutely right. 

Dr Pelman (32:43):

Well I really appreciate you spending time, and it’s been wonderful. Aging is the spectrum that we all face. And so it’s great to have a resource and hopefully there’ll be more geriatricians in the future.

Dr Gassman (32:57):

Yeah, that would be great. And thank you so much for this opportunity. 

Dr Pelman

We appreciate it. Thank you, Dr. Gassman. 

Dr Gassman

You’re welcome.

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