May 17, 2024 • 53 mins
According to the National Academies of Sciences, Engineering, and Medicine (NASEM), nearly one-fourth of older adults aged 65 and older are at increased risk for loneliness and are considered to be socially isolated, with risk factors being attributed to hearing loss, losing family or friends, role changes such as retirement, living alone, and chronic disease. Geriatric syndromes — such as polypharmacy, falls, cognitive impairment like dementia and Alzheimer's disease, malnutrition, and incontinence — are clinical conditions and multifactorial impairments that are more commonly identified in older adults. Aging is definitely the normal trajectory of human life, but how can one age in a way that is considered healthy and with an optimal quality of life? How can an older adult look forward to the remaining years of life despite chronic illness? How can we help safeguard a geriatric's mental health despite feelings of abandonment, loneliness, and fear of being a burden to their caregiver/s?
We are joined today by Dr. Christina Chen, a double board-certified geriatrician and internist at Mayo Clinic. She received her BS in Biology and Psychology from Michigan State University, MD from St George's University School Of Medicine, Internal Medicine residency at the University of Illinois College of Medicine, and Geriatric Medicine fellowship at the Mayo Clinic College of Medicine. She further achieved certificates in Acupuncture for Physicians from Helms Medical Institute and Executive Women in Leadership from Cornell University. Dr. Chen currently stands as an Attending Geriatrician and Assistant Professor of Medicine at Mayo Clinic Rochester, the Host of the Aging Forward Podcast, the Course Director of the Mayo Clinic Alix School of Medicine Senior Sages Curriculum. the Editor of the Mayo Clinic on Healthy Aging book, and the Medical Advisory Board of GrandPad, a customizable platform that delivers virtual care to seniors at home while keeping seniors connected to reduce social isolation and improve the telehealth experience.
Livestream Air Date: August 17, 2023
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Episode Transcript
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(00:00):
Hi friends, how are you all doing? Happy Friday! Another Friends of France Friday. And I cannot
(00:10):
believe it, we are in the third to last episode of the third season of the podcast. Wow. It's
so bittersweet just thinking about the near end of the season. I'm also excited to close
this chapter of the show and hopefully await a new phase in the near future. How are you?
How are your seasonal allergies? Everyone made job has been sick with their springtime allergies
(00:32):
and I think I'm next. I was walking through Central Park the other weekend and I just saw
so many people sneezing. It's definitely those pollens flying around. But that's just one
of the things you can see happening at Central Park on any given day. It's truly a garden
of wonders, of sights and experiences. I feel like Central Park is one of those places in
(00:53):
New York City that I have so many memories of because it's so huge. And I visit with
different groups of people each time. One of my more recent memories is walking alongside
the 5th Avenue side of the park during early December. I was on a day, a second day actually,
the tea. We spent some time inside the Met Museum, which is on East 82nd Street. And
(01:15):
we walked all the way to K-Town on 32nd Street for dinner. I literally walked 50 long streets
and a couple of avenues with my date, just talking about life and everything. Now, each
time I pass by the park while driving by, all I can think is, wow, I can't believe
we walked all of those streets. But that's just one of the magic of Central Park for
(01:39):
me. But to your side, Central Park reminds me of one more thing, nursing school. During
my first semester of nursing school, or my fundamentals of nursing class, my first ever
clinical rotation was in a nursing home on the Upper East Side, also along the 5th Avenue
side of the park. I remember walking by the park to get to the facility where I would
(02:01):
then spend 8-10 hours taking care of the nursing home residents. This really opened my eyes
to the world of nursing, which I had never thought of before. Growing up with my mom,
who was a hospital nurse herself, I think I somewhat glamorized the nursing profession
I had in mind. Procedures, injections, anesthesia, codes, always pleasant patients. I never really
(02:23):
saw the patient bed baths and tracheostomy care and turning patients and ulcers and poop
and pee and making beds and this is all that we did in the nursing home rotation. I just
remember the bed boundary at the patients, mostly in their 70s through 90s, who we had
to turn every 2 hours so they could avoid pressure ulcers. However, the one clinical
(02:46):
rotation memory I will never forget is a resident in her late 80s. I remember knocking on her
door and she was just sitting down in her chair and looking out the window while eating
a pudding.
Hi, I said. How's your morning?
I am just here waiting, I remember her saying.
Waiting for who? I asked.
Someone to visit me, she said. My son hasn't visited me for a few years. Can you be my
(03:09):
son while you're here? She asked me. I remember my heart sinking.
And this is the situation of many of the residents in that nursing home and nursing homes in
general. For whatever reason unknown to us, the residents were rarely, if at all, visited
by their families or loved ones. One of the nurses told us that sometimes, the nursing
staff is all these residents have because they have been abandoned by their families.
(03:32):
According to the National Academies of Sciences, Engineering and Medicine, nearly one-fourth
of older adults aged 65 and older are at increased risk for loneliness and are considered to
be socially isolated, with risk factors being attributed to losing family or friends, hearing
loss, role changes such as retirement, living alone, and chronic disease.
(03:53):
When it comes to older adults, I have a very touchy part in my heart because I grew up
with my grandma, who stayed with us here in New York before moving back to Asia when I
started high school. Because my mom was a single mom and a night-trip nurse for most
of my childhood, my grandma took care of me most of the time. Walked me to school, made
me lunch, took me to the farm school, took me to piano lessons and Kuman tutoring. Ugh,
(04:15):
the Asian PTSD. Who can relate? And to think that there are grandmas and grandpas out there
who are just looking out a window somewhere and waiting for their loved ones because they
think they have been abandoned, my heart can't fully take that thought.
The field of geriatric medicine is truly one that is beyond the scientific and the clinical.
It is the emotional and the mental. Beyond finding the empirical solutions to geriatric
(04:38):
syndromes that most older adults face, such as malnutrition, cognitive impairment like
dementia, polypharmacy, false inferiority, and of the like, the mental and emotional
toss of living in spite of chronic disease, battling loneliness and depression, and maximizing
quality of life despite these hurdles are the crux of the field.
And for this topic, I am beyond honored to be joined today by double board certified
(05:02):
internist and geriatrician for Mayo Clinic, Dr. Christina Chen. Dr. Chen currently stands
as an attending geriatrician and assistant professor of medicine at Mayo Clinic Rochester,
the host of the Aging Forward podcast, the course director of the Mayo Clinic Alex School
of Medicine, Seniors Ages Curriculum, and the Medical Advisory Board of Grand Pad, a
customizable platform that delivers virtual care to seniors at home while keeping seniors
(05:27):
connected to reduce social isolation and improve the telehealth experience.
This is such a personal topic for me, and I hope you get to learn a lot just as I did.
Hi, Doc. How are you doing?
Hey, Christian.
Thank you so much for training me tonight.
Good, how are you? Yeah, thanks for the invite. Love it.
So honored to have you on tonight. I've been actually wanting to invite you to our podcast
(05:52):
episode for such a long time now, for several months now, and it's finally here. If you
could just first please introduce yourself to our future podcast listeners, please.
And thank you so much.
Yeah, sure. Hi, everyone. My name is Christina Chen. I am a geriatrician. I practice at Mayo
Clinic in Rochester, Minnesota. Lived here for about 11 years, trained here for fellowship.
(06:14):
Prior to that, I trained in Illinois for residency and originally from Michigan, where I lived
for 20 something years. I forget now, but yeah, I've been here for a while and I think
we're here to stay. So we have a family, two kids, two chickens that I recently got, two
birds. So we're kind of settling on our roots.
(06:38):
I love it.
Our family is here to stay probably.
I love the chickens. That's so cute. I mean, I've been wanting to speak to Geriatrician
for such a while now because it holds such a dear place in my heart. My first rotation
in nursing school was in a nursing home. And that was the first time I was like, whoa,
(07:01):
this is such a very niche field too. I mean, I grew up also with my grandma who took care
of me. So I grew up with a single mom who was working all the time as a nurse too. So
my grandma took care of me growing up. So I feel like I've always had this deep love
and appreciation for her elderly. And I'm like, we need a whole podcast episode on all
(07:23):
of the changes and all of the things that make the field of Geriatrics special. And
again, I'm so honored that it's you who's with me tonight in this episode. I first wanted
to do a deep dive into your journey into medicine. I mean, you know, it's a long road getting
to where you are now as a physician. I want to know what's your first inspiration in becoming
(07:45):
a physician entering the field of medicine? Is it a family, friend or personal experience?
Yeah, so I've always grown up in a very scientific family. You know, my father worked in various
aspects of science. So he was a biochemist. He taught parasitology, chemistry at Michigan
State University. So I spent my life like in the lab all the time. I would always go
(08:07):
to work with him. I dissected my first mouse at the age of five. So I just loved anatomy,
physiology, and was always immersed in science. And I just loved that growing up in high school
and in college. But I feel like the geriatric aspect really came from my just being raised
by my grandmother. So my grandmother came to the States when I was young to help take
(08:28):
care of me. And so she was like my, my mentor, you know, she ended up passing away at age
99. But I always saw her as my, she was my hero. And she was like invincible to me. She
didn't have a single health issue, was cognitively intact until the day that she passed away.
And so I just, I really saw her as my role model. And I always hung out with old people
(08:48):
as well. Even at, you know, parties, all the kids would be playing with all their kids.
And I would just find that like, you know, lonely older adult and just sit with them
and learn from them. So I think I just had a heart for people who were more, I don't
know, more vulnerable maybe and just needed a listening ear. So combining science as a
(09:09):
love with older adults as, you know, mentorship and just people that I love to be with, it
just made sense to, to.
So would you say that you pursued medicine even more because you know, you wanted to
be a geriatrician, like from the get go, did you know you wanted to work with older people?
I didn't know geriatrics was a subspecialty until residency. And so I went through the
(09:31):
whole exploration phase. I really loved cardiology to the physiology of the heart. I love GI.
And so I explored all of that. And then it wasn't until I went through a geriatric rotation
where I was like, wow, this is, this is actually a field and just fell in love with that aspect
of not just handling chronic disease, but handling the life journey of people throughout
(09:53):
their health spectrum. And I found that it was a combination of internal medicine, but
everything that I loved plus population that I loved. So yeah. And I think that's the main
challenges. Most people are not exposed to geriatrics until, you know, it wasn't until
recently that medical school has more of a integrated or needed curriculum for most,
(10:13):
most medical schools. Prior to that, there wasn't a lot of dedicated curriculum for geriatric
training. So things are changing now, but I think it might be a little bit better lately.
I know that you also are like the course director at Mayo Clinic for the SAGES curriculum. And
I guess you're like really contributing to this push for really learning more about the
(10:35):
geriatric population, right?
I think the early exposure experience is so important. The earlier, the better. We just
had a senior SAGE initial kickoff event, which is where our students, our first year students
are matched with a senior in the community. And they kind of learn from each other over
the course of four years that the students are there training and they learn about geriatric
(10:56):
medicine through the eyes of someone who's going through that experience. So it's like
a relationship that they build over four years, but also just a really unique and creative
way of learning geriatrics.
Yeah, I love that so much. I actually believe that early exposure is so integral, right?
To, I guess, even just developing like a baseline of spec, right? Especially in a world where
(11:18):
lack of knowledge is real and ageism is real too, right? In this society. So, well, I guess
as you take a deep dive into the whole field of geriatrics, geriatric medicine, for the
only person who might not even know what the word geriatrics means, right? As the expert
here, as the attending here, what is the field of geriatrics all about? What is the premise
(11:38):
of the whole field? And I guess what is the demarcation line between regular adult medicine
and geriatric medicine?
Yeah, good question. So think of geriatrics as the opposite of pediatrics. You know, pediatrics
would take care of kids, geriatrics older adults. And the reason is because the human
body changes over time. The way that we treat children is completely different than the
(12:00):
way that we manage the general adult population, which is different than the older adult population.
So the health needs change over time. And the age cut off right now is 65. 65 and above
is considered geriatric or older adult. But I would argue that there's a lot of 65-year-olds
that are actually quite healthy without any health issues and very robust. And so that
(12:21):
line is sort of a little bit muddy there, but it's right now by definition 65 and above.
And our focus is a lot of different things. Our focus is not just prevention of disease.
It's not just, you know, diagnosing disease, but we're also handling a lot of the sequelae
or the outcome of living with long-term disease. And in many situations, people are living
(12:42):
with more functional impairment, with cognitive impairment, and the outcome of just living
with say diabetes or heart failure or COPD for a long time, which impacts their ability
to stay independent. So our goal is not just managing those specific health issues, but
how do we help them live well despite living with disease? And it's a challenge because
(13:06):
in this day and age of modern medicine where everything is supposedly treatable, right,
we have a treatment for everything. We've got a way to like cure disease and reverse
disease and it's hard to have that perception change of, okay, at some point we have to
realize that, you know, we're living with this and there's no reversal. And at some
point, you know, it might affect our quality of life and function and helping people not
(13:30):
just adapt to that, but thrive in that environment so that they feel empowered to continue to
live well despite what they are diagnosed with is kind of the art of geriatric medicine
that I've really grown to love. So I think there's a lot of ways you can weave in geriatric
medicine to other subspecialties. Like not everyone is meant to be a geriatrician. I
mean, we need cardiologists and we need gastroenterologists, but how do we weave in geriatric concepts
(13:56):
so that, yes, you're seeing this person for heart disease, but also understanding how
it's impacting their function or their quality of life so that we're also managing their
health conditions in a more meaningful way.
Yeah, got it. So beautiful. And I think speaking also like interweaving geriatric medicine,
I guess, the care for it in different specialties as well. So I think it's also true that there's
geriatrics everywhere, right, in different settings. So I guess the next question would
(14:20):
be as a geriatrician, where are the places we would see geriatricians, right? I guess
in what settings does the specialty usually work in? Is it just the hospitals, just clinics,
or what?
Oh, everywhere. It's such a versatile field. You can work in the inpatient setting. You
can work in the clinical outpatient setting and have your own patient panel. A lot of
(14:42):
geriatricians work in long-term care settings. So nursing homes, they can be medical directors
of nursing homes, academic medicine, you know, you can do teaching. So my practice is a blend
of all of that. I do a little bit of everything. I have my own clinical practice, but I also
work in the nursing homes one day a week. I don't do inpatient medicine, but I did that
for a little bit during my first part of my career. I also do a little bit of integrative
(15:05):
medicine too. So you can really become creative. So I train in acupuncture with the goal of
helping older adults live better with their pain experience and just integrating that
into their care. So you can get really creative and it makes each day fun because you're not
just doing the same thing over and over, right? Each day is a little bit different. And I
also have the honor of working with our medical students too, who are just amazing and they're
(15:29):
so willing to learn and so enthusiastic to learn about, you know, geriatric medicine.
So it's a lot of teaching, learning along the way and practice.
I love that. And I guess I want to talk more also about, I guess the bread and butter of
your work. Like on a daily, I guess, how does the usual day of work look like? And I guess
what would be the reasons for the elderly that you're seeing under your service, right?
(15:54):
Why are they usually more at the time? Like bread and butter diagnoses and such.
So it depends on which setting you work in. So for example, in my outpatient practice,
I see a lot of general chronic disease management and it's not just managing their preexisting
disease. A lot of times we're diagnosing new conditions as well. It's very versatile. We
see a lot of cognitive impairment and new diagnosis of, of dementias, which can be
(16:19):
hard for the families and caregivers because it's, it's really a journey. And so helping
them go through that journey is a common thing that we, we do in our practice.
And the nursing home is different because these nursing home patients have been living
there for many years, or they may be in the rehab setting where they're recovering from
a recent illness. And so we, we do admissions there. We help them transition safely back
(16:41):
home or we see them if they are there long-term, we see them routinely as almost like primary
care for this to make sure that they're doing well. And so each practice is a little bit
different, but the bread and butter is again, helping people live well despite their current
situation and how do we still find ways to improve their quality of life? Even if it
(17:01):
seems like things are hopeless or that they don't have much time left. I just feel so
badly when, when that general perception of geriatric medicine is that, you know, it seems
like a hopeless situation, right? It just, it seems like what else can we do for them?
But there's, there's so much we can still do for them because I think every life is
so important and, and their dignity needs to be preserved and to approach each patient
(17:24):
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I think before we even deep dive into some of those problems that you mentioned, those
(20:45):
chronic diseases, I think all of these terms that you just said, I think the general public
can develop it in the word of aging, right? Like, oh, that's common, or that's normal,
that's expected because people age, dot dot dot, right? So I guess as someone who sees
aging as a progressive thing, as a progression thing, as a geriatrician, to you, what does
(21:09):
aging actually mean? What does it mean that, oh, I'm of old age now, right? And so that
notes, as you see a lot of diseases and all of that, is there such thing as healthy aging?
Is there such thing as even if I'm 80 years old, I can still be considered as a healthy
aged person?
Absolutely. I see tons of 80 and 90 year olds still out there jet skiing and enjoying their
(21:37):
lives to the max. And I'm just, I sometimes I'm jealous, but I'm like, wow, you are rocking
it. You are just loving life. That's amazing. But we are aging as soon as we're born. Honestly,
that's the reality. As soon as we're born, yes, we're growing, but our cells are aging.
It's a physiologic, biologic change that just happens with time. There's nothing we can
(22:01):
do about it, unfortunately. And every part of our organ ages and people age in different
ways. Some people may have the chronologic age may be different than biologic age, meaning
that some people may age better than others. You often see these 80 year olds who you're
like, wow, they don't look like they're 80 because they're so functional and they're
(22:21):
still bright and you know, cognitively intact and just doing so much. And then you'll see
60 year olds who are completely debilitated in wheelchairs and can't take care of themselves.
So it's such a wide spectrum. And to answer your question about healthy aging, I think
that is really up to how people perceive aging to be for them. Healthy aging doesn't mean
(22:45):
to be completely absent of disease because I don't think that's completely possible.
Right? We're all bound to develop arthritis at some point in their lives. I mean, I probably
already, I have arthritis. I can tell you that for a certainty. We're all going to start
to wrinkle. And so these are all things that are expected. But how do we approach the aging
(23:09):
process and living with chronic disease? Like I said, it can either be a very hard process
or we can find ways to develop that resiliency. And despite living with a history of stroke
or diabetes or heart failure, there are still ways that we can go through life in a meaningful
way and to set those goals for ourselves. And that's what I try to really coach my patients
(23:35):
to discover for themselves is despite your current situation, what does healthy aging
mean to you? What are you still looking forward to doing? And how can we get you there without
feeling like throwing our hands up to say, okay, there's not much else we can do. Because
my mantra is there's always something we can do for each patient. You just have to kind
(23:56):
of get a little bit creative and discover what their goals are and what their aspirations
are and how do we get them there? Even if it's more than once a month.
Definitely. And I think that's what they always say, like medicine is science and art, right?
We have all of those logistical things like textbook things and things that's obviously
evidence based and on the data on the dot. And then there's things like outside of the
(24:19):
box you think of that are creative. And I think like even like EQ over IQ too, right?
And how we relate to the patients and how we interweave their emotions and how their
culture may be into the care that they receive, right? And you also mentioned a lot about
the disease and the aging process. I guess about the years that you've been practicing
(24:43):
now, would you say that there are diseases that are just expected or just people are
just prone to throughout the aging process? I guess as we reach that line of geriatrics,
the age that we consider as geriatrics, can you say that there are diseases that not that
they're not preventable, but you would expect that, oh, by the time we reach this age, we
(25:04):
probably have this.
Yeah, that's a hard question because I think it's a combination of things. Genes play a
big part into that, our environment, our habits. And so I think, I mean, the physiologic changes
are for sure. When things are going to degenerate, we lose about a third of our nephrons over
(25:28):
our lifetime. So we're bound to have a little bit of at least slowing of our renal capacity
and filtration. We're all bound to develop a little bit of arthritis, I think. So these
things are probably expected just from the biologic changes. And then everything else
compounds on top of that. If you lived a life of high stress and you're prone to hypertension,
(25:52):
if your genetics put you at risk of heart disease, I mean, that all impacts how things
sort of develop and progress. And then it's just sort of the outcome of that. And some
people may have high risk, but then they live a healthy life and they don't develop any
of these things. So it's really hard to predict for each person. That's why there's so much
(26:14):
variety. There's such a huge spectrum of how people age. And so I don't know if I'm answering
your question, but I don't think we're expected to develop anything at a certain time. I think
there's a lot of different variables.
I guess it's supposed to just expect the diseases. I think there are also just experiences that
I guess are experienced more by the geriatric population. I've also worked in a nursing
(26:40):
home and I have rotated through it. And I actually asked followers to send in words
or even medical concepts that they think of when they hear the word the elderly or geriatric.
So I'm going to say a few, and I guess for each one, I wonder what your approach is as
(27:00):
a geriatrician, right? And also maybe a general term that's so easy to understand, but I guess
from your point of view, what do you think it is? And I think the first one that came
a lot is the principle of frailty and false. As a geriatrician, what does that mean to
you and are the elderly more prone to false really? And what is your approach for that?
(27:24):
Yeah, you're hitting all the big topics here. And frailty and false, they're both like two
huge lectures in itself that I could go on and on forever about. But I saw the list that
you mentioned. I'm just like, wow, Christian really did his homework because this is like
the bread and butter of geriatrics, frailty and false. And I'm just sort of going to lump
(27:47):
them together. You mentioned urinary incontinence, osteoporosis, malnutrition, and Alzheimer's
dementia and everything that you listed fall into the category of what we call geriatric
syndromes. And what that means is a syndrome is a, it comes from Greek roots, dromos meaning
(28:08):
running together. And so it's basically things that happen over and over in secret in a pattern,
not specifically a disease, you know, entity. It's not like diabetes or hypertension, but
it's a pattern that happens over and over specifically in older adults. So for example,
how come Christian, you don't fall every day? Right? How come you don't have urinary incontinence?
(28:29):
At least I hope you don't have urinary incontinence. You know, why do these things happen just
in older adults? And it's because it's a combination of things where if you combine biological
changes in their body on top of other issues, like the impact of chronic disease on top
of being on medications for so many years, and then polypharmacy, and then being more
(28:51):
prone to like dehydration or sepsis and illness in combination, if you, if that all happens
at the same time, it puts people at higher risk of developing things like faults, right?
If you're on 10 medications, plus you have arthritis and you've got a little bit of
dementia and perhaps you had a stroke, you know, years ago, it affects your balance,
(29:14):
it affects your sensory perception, it affects your ability to maneuver complex paths. And
so you're just prone to falling. Similar to frailty, it's a phenotype that is characterized
by five major phenotypes, loss of the subjective sense of weakness or reduced strength, weight
loss, exhaustion. And so these are all kind of similar symptoms or syndromes that seem
(29:40):
to occur in older adults who are prone to that phenotype and puts them at a higher risk
because they're just more vulnerable to begin with. And so you can stick any geriatric syndrome,
any word in that like, in that category. And the learning point here for all students or
residents or whoever's in training, if you see a geriatric syndrome, it can be anything,
(30:03):
think of it as there's probably more than one thing going on. And so always explore
more than just one thing. If they come in or they fall, it's not just a mechanical fall
that they tripped over a stool. Look into a little bit deeper. What meds are they on?
How long have they lived with, you know, arthritis? Is there pain affecting their joints that
could be impacting their balance? Are they using a locker safely? You know, what's their
(30:29):
environment like? Are they living in this dark home with like numerous stairs and trip
hazards? So all these things, you know, in combination, puts people at higher risk of
these, these syndromes. So in a nutshell, if you're seeing any of these issues, try
to look at at least a couple different avenues, a couple different pillars of care to see
(30:52):
what are some of these risks and what can we do to mitigate some of these risks, because
all you have to do is maybe address two or three of them and it can make a huge impact
on one's fall risk or frailty risk so that they're not at risk of having that happen
again or having long term outcomes from that. So we, again, we can go through each like
health condition separately, but, and I'm happy to do more lives to talk about, you
(31:16):
know, our mental health and dementia care and weight loss. I mean, those are big topics.
I want to off the list, I think the one that I really want to talk about is dementia and
Alzheimer's disease. I don't know if you've seen the movie, the notebook, Nicholas Sparks
and I had watched it as a kid, seeing the ending where I guess the other people forgot
(31:40):
who their children were and then they were sundowning and I think as a kid I was like,
oh my gosh, this is going to happen to my grandma as well. Well, my grandma actually
has Alzheimer's now and doesn't remember me or her children. I can't imagine how often
you see this in practice, right? And I think this is the one that I really wanted to make
(32:04):
a speech to your brains about is what is dementia? What is Alzheimer's? Are they the same thing?
Is it just, I think when people mostly think about dementia and Alzheimer's, they mostly
think of memory loss. But obviously, when I'm reading about it and studying about it in
school, I'm just like, okay, it's not just memory loss. It's like a whole cascade of
different things. What is Alzheimer's? What is dementia?
(32:26):
Yeah, good question. And it's funny you mention this because I just did a podcast on this
yesterday for our AZ4 podcast. So that'll be coming out hopefully next week, but it's
a good talk. Dr. Tong, Erica Tong, who's kind of our dementia expert is our speaker. So
but I can give a summary. So dementia is kind of an umbrella term that describes memory
(32:50):
impairment and it can be caused by numerous causes, but memory impairment that is significant
enough to impact one's ability to function independently. So we all have some degree
of memory loss. I mean, I forget what I eat this morning for breakfast, right? And I always
lose my keys, but those are like brain lapses that we all go through. But dementia is memory
(33:11):
loss plus some deficit of a cognitive domain, whether it's learning or language or executive
function that is severe enough to impact their ability to live independently and thrive in
the community. And so dementia is that umbrella term. Alzheimer's is a type of dementia. It's
one of the causes of dementia. There's many other causes of dementia as well. So for example,
(33:36):
V-body dementia is also is probably the second most common now. Vascular dementia is when
people have a history of multiple strokes and each time they've had a stroke, you know,
parts of their brain dies and becomes scarred and doesn't work as well. Parkinson's disease,
a lot of people in late stage disease can develop dementia and then you've got like
they're really more rare, I suppose, like an NPH and so forth in the degenerative process
(34:01):
of disease. But all of that can lead to a global loss of cognitive function severe enough
to impact their ability to function. And so, you know, as we talk about Alzheimer's is
the most common type, it's about two thirds of the dementia prevalence and it's very devastating.
I mean, it's a very slow progressive process. It can happen over many years, sometimes over
(34:26):
a decade before it's even diagnosed because the changes can be so subtle before it's like,
hey, something's not right with mom, you know, she all of a sudden just can't find her way
back home. And it's like that's, you know, that is concerning. But sometimes these, the
diagnosis can be delayed because people can live with it and they can kind of, you know,
(34:47):
get by living with it and others don't notice. V-body is a little bit more dramatic. People
tend to have more like hallucinations and delusions and have just like perceptual changes,
changes in sensorium. And so that can be very distressing. And so each dementia type has
its own features. But overall bottom line is that it becomes progressive to a point
(35:11):
where people just can't handle day-to-day cares anymore. So that's where it becomes
hard to live on their own. And then then we're talking about where do we, where do we go
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(39:03):
All this like, just the quality of life, right? And I think that's also tied to a lot of
like this mental health in the other way, right? Like the feeling of, oh, I can't do
the things I used to be able to do anymore, or I can't, I can't do the simple tasks that
I used to be for the people around me or for myself. And I guess even as we mentioned the
(39:24):
age of 65, right? Even like retirements, like, oh, what do I do with my life now? Or I'm
in a different role or season in life than I was before. Like, I remember my mom actually
just retired, she's 65, not turning 66. And I remember after she retired, she's been
a nurse for decades now. She's like, I don't know what to do with my life anymore. I don't
(39:46):
know what to do next. And I feel like these are things that I guess we don't really think
about until we get to that point, right? Like, kind of a mental health, especially for the
elderly. And it's very interesting because I guess there are pains, like a fall where
the person who fell can feel it, right? Or wounds that we can see. But I feel like there's
(40:11):
some wounds, there's some injuries that are invisible to everybody, right? And I feel
like those kind of wounds, especially in the elderly are, I guess, like loneliness and
maybe abandonment. I remember, I'll never forget, I was a first year nursing student
at a nursing home in the city. And I sat to one of the residents during their lunchtime
(40:37):
and she was like, you know, my children haven't visited me for four years now. She's like,
can you be my son while we're having lunch? And in my mind, I was like, it's like loneliness
and abandonment and the feeling like loss of, I guess, autonomy and just control of their
(40:58):
life is such a real thing, especially in the geriatric population. As the geriatrician,
the physician who sees this and obviously you make executive decisions for this age
population beyond the textbook for physical manifestations of aging and disease. How
do you deal with things that are unseen and maybe invisible, like loneliness and heartbreak
(41:24):
and fear of the remaining future?
Oh boy, that's a loaded question. I share your sentiment about the nursing home experience
because I hate using the word sad, but I can't help but just feel like my heart aches every
time I go into a nursing home and I just see people sitting there by themselves, they're
(41:48):
eating by themselves. And yeah, I'm sure their families have visited, but you know,
you sort of see people in their empty shell of who they were before. And it's not uncommon
that people are depressed and lonely and anxious because they just don't have that stimulation.
And so I guess a broad way to answer your question is that I think we have to remember
(42:14):
that despite what people look like to us on the surface, they may look older and frail
and helpless in many ways, but they still are people, right? They still are valuable
and their legacy deserves to be preserved. They were functioning people at some point
(42:38):
in their lives. They contributed to society. They were scientists and artists and teachers
and engineers. I mean, they are human and they have families, they have people who love
them. And it's hard to see that when you meet them for the first time. And it's even
harder when they can't talk back to you, right? They can't like share some of their experiences
(43:00):
with you, especially if they're against dementia. So I see what you're saying. It's really
hard to help people who are already feeling lonely. And that's why whenever I see older
adults in the nursing home, I always just spend a little bit more time with them. If
they're in the dining room, I might just sit there and just share a meal with them and
(43:22):
chat with them a little bit and just hear about their life story. And they may not remember
who I am, but they will remember that someone was there to listen to them. And I always
try to weave in their family members back into the picture in some way, whether it's
just to call them for an update to say, Hey, mom, I saw mom today. She's doing well. She
would really enjoy your company. And if there's any ways of just staying more connected, I
(43:46):
think she will really appreciate it. And just try to find ways of bringing families back,
especially if I feel like they haven't been visiting much. And so these unseen things
are usually years of accumulated sort of deficits of just feeling like you've lost so much along
the way. And that's what I've been trying to change is it doesn't have to feel like
(44:07):
loss along the way. Retirement is funny that you mentioned that retirement feels like a
big loss for people because all of a sudden, the first two months are great. You're like,
yay, I don't have to work anymore. I can go read books and do things, but humans are made
to have purpose. And it's the reason why retirement is actually one of the top 10 stressors of
(44:28):
life. People don't realize that, but it's actually a stressful experience. You don't
prepare for it. All of a sudden you have nothing to do. And then that can be a trigger to actually
a stressful transition into your next chapter of life. And so finding those transition points
that could trigger depression and anxiety or loneliness and helping people make those
(44:48):
transitions a little bit earlier or living with chronic disease in a more meaningful
way so that they still feel like they have things to look forward to and things to do.
I think that earlier we tackled these things along the way and it doesn't accumulate as
much to the point where all of a sudden it's just so devastating that you can't do anything.
It's learning how to be able to do more with less, if that's the best way to describe it.
(45:14):
And I feel like I've gone off on a completely different tangent, but tackling loneliness
as a whole, depression triggers, but also I think depression, loneliness and neglect
in the nursing home is a completely separate issue that if we just remember everyone is
human and they all deserve our time, attention and our presence.
(45:36):
Yeah, this is making me teary eyed. I mean, it's such a... Yeah, like so many people need
care, right? Especially within the geriatric population, but aren't there enough people
to care for them, right? And tying this to the statistic that says that there are approximately
7,000 geriatricians nationally only and we need about 30,000 more by 2030 to meet the
(46:00):
needs of the Asian population. The crisis is the crisis.
I know, that's crazy.
Who will care? There will always be a geriatric population because everyone will age and everyone
will grow old. As a physician, as a geriatrician, how would you encourage future physicians
to enter this field of geriatrics and be the guiding light for our future elderly populations?
(46:22):
Yeah. Well, and this is not just for physicians, it's for all care providers who take care
of patients, you know, PAs, NPs, nursing. It's just that there is a heart for geriatrics
for everyone. And I would say that, first of all, it's just such a rewarding field.
I don't think people really know about geriatrics because it's not glamorous. It's not like
(46:45):
plastic surgery or trauma surgery or something cool. Anesthesia, this is like... I feel like
those are the hot specialties. They're all great. I'm not downplaying them. They're all
fantastic. But I think geriatrics is sort of buried a little bit because it's not something
that's talked about much. Like I didn't even hear about it until residency. And so I think
(47:06):
there just needs to be, number one, more awareness, more mentorship, more inspirational, I guess,
moments where people can experience like taking care of an older adult is such a rewarding
opportunity to be able to make meaningful changes in their lives and to be part of that
health journey with them. I think the earlier exposure, the better. You know, so our medical
(47:26):
students, they're exposed on day one. And I feel like they graduate as just really well-rounded
physicians because they understand geriatric medicine very well. You know, as we're learning
about different aspects of medicine and you go through different rotations, we're also
exposing our students to elements of geriatric medicines and those rotational experiences.
(47:48):
So for example, perioperative medicine and surgery, they learn about how to do a perioperative
examination. How do we do a geriatric assessment so that we can prevent delirium, the risk
of delirium as an outcome. And so early education, good mentorship, and just like this is such
underserved field, helping people understand that there's a lot you can do within that
(48:08):
field is not just seeing patients in nursing homes. You can be an educator, you can be
an academic medicine, you can be a medical director, you can innovate. There's a lot
of innovation in healthy aging and the healthy aging. Research too. That's kind of what I'm
involved in as well. Research, tons of research. Yeah. Research is especially important because
a lot of older adults are kind of excluded from major research studies. And so we need
(48:33):
a lot more research in that area. So there's a lot of exciting things in geriatric medicine.
And I think it's just off to the side geriatric. Geriatricians are probably the happiest people
just because I think we really enjoy what we do. And it's not, there's always stressful
parts to every specialty, you know, but it's, I feel like the stress is not something that
(48:55):
impacts me negatively. It's really helping my patients. My patients stress becomes my
stress in some ways because I want them to, you know, understand how to just live better,
but guiding them through that journey, I think it's per the reward. And then I would also
say that not everyone is meant to be a geriatrician. Obviously if you've got interest to be a pediatrician
(49:19):
or OB or surgeon, that's awesome. My goal is that, you know, we can't, we probably can't
get 30,000 geriatricians by 2050 or whatever. But if every person in their specialty can
be a mini geriatrician in some ways where they have some understanding of how to weave in
(49:41):
some of these elements into their practice, I think that's a great win as well. That you
don't have to be a full blown geriatrician, but you can be a cardiologist with geriatric
understanding or a surgeon who knows, okay, this is what I need to do to prevent delirium
as an outcome. So just having those elements within your practice, I think is, is an opportunity.
(50:03):
I guess I've learned so much today. We talked a lot and I think a lot of our conversations,
not just educational, but we talk a lot about the care team that takes care for geriatrics.
Well, I guess one of the last questions would be, what would be your message for the geriatric
population itself? In the midst of whoever probably stumble upon this someday, I don't
(50:26):
know, someone who just retired and feeling lost in life or someone who's listening to
the podcast episodes on their 70s or 80s and they live alone, what would be your message
as a geriatrician to our elderly population or something that you may want to say to the
geriatric population, even though they may no longer remember what you say?
(50:48):
Yeah, that's interesting. So a common thing that older adults always tell me is like,
they always use the same phrase. It's like getting old stinks. It really sucks. Like
don't look forward to getting old because the golden years are not golden. And I think
that's, that's really sad to just hear them say that because I think there is a way that
(51:11):
we can always look forward to living well. And that would be my just global answer to
them is there's, there's always a way to live well, no matter what situation or circumstance
that you're in. It may seem the situation may seem grim. You may be experiencing a lot
of symptoms, your health may be not doing well, but you have a medical team. You have
(51:35):
a partnership with myself and they find it so comforting when they understand that their
doctor is here to partner with them, not just today, but for the longterm, you know, so
that actually brings them a lot of comfort to know that I'm not going through this myself
and there's a support system, there's a care team and that there's always something to
(51:56):
look forward to. So find that next thing to look forward to, whether it's learning a new
skill or finding a way to regain that functional ability that we lost, whether it's driving
or walking or simply making it to the bathroom. Sometimes just helping them make those small
goals and giving them that little bit of hope can be a, can make a profound difference.
(52:17):
So to answer your question, I guess I try to find that specific individual like goal
for each person, which is very different, but it's, it's just instilling that sense
of hope again. I think it's very powerful.
I love that. Your heart is so full. Dr. Ben, it is such an honor to have you on today and
(52:38):
thank you. Thank you so much. Thank you. I learned so much and it's just this new found
love and passion for people around me and especially more of our other population and
it has felt so cool. Thank you so much for joining me in today's episode.
(53:00):
Yeah. I hope it was helpful for people who come through and I hope that I was able to
answer some of your questions. I'm happy to answer questions offline. If you have interest
in geriatric medicine, what the training is like, what to anticipate after training, what
life is like as an attending. It's a lot, lots to talk about.
(53:22):
Yes. And this is not the last time we will talk. We'll have more to talk about. Thank
you so much for spending time with me to talk about all of this. I hope you have a great
rest of the night. Thank you.
Hi friends, how are you all doing? Happy Friday! Another Friends of France Friday. And I cannot
(00:10):
believe it, we are in the third to last episode of the third season of the podcast. Wow. It's
so bittersweet just thinking about the near end of the season. I'm also excited to close
this chapter of the show and hopefully await a new phase in the near future. How are you?
How are your seasonal allergies? Everyone made job has been sick with their springtime allergies
(00:32):
and I think I'm next. I was walking through Central Park the other weekend and I just saw
so many people sneezing. It's definitely those pollens flying around. But that's just one
of the things you can see happening at Central Park on any given day. It's truly a garden
of wonders, of sights and experiences. I feel like Central Park is one of those places in
(00:53):
New York City that I have so many memories of because it's so huge. And I visit with
different groups of people each time. One of my more recent memories is walking alongside
the 5th Avenue side of the park during early December. I was on a day, a second day actually,
the tea. We spent some time inside the Met Museum, which is on East 82nd Street. And
(01:15):
we walked all the way to K-Town on 32nd Street for dinner. I literally walked 50 long streets
and a couple of avenues with my date, just talking about life and everything. Now, each
time I pass by the park while driving by, all I can think is, wow, I can't believe
we walked all of those streets. But that's just one of the magic of Central Park for
(01:39):
me. But to your side, Central Park reminds me of one more thing, nursing school. During
my first semester of nursing school, or my fundamentals of nursing class, my first ever
clinical rotation was in a nursing home on the Upper East Side, also along the 5th Avenue
side of the park. I remember walking by the park to get to the facility where I would
(02:01):
then spend 8-10 hours taking care of the nursing home residents. This really opened my eyes
to the world of nursing, which I had never thought of before. Growing up with my mom,
who was a hospital nurse herself, I think I somewhat glamorized the nursing profession
I had in mind. Procedures, injections, anesthesia, codes, always pleasant patients. I never really
(02:23):
saw the patient bed baths and tracheostomy care and turning patients and ulcers and poop
and pee and making beds and this is all that we did in the nursing home rotation. I just
remember the bed boundary at the patients, mostly in their 70s through 90s, who we had
to turn every 2 hours so they could avoid pressure ulcers. However, the one clinical
(02:46):
rotation memory I will never forget is a resident in her late 80s. I remember knocking on her
door and she was just sitting down in her chair and looking out the window while eating
a pudding.
Hi, I said. How's your morning?
I am just here waiting, I remember her saying.
Waiting for who? I asked.
Someone to visit me, she said. My son hasn't visited me for a few years. Can you be my
(03:09):
son while you're here? She asked me. I remember my heart sinking.
And this is the situation of many of the residents in that nursing home and nursing homes in
general. For whatever reason unknown to us, the residents were rarely, if at all, visited
by their families or loved ones. One of the nurses told us that sometimes, the nursing
staff is all these residents have because they have been abandoned by their families.
(03:32):
According to the National Academies of Sciences, Engineering and Medicine, nearly one-fourth
of older adults aged 65 and older are at increased risk for loneliness and are considered to
be socially isolated, with risk factors being attributed to losing family or friends, hearing
loss, role changes such as retirement, living alone, and chronic disease.
(03:53):
When it comes to older adults, I have a very touchy part in my heart because I grew up
with my grandma, who stayed with us here in New York before moving back to Asia when I
started high school. Because my mom was a single mom and a night-trip nurse for most
of my childhood, my grandma took care of me most of the time. Walked me to school, made
me lunch, took me to the farm school, took me to piano lessons and Kuman tutoring. Ugh,
(04:15):
the Asian PTSD. Who can relate? And to think that there are grandmas and grandpas out there
who are just looking out a window somewhere and waiting for their loved ones because they
think they have been abandoned, my heart can't fully take that thought.
The field of geriatric medicine is truly one that is beyond the scientific and the clinical.
It is the emotional and the mental. Beyond finding the empirical solutions to geriatric
(04:38):
syndromes that most older adults face, such as malnutrition, cognitive impairment like
dementia, polypharmacy, false inferiority, and of the like, the mental and emotional
toss of living in spite of chronic disease, battling loneliness and depression, and maximizing
quality of life despite these hurdles are the crux of the field.
And for this topic, I am beyond honored to be joined today by double board certified
(05:02):
internist and geriatrician for Mayo Clinic, Dr. Christina Chen. Dr. Chen currently stands
as an attending geriatrician and assistant professor of medicine at Mayo Clinic Rochester,
the host of the Aging Forward podcast, the course director of the Mayo Clinic Alex School
of Medicine, Seniors Ages Curriculum, and the Medical Advisory Board of Grand Pad, a
customizable platform that delivers virtual care to seniors at home while keeping seniors
(05:27):
connected to reduce social isolation and improve the telehealth experience.
This is such a personal topic for me, and I hope you get to learn a lot just as I did.
Hi, Doc. How are you doing?
Hey, Christian.
Thank you so much for training me tonight.
Good, how are you? Yeah, thanks for the invite. Love it.
So honored to have you on tonight. I've been actually wanting to invite you to our podcast
(05:52):
episode for such a long time now, for several months now, and it's finally here. If you
could just first please introduce yourself to our future podcast listeners, please.
And thank you so much.
Yeah, sure. Hi, everyone. My name is Christina Chen. I am a geriatrician. I practice at Mayo
Clinic in Rochester, Minnesota. Lived here for about 11 years, trained here for fellowship.
(06:14):
Prior to that, I trained in Illinois for residency and originally from Michigan, where I lived
for 20 something years. I forget now, but yeah, I've been here for a while and I think
we're here to stay. So we have a family, two kids, two chickens that I recently got, two
birds. So we're kind of settling on our roots.
(06:38):
I love it.
Our family is here to stay probably.
I love the chickens. That's so cute. I mean, I've been wanting to speak to Geriatrician
for such a while now because it holds such a dear place in my heart. My first rotation
in nursing school was in a nursing home. And that was the first time I was like, whoa,
(07:01):
this is such a very niche field too. I mean, I grew up also with my grandma who took care
of me. So I grew up with a single mom who was working all the time as a nurse too. So
my grandma took care of me growing up. So I feel like I've always had this deep love
and appreciation for her elderly. And I'm like, we need a whole podcast episode on all
(07:23):
of the changes and all of the things that make the field of Geriatrics special. And
again, I'm so honored that it's you who's with me tonight in this episode. I first wanted
to do a deep dive into your journey into medicine. I mean, you know, it's a long road getting
to where you are now as a physician. I want to know what's your first inspiration in becoming
(07:45):
a physician entering the field of medicine? Is it a family, friend or personal experience?
Yeah, so I've always grown up in a very scientific family. You know, my father worked in various
aspects of science. So he was a biochemist. He taught parasitology, chemistry at Michigan
State University. So I spent my life like in the lab all the time. I would always go
(08:07):
to work with him. I dissected my first mouse at the age of five. So I just loved anatomy,
physiology, and was always immersed in science. And I just loved that growing up in high school
and in college. But I feel like the geriatric aspect really came from my just being raised
by my grandmother. So my grandmother came to the States when I was young to help take
(08:28):
care of me. And so she was like my, my mentor, you know, she ended up passing away at age
99. But I always saw her as my, she was my hero. And she was like invincible to me. She
didn't have a single health issue, was cognitively intact until the day that she passed away.
And so I just, I really saw her as my role model. And I always hung out with old people
(08:48):
as well. Even at, you know, parties, all the kids would be playing with all their kids.
And I would just find that like, you know, lonely older adult and just sit with them
and learn from them. So I think I just had a heart for people who were more, I don't
know, more vulnerable maybe and just needed a listening ear. So combining science as a
(09:09):
love with older adults as, you know, mentorship and just people that I love to be with, it
just made sense to, to.
So would you say that you pursued medicine even more because you know, you wanted to
be a geriatrician, like from the get go, did you know you wanted to work with older people?
I didn't know geriatrics was a subspecialty until residency. And so I went through the
(09:31):
whole exploration phase. I really loved cardiology to the physiology of the heart. I love GI.
And so I explored all of that. And then it wasn't until I went through a geriatric rotation
where I was like, wow, this is, this is actually a field and just fell in love with that aspect
of not just handling chronic disease, but handling the life journey of people throughout
(09:53):
their health spectrum. And I found that it was a combination of internal medicine, but
everything that I loved plus population that I loved. So yeah. And I think that's the main
challenges. Most people are not exposed to geriatrics until, you know, it wasn't until
recently that medical school has more of a integrated or needed curriculum for most,
(10:13):
most medical schools. Prior to that, there wasn't a lot of dedicated curriculum for geriatric
training. So things are changing now, but I think it might be a little bit better lately.
I know that you also are like the course director at Mayo Clinic for the SAGES curriculum. And
I guess you're like really contributing to this push for really learning more about the
(10:35):
geriatric population, right?
I think the early exposure experience is so important. The earlier, the better. We just
had a senior SAGE initial kickoff event, which is where our students, our first year students
are matched with a senior in the community. And they kind of learn from each other over
the course of four years that the students are there training and they learn about geriatric
(10:56):
medicine through the eyes of someone who's going through that experience. So it's like
a relationship that they build over four years, but also just a really unique and creative
way of learning geriatrics.
Yeah, I love that so much. I actually believe that early exposure is so integral, right?
To, I guess, even just developing like a baseline of spec, right? Especially in a world where
(11:18):
lack of knowledge is real and ageism is real too, right? In this society. So, well, I guess
as you take a deep dive into the whole field of geriatrics, geriatric medicine, for the
only person who might not even know what the word geriatrics means, right? As the expert
here, as the attending here, what is the field of geriatrics all about? What is the premise
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of the whole field? And I guess what is the demarcation line between regular adult medicine
and geriatric medicine?
Yeah, good question. So think of geriatrics as the opposite of pediatrics. You know, pediatrics
would take care of kids, geriatrics older adults. And the reason is because the human
body changes over time. The way that we treat children is completely different than the
(12:00):
way that we manage the general adult population, which is different than the older adult population.
So the health needs change over time. And the age cut off right now is 65. 65 and above
is considered geriatric or older adult. But I would argue that there's a lot of 65-year-olds
that are actually quite healthy without any health issues and very robust. And so that
(12:21):
line is sort of a little bit muddy there, but it's right now by definition 65 and above.
And our focus is a lot of different things. Our focus is not just prevention of disease.
It's not just, you know, diagnosing disease, but we're also handling a lot of the sequelae
or the outcome of living with long-term disease. And in many situations, people are living
(12:42):
with more functional impairment, with cognitive impairment, and the outcome of just living
with say diabetes or heart failure or COPD for a long time, which impacts their ability
to stay independent. So our goal is not just managing those specific health issues, but
how do we help them live well despite living with disease? And it's a challenge because
(13:06):
in this day and age of modern medicine where everything is supposedly treatable, right,
we have a treatment for everything. We've got a way to like cure disease and reverse
disease and it's hard to have that perception change of, okay, at some point we have to
realize that, you know, we're living with this and there's no reversal. And at some
point, you know, it might affect our quality of life and function and helping people not
(13:30):
just adapt to that, but thrive in that environment so that they feel empowered to continue to
live well despite what they are diagnosed with is kind of the art of geriatric medicine
that I've really grown to love. So I think there's a lot of ways you can weave in geriatric
medicine to other subspecialties. Like not everyone is meant to be a geriatrician. I
mean, we need cardiologists and we need gastroenterologists, but how do we weave in geriatric concepts
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so that, yes, you're seeing this person for heart disease, but also understanding how
it's impacting their function or their quality of life so that we're also managing their
health conditions in a more meaningful way.
Yeah, got it. So beautiful. And I think speaking also like interweaving geriatric medicine,
I guess, the care for it in different specialties as well. So I think it's also true that there's
geriatrics everywhere, right, in different settings. So I guess the next question would
(14:20):
be as a geriatrician, where are the places we would see geriatricians, right? I guess
in what settings does the specialty usually work in? Is it just the hospitals, just clinics,
or what?
Oh, everywhere. It's such a versatile field. You can work in the inpatient setting. You
can work in the clinical outpatient setting and have your own patient panel. A lot of
(14:42):
geriatricians work in long-term care settings. So nursing homes, they can be medical directors
of nursing homes, academic medicine, you know, you can do teaching. So my practice is a blend
of all of that. I do a little bit of everything. I have my own clinical practice, but I also
work in the nursing homes one day a week. I don't do inpatient medicine, but I did that
for a little bit during my first part of my career. I also do a little bit of integrative
(15:05):
medicine too. So you can really become creative. So I train in acupuncture with the goal of
helping older adults live better with their pain experience and just integrating that
into their care. So you can get really creative and it makes each day fun because you're not
just doing the same thing over and over, right? Each day is a little bit different. And I
also have the honor of working with our medical students too, who are just amazing and they're
(15:29):
so willing to learn and so enthusiastic to learn about, you know, geriatric medicine.
So it's a lot of teaching, learning along the way and practice.
I love that. And I guess I want to talk more also about, I guess the bread and butter of
your work. Like on a daily, I guess, how does the usual day of work look like? And I guess
what would be the reasons for the elderly that you're seeing under your service, right?
(15:54):
Why are they usually more at the time? Like bread and butter diagnoses and such.
So it depends on which setting you work in. So for example, in my outpatient practice,
I see a lot of general chronic disease management and it's not just managing their preexisting
disease. A lot of times we're diagnosing new conditions as well. It's very versatile. We
see a lot of cognitive impairment and new diagnosis of, of dementias, which can be
(16:19):
hard for the families and caregivers because it's, it's really a journey. And so helping
them go through that journey is a common thing that we, we do in our practice.
And the nursing home is different because these nursing home patients have been living
there for many years, or they may be in the rehab setting where they're recovering from
a recent illness. And so we, we do admissions there. We help them transition safely back
(16:41):
home or we see them if they are there long-term, we see them routinely as almost like primary
care for this to make sure that they're doing well. And so each practice is a little bit
different, but the bread and butter is again, helping people live well despite their current
situation and how do we still find ways to improve their quality of life? Even if it
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seems like things are hopeless or that they don't have much time left. I just feel so
badly when, when that general perception of geriatric medicine is that, you know, it seems
like a hopeless situation, right? It just, it seems like what else can we do for them?
But there's, there's so much we can still do for them because I think every life is
so important and, and their dignity needs to be preserved and to approach each patient
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I think before we even deep dive into some of those problems that you mentioned, those
(20:45):
chronic diseases, I think all of these terms that you just said, I think the general public
can develop it in the word of aging, right? Like, oh, that's common, or that's normal,
that's expected because people age, dot dot dot, right? So I guess as someone who sees
aging as a progressive thing, as a progression thing, as a geriatrician, to you, what does
(21:09):
aging actually mean? What does it mean that, oh, I'm of old age now, right? And so that
notes, as you see a lot of diseases and all of that, is there such thing as healthy aging?
Is there such thing as even if I'm 80 years old, I can still be considered as a healthy
aged person?
Absolutely. I see tons of 80 and 90 year olds still out there jet skiing and enjoying their
(21:37):
lives to the max. And I'm just, I sometimes I'm jealous, but I'm like, wow, you are rocking
it. You are just loving life. That's amazing. But we are aging as soon as we're born. Honestly,
that's the reality. As soon as we're born, yes, we're growing, but our cells are aging.
It's a physiologic, biologic change that just happens with time. There's nothing we can
(22:01):
do about it, unfortunately. And every part of our organ ages and people age in different
ways. Some people may have the chronologic age may be different than biologic age, meaning
that some people may age better than others. You often see these 80 year olds who you're
like, wow, they don't look like they're 80 because they're so functional and they're
(22:21):
still bright and you know, cognitively intact and just doing so much. And then you'll see
60 year olds who are completely debilitated in wheelchairs and can't take care of themselves.
So it's such a wide spectrum. And to answer your question about healthy aging, I think
that is really up to how people perceive aging to be for them. Healthy aging doesn't mean
(22:45):
to be completely absent of disease because I don't think that's completely possible.
Right? We're all bound to develop arthritis at some point in their lives. I mean, I probably
already, I have arthritis. I can tell you that for a certainty. We're all going to start
to wrinkle. And so these are all things that are expected. But how do we approach the aging
(23:09):
process and living with chronic disease? Like I said, it can either be a very hard process
or we can find ways to develop that resiliency. And despite living with a history of stroke
or diabetes or heart failure, there are still ways that we can go through life in a meaningful
way and to set those goals for ourselves. And that's what I try to really coach my patients
(23:35):
to discover for themselves is despite your current situation, what does healthy aging
mean to you? What are you still looking forward to doing? And how can we get you there without
feeling like throwing our hands up to say, okay, there's not much else we can do. Because
my mantra is there's always something we can do for each patient. You just have to kind
(23:56):
of get a little bit creative and discover what their goals are and what their aspirations
are and how do we get them there? Even if it's more than once a month.
Definitely. And I think that's what they always say, like medicine is science and art, right?
We have all of those logistical things like textbook things and things that's obviously
evidence based and on the data on the dot. And then there's things like outside of the
(24:19):
box you think of that are creative. And I think like even like EQ over IQ too, right?
And how we relate to the patients and how we interweave their emotions and how their
culture may be into the care that they receive, right? And you also mentioned a lot about
the disease and the aging process. I guess about the years that you've been practicing
(24:43):
now, would you say that there are diseases that are just expected or just people are
just prone to throughout the aging process? I guess as we reach that line of geriatrics,
the age that we consider as geriatrics, can you say that there are diseases that not that
they're not preventable, but you would expect that, oh, by the time we reach this age, we
(25:04):
probably have this.
Yeah, that's a hard question because I think it's a combination of things. Genes play a
big part into that, our environment, our habits. And so I think, I mean, the physiologic changes
are for sure. When things are going to degenerate, we lose about a third of our nephrons over
(25:28):
our lifetime. So we're bound to have a little bit of at least slowing of our renal capacity
and filtration. We're all bound to develop a little bit of arthritis, I think. So these
things are probably expected just from the biologic changes. And then everything else
compounds on top of that. If you lived a life of high stress and you're prone to hypertension,
(25:52):
if your genetics put you at risk of heart disease, I mean, that all impacts how things
sort of develop and progress. And then it's just sort of the outcome of that. And some
people may have high risk, but then they live a healthy life and they don't develop any
of these things. So it's really hard to predict for each person. That's why there's so much
(26:14):
variety. There's such a huge spectrum of how people age. And so I don't know if I'm answering
your question, but I don't think we're expected to develop anything at a certain time. I think
there's a lot of different variables.
I guess it's supposed to just expect the diseases. I think there are also just experiences that
I guess are experienced more by the geriatric population. I've also worked in a nursing
(26:40):
home and I have rotated through it. And I actually asked followers to send in words
or even medical concepts that they think of when they hear the word the elderly or geriatric.
So I'm going to say a few, and I guess for each one, I wonder what your approach is as
(27:00):
a geriatrician, right? And also maybe a general term that's so easy to understand, but I guess
from your point of view, what do you think it is? And I think the first one that came
a lot is the principle of frailty and false. As a geriatrician, what does that mean to
you and are the elderly more prone to false really? And what is your approach for that?
(27:24):
Yeah, you're hitting all the big topics here. And frailty and false, they're both like two
huge lectures in itself that I could go on and on forever about. But I saw the list that
you mentioned. I'm just like, wow, Christian really did his homework because this is like
the bread and butter of geriatrics, frailty and false. And I'm just sort of going to lump
(27:47):
them together. You mentioned urinary incontinence, osteoporosis, malnutrition, and Alzheimer's
dementia and everything that you listed fall into the category of what we call geriatric
syndromes. And what that means is a syndrome is a, it comes from Greek roots, dromos meaning
(28:08):
running together. And so it's basically things that happen over and over in secret in a pattern,
not specifically a disease, you know, entity. It's not like diabetes or hypertension, but
it's a pattern that happens over and over specifically in older adults. So for example,
how come Christian, you don't fall every day? Right? How come you don't have urinary incontinence?
(28:29):
At least I hope you don't have urinary incontinence. You know, why do these things happen just
in older adults? And it's because it's a combination of things where if you combine biological
changes in their body on top of other issues, like the impact of chronic disease on top
of being on medications for so many years, and then polypharmacy, and then being more
(28:51):
prone to like dehydration or sepsis and illness in combination, if you, if that all happens
at the same time, it puts people at higher risk of developing things like faults, right?
If you're on 10 medications, plus you have arthritis and you've got a little bit of
dementia and perhaps you had a stroke, you know, years ago, it affects your balance,
(29:14):
it affects your sensory perception, it affects your ability to maneuver complex paths. And
so you're just prone to falling. Similar to frailty, it's a phenotype that is characterized
by five major phenotypes, loss of the subjective sense of weakness or reduced strength, weight
loss, exhaustion. And so these are all kind of similar symptoms or syndromes that seem
(29:40):
to occur in older adults who are prone to that phenotype and puts them at a higher risk
because they're just more vulnerable to begin with. And so you can stick any geriatric syndrome,
any word in that like, in that category. And the learning point here for all students or
residents or whoever's in training, if you see a geriatric syndrome, it can be anything,
(30:03):
think of it as there's probably more than one thing going on. And so always explore
more than just one thing. If they come in or they fall, it's not just a mechanical fall
that they tripped over a stool. Look into a little bit deeper. What meds are they on?
How long have they lived with, you know, arthritis? Is there pain affecting their joints that
could be impacting their balance? Are they using a locker safely? You know, what's their
(30:29):
environment like? Are they living in this dark home with like numerous stairs and trip
hazards? So all these things, you know, in combination, puts people at higher risk of
these, these syndromes. So in a nutshell, if you're seeing any of these issues, try
to look at at least a couple different avenues, a couple different pillars of care to see
(30:52):
what are some of these risks and what can we do to mitigate some of these risks, because
all you have to do is maybe address two or three of them and it can make a huge impact
on one's fall risk or frailty risk so that they're not at risk of having that happen
again or having long term outcomes from that. So we, again, we can go through each like
health condition separately, but, and I'm happy to do more lives to talk about, you
(31:16):
know, our mental health and dementia care and weight loss. I mean, those are big topics.
I want to off the list, I think the one that I really want to talk about is dementia and
Alzheimer's disease. I don't know if you've seen the movie, the notebook, Nicholas Sparks
and I had watched it as a kid, seeing the ending where I guess the other people forgot
(31:40):
who their children were and then they were sundowning and I think as a kid I was like,
oh my gosh, this is going to happen to my grandma as well. Well, my grandma actually
has Alzheimer's now and doesn't remember me or her children. I can't imagine how often
you see this in practice, right? And I think this is the one that I really wanted to make
(32:04):
a speech to your brains about is what is dementia? What is Alzheimer's? Are they the same thing?
Is it just, I think when people mostly think about dementia and Alzheimer's, they mostly
think of memory loss. But obviously, when I'm reading about it and studying about it in
school, I'm just like, okay, it's not just memory loss. It's like a whole cascade of
different things. What is Alzheimer's? What is dementia?
(32:26):
Yeah, good question. And it's funny you mention this because I just did a podcast on this
yesterday for our AZ4 podcast. So that'll be coming out hopefully next week, but it's
a good talk. Dr. Tong, Erica Tong, who's kind of our dementia expert is our speaker. So
but I can give a summary. So dementia is kind of an umbrella term that describes memory
(32:50):
impairment and it can be caused by numerous causes, but memory impairment that is significant
enough to impact one's ability to function independently. So we all have some degree
of memory loss. I mean, I forget what I eat this morning for breakfast, right? And I always
lose my keys, but those are like brain lapses that we all go through. But dementia is memory
(33:11):
loss plus some deficit of a cognitive domain, whether it's learning or language or executive
function that is severe enough to impact their ability to live independently and thrive in
the community. And so dementia is that umbrella term. Alzheimer's is a type of dementia. It's
one of the causes of dementia. There's many other causes of dementia as well. So for example,
(33:36):
V-body dementia is also is probably the second most common now. Vascular dementia is when
people have a history of multiple strokes and each time they've had a stroke, you know,
parts of their brain dies and becomes scarred and doesn't work as well. Parkinson's disease,
a lot of people in late stage disease can develop dementia and then you've got like
they're really more rare, I suppose, like an NPH and so forth in the degenerative process
(34:01):
of disease. But all of that can lead to a global loss of cognitive function severe enough
to impact their ability to function. And so, you know, as we talk about Alzheimer's is
the most common type, it's about two thirds of the dementia prevalence and it's very devastating.
I mean, it's a very slow progressive process. It can happen over many years, sometimes over
(34:26):
a decade before it's even diagnosed because the changes can be so subtle before it's like,
hey, something's not right with mom, you know, she all of a sudden just can't find her way
back home. And it's like that's, you know, that is concerning. But sometimes these, the
diagnosis can be delayed because people can live with it and they can kind of, you know,
(34:47):
get by living with it and others don't notice. V-body is a little bit more dramatic. People
tend to have more like hallucinations and delusions and have just like perceptual changes,
changes in sensorium. And so that can be very distressing. And so each dementia type has
its own features. But overall bottom line is that it becomes progressive to a point
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All this like, just the quality of life, right? And I think that's also tied to a lot of
like this mental health in the other way, right? Like the feeling of, oh, I can't do
the things I used to be able to do anymore, or I can't, I can't do the simple tasks that
I used to be for the people around me or for myself. And I guess even as we mentioned the
(39:24):
age of 65, right? Even like retirements, like, oh, what do I do with my life now? Or I'm
in a different role or season in life than I was before. Like, I remember my mom actually
just retired, she's 65, not turning 66. And I remember after she retired, she's been
a nurse for decades now. She's like, I don't know what to do with my life anymore. I don't
(39:46):
know what to do next. And I feel like these are things that I guess we don't really think
about until we get to that point, right? Like, kind of a mental health, especially for the
elderly. And it's very interesting because I guess there are pains, like a fall where
the person who fell can feel it, right? Or wounds that we can see. But I feel like there's
(40:11):
some wounds, there's some injuries that are invisible to everybody, right? And I feel
like those kind of wounds, especially in the elderly are, I guess, like loneliness and
maybe abandonment. I remember, I'll never forget, I was a first year nursing student
at a nursing home in the city. And I sat to one of the residents during their lunchtime
(40:37):
and she was like, you know, my children haven't visited me for four years now. She's like,
can you be my son while we're having lunch? And in my mind, I was like, it's like loneliness
and abandonment and the feeling like loss of, I guess, autonomy and just control of their
(40:58):
life is such a real thing, especially in the geriatric population. As the geriatrician,
the physician who sees this and obviously you make executive decisions for this age
population beyond the textbook for physical manifestations of aging and disease. How
do you deal with things that are unseen and maybe invisible, like loneliness and heartbreak
(41:24):
and fear of the remaining future?
Oh boy, that's a loaded question. I share your sentiment about the nursing home experience
because I hate using the word sad, but I can't help but just feel like my heart aches every
time I go into a nursing home and I just see people sitting there by themselves, they're
(41:48):
eating by themselves. And yeah, I'm sure their families have visited, but you know,
you sort of see people in their empty shell of who they were before. And it's not uncommon
that people are depressed and lonely and anxious because they just don't have that stimulation.
And so I guess a broad way to answer your question is that I think we have to remember
(42:14):
that despite what people look like to us on the surface, they may look older and frail
and helpless in many ways, but they still are people, right? They still are valuable
and their legacy deserves to be preserved. They were functioning people at some point
(42:38):
in their lives. They contributed to society. They were scientists and artists and teachers
and engineers. I mean, they are human and they have families, they have people who love
them. And it's hard to see that when you meet them for the first time. And it's even
harder when they can't talk back to you, right? They can't like share some of their experiences
(43:00):
with you, especially if they're against dementia. So I see what you're saying. It's really
hard to help people who are already feeling lonely. And that's why whenever I see older
adults in the nursing home, I always just spend a little bit more time with them. If
they're in the dining room, I might just sit there and just share a meal with them and
(43:22):
chat with them a little bit and just hear about their life story. And they may not remember
who I am, but they will remember that someone was there to listen to them. And I always
try to weave in their family members back into the picture in some way, whether it's
just to call them for an update to say, Hey, mom, I saw mom today. She's doing well. She
would really enjoy your company. And if there's any ways of just staying more connected, I
(43:46):
think she will really appreciate it. And just try to find ways of bringing families back,
especially if I feel like they haven't been visiting much. And so these unseen things
are usually years of accumulated sort of deficits of just feeling like you've lost so much along
the way. And that's what I've been trying to change is it doesn't have to feel like
(44:07):
loss along the way. Retirement is funny that you mentioned that retirement feels like a
big loss for people because all of a sudden, the first two months are great. You're like,
yay, I don't have to work anymore. I can go read books and do things, but humans are made
to have purpose. And it's the reason why retirement is actually one of the top 10 stressors of
(44:28):
life. People don't realize that, but it's actually a stressful experience. You don't
prepare for it. All of a sudden you have nothing to do. And then that can be a trigger to actually
a stressful transition into your next chapter of life. And so finding those transition points
that could trigger depression and anxiety or loneliness and helping people make those
(44:48):
transitions a little bit earlier or living with chronic disease in a more meaningful
way so that they still feel like they have things to look forward to and things to do.
I think that earlier we tackled these things along the way and it doesn't accumulate as
much to the point where all of a sudden it's just so devastating that you can't do anything.
It's learning how to be able to do more with less, if that's the best way to describe it.
(45:14):
And I feel like I've gone off on a completely different tangent, but tackling loneliness
as a whole, depression triggers, but also I think depression, loneliness and neglect
in the nursing home is a completely separate issue that if we just remember everyone is
human and they all deserve our time, attention and our presence.
(45:36):
Yeah, this is making me teary eyed. I mean, it's such a... Yeah, like so many people need
care, right? Especially within the geriatric population, but aren't there enough people
to care for them, right? And tying this to the statistic that says that there are approximately
7,000 geriatricians nationally only and we need about 30,000 more by 2030 to meet the
(46:00):
needs of the Asian population. The crisis is the crisis.
I know, that's crazy.
Who will care? There will always be a geriatric population because everyone will age and everyone
will grow old. As a physician, as a geriatrician, how would you encourage future physicians
to enter this field of geriatrics and be the guiding light for our future elderly populations?
(46:22):
Yeah. Well, and this is not just for physicians, it's for all care providers who take care
of patients, you know, PAs, NPs, nursing. It's just that there is a heart for geriatrics
for everyone. And I would say that, first of all, it's just such a rewarding field.
I don't think people really know about geriatrics because it's not glamorous. It's not like
(46:45):
plastic surgery or trauma surgery or something cool. Anesthesia, this is like... I feel like
those are the hot specialties. They're all great. I'm not downplaying them. They're all
fantastic. But I think geriatrics is sort of buried a little bit because it's not something
that's talked about much. Like I didn't even hear about it until residency. And so I think
(47:06):
there just needs to be, number one, more awareness, more mentorship, more inspirational, I guess,
moments where people can experience like taking care of an older adult is such a rewarding
opportunity to be able to make meaningful changes in their lives and to be part of that
health journey with them. I think the earlier exposure, the better. You know, so our medical
(47:26):
students, they're exposed on day one. And I feel like they graduate as just really well-rounded
physicians because they understand geriatric medicine very well. You know, as we're learning
about different aspects of medicine and you go through different rotations, we're also
exposing our students to elements of geriatric medicines and those rotational experiences.
(47:48):
So for example, perioperative medicine and surgery, they learn about how to do a perioperative
examination. How do we do a geriatric assessment so that we can prevent delirium, the risk
of delirium as an outcome. And so early education, good mentorship, and just like this is such
underserved field, helping people understand that there's a lot you can do within that
(48:08):
field is not just seeing patients in nursing homes. You can be an educator, you can be
an academic medicine, you can be a medical director, you can innovate. There's a lot
of innovation in healthy aging and the healthy aging. Research too. That's kind of what I'm
involved in as well. Research, tons of research. Yeah. Research is especially important because
a lot of older adults are kind of excluded from major research studies. And so we need
(48:33):
a lot more research in that area. So there's a lot of exciting things in geriatric medicine.
And I think it's just off to the side geriatric. Geriatricians are probably the happiest people
just because I think we really enjoy what we do. And it's not, there's always stressful
parts to every specialty, you know, but it's, I feel like the stress is not something that
(48:55):
impacts me negatively. It's really helping my patients. My patients stress becomes my
stress in some ways because I want them to, you know, understand how to just live better,
but guiding them through that journey, I think it's per the reward. And then I would also
say that not everyone is meant to be a geriatrician. Obviously if you've got interest to be a pediatrician
(49:19):
or OB or surgeon, that's awesome. My goal is that, you know, we can't, we probably can't
get 30,000 geriatricians by 2050 or whatever. But if every person in their specialty can
be a mini geriatrician in some ways where they have some understanding of how to weave in
(49:41):
some of these elements into their practice, I think that's a great win as well. That you
don't have to be a full blown geriatrician, but you can be a cardiologist with geriatric
understanding or a surgeon who knows, okay, this is what I need to do to prevent delirium
as an outcome. So just having those elements within your practice, I think is, is an opportunity.
(50:03):
I guess I've learned so much today. We talked a lot and I think a lot of our conversations,
not just educational, but we talk a lot about the care team that takes care for geriatrics.
Well, I guess one of the last questions would be, what would be your message for the geriatric
population itself? In the midst of whoever probably stumble upon this someday, I don't
(50:26):
know, someone who just retired and feeling lost in life or someone who's listening to
the podcast episodes on their 70s or 80s and they live alone, what would be your message
as a geriatrician to our elderly population or something that you may want to say to the
geriatric population, even though they may no longer remember what you say?
(50:48):
Yeah, that's interesting. So a common thing that older adults always tell me is like,
they always use the same phrase. It's like getting old stinks. It really sucks. Like
don't look forward to getting old because the golden years are not golden. And I think
that's, that's really sad to just hear them say that because I think there is a way that
(51:11):
we can always look forward to living well. And that would be my just global answer to
them is there's, there's always a way to live well, no matter what situation or circumstance
that you're in. It may seem the situation may seem grim. You may be experiencing a lot
of symptoms, your health may be not doing well, but you have a medical team. You have
(51:35):
a partnership with myself and they find it so comforting when they understand that their
doctor is here to partner with them, not just today, but for the longterm, you know, so
that actually brings them a lot of comfort to know that I'm not going through this myself
and there's a support system, there's a care team and that there's always something to
(51:56):
look forward to. So find that next thing to look forward to, whether it's learning a new
skill or finding a way to regain that functional ability that we lost, whether it's driving
or walking or simply making it to the bathroom. Sometimes just helping them make those small
goals and giving them that little bit of hope can be a, can make a profound difference.
(52:17):
So to answer your question, I guess I try to find that specific individual like goal
for each person, which is very different, but it's, it's just instilling that sense
of hope again. I think it's very powerful.
I love that. Your heart is so full. Dr. Ben, it is such an honor to have you on today and
(52:38):
thank you. Thank you so much. Thank you. I learned so much and it's just this new found
love and passion for people around me and especially more of our other population and
it has felt so cool. Thank you so much for joining me in today's episode.
(53:00):
Yeah. I hope it was helpful for people who come through and I hope that I was able to
answer some of your questions. I'm happy to answer questions offline. If you have interest
in geriatric medicine, what the training is like, what to anticipate after training, what
life is like as an attending. It's a lot, lots to talk about.
(53:22):
Yes. And this is not the last time we will talk. We'll have more to talk about. Thank
you so much for spending time with me to talk about all of this. I hope you have a great
rest of the night. Thank you.
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