Season 1 | Episode 4
Description: Providing medical care to older people can be complicated. People often see multiple specialists and take various different medications. Dr. Michael Wasserman joins us to share some insights and break down the biggest myths around aging, while also sharing tips for how family members and caregivers can take a more active part in older people’s care.
>> Dr. Michael Wasserman: When I was 17, I went to college. I lived in a dorm, I had a roommate, I went to the dining hall every day, I went to class, I had activities every day and I had the time of my life! But if you’re 85 years old and have a roommate, eat in a dining hall and do activities every day you’re considered institutionalized! And I have trouble with that analogy because why is it okay to be 17 and go through that and not when you’re 85?
>> Narrator: Welcome to the Medical Myths podcast where we set the record straight on today’s most talked about medical topics and questions. On every episode, you’ll hear stories from the frontlines of medical care to help dispel common myths and maybe answer some questions you’ve been itching to ask your doctor. Remember, you can always find more information on this week’s topic and hundreds of others on merckmanuals.com. Now, here’s your host, editor in chief of the Merck Manuals, Dr. Robert Porter.
>> Dr. Robert Porter: Welcome to the Medical Myths podcast where we set the record straight on today’s most talked about medical topics and questions. I’m your host, Dr. Robert Porter, editor in chief of the Merck Manuals, the world’s most trusted medical resource. On this episode, we will be talking to Dr. Michael Wasserman M.D. Dr. Wasserman is geriatrician and a board member of the American Geriatric Society Foundation for Health and Aging.
>> Dr. Wasserman: Thanks so much for having me here Rob, happy to be here.
>> Dr. Porter: Thanks for joining us, Mike! We’re thrilled to have you. Now, providing health care to older patients can be very complicated. Folks can have different health practitioners; there are many different places- things like travel and transport get a lot more difficult as people age. So, we’re really grateful to have Dr. Wasserman on the podcast today; he’s going to break down some of the myths around ages and talk about some of the complexities of continuity of care. I know if we had an older patient in my emergency department and we had a geriatrician I would call them and they were going to know everything about that patient: what was happening, what specialists recommended and what they were doing and they were the quarterback.
>> Dr. Wasserman: I often like to use the analogy of the primary care physician being the head coach. And that’s necessary because in today’s world there are so many places in healthcare that the individual is interacting with that it’s really important that the primary care provider take that role and responsibility so that someone is always looking after the best interests of the patient. But I think this is an area that the patient and their families as consumers can just encourage the doctor – the primary care doctor - to just focus on the needs of the individual and I think many physicians are quite capable of doing that when given the opportunity.
>> Dr. Porter: Yes, that’s a great analogy, Mike! Okay, so, whether the primary care doctor is the quarterback or the head coach we recognize that that person is going to coordinating care, but what can the person, themselves, do to get ready for the appointment?
>> Dr. Wasserman: I know many doctors get nervous when they see a patient coming in the door with a list, but I think that list is the single most important thing a person can have when they go and see their doctor for many reasons. The first and foremost reason is that once you’re in the exam room, it is easy to forget what you came in for and that has nothing to do with age, but once you start one discussion you may just forget the other things that matter to you, so I think preparing a list is critical. And number two, it’s really important that the patient give that doctor the list the moment they come in because the last thing you want to do is spend 15-20 minutes with your doctor and then say “oh by the way doctor I brought my list in.” That generally doesn’t work out too well and adds stress to everyone.
>> Dr. Porter: Plus, it allows the doctor to quickly glance over the list and prioritize where they want to go and even get an initial idea of which ones might be related so they can pursue them together. Now I would always love when patients would come in with lists like that and lists of their medicine too.
>> Dr. Wasserman: And actually, I agree, the number one thing is to have a list of the medications that they’re actually taking when they’re taking it, how they’re taking it, how they’re doing with it…
>> Dr. Porter: Speaking of lists, how do patients keep track of all the advice and instructions you give them? So, if they have 6-8 items on their list and they go back home, and their daughter says “well what did the doctor say about #6?” should they be taking notes?
>> Dr. Wasserman: This is one of the greatest challenges in today’s healthcare world. Sometimes physicians will go in and see a patient, and they might not complete their note till later in the evening, but the information they’re putting into that note will include instructions or plans. I think the patient can help both themselves and their doctor by making sure they go down one by one the recommendations the doctor has. They put it in writing of some sort and have the patient walk out with it, with something tangible that tells them what they talked about and what they’re supposed to be doing. Because if they don’t do that then they are very likely to forget some of the recommendations.
>> Dr. Porter: That’s a great point. Isn’t there also a myth that older people shouldn’t try anything new?
>> Dr. Wasserman: I think there’s a general myth that just because you’re getting older that means you’re declining. And I’ve often told people that that doesn’t really start being true until, for some people, when they’re 100 or even 110. The reality is that as we get older, the longer we live on this earth, the greater the likelihood that we’ll pick up a disease or an illness or an injury. Age in and of itself isn’t the problem, the longer we live it is just the chances are that something will happen to us.
>> Dr. Porter: Now that does bring up the question though that despite all of our best intentions we do tend to accumulate illnesses as we get older and it’s kind of hard to avoid specialists when you have a specialized sort of problem. Cancer is the one that comes to mind, a person with cancer is going to want to see an oncologist, and as I’m sure you know in your practice, that older people end up with multiple specialists. So, what are some of the problems that you see when a patient has multiple specialists?
>> Dr. Wasserman: Well there’s actually some literature that actually suggests that having too many specialists probably doesn’t lead to better care or to better outcomes. I think the best way I can put this is that a 90-year-old might have arthritis and diabetes and heart failure and any number of healthcare issues and if they go to 6-7 specialists for each individual problem, they actually are not going to get the best care. The reason for that is that the treatment for each one of those problems can overlap. And I am a huge proponent for older adults having one primary care physician who really knows who they are and what their needs are so they can factor in all the aspects in their health care, and you really can’t focus on each individual problem without taking into context the whole person.
>> Dr. Porter: So, do primary care doctors even have the time to do that anymore?
>> Dr. Wasserman: Call me old fashioned, but I still believe that doctors have to take the time that they need to take for their patients and you know when I was in practice, and I was running behind or spending a lot of time with someone else - when they needed the time, I was going to give it to them. I think we’ve lost that a little bit in today’s world, but we are trying to get it back, and if we are going to be doing personalized care then we can’t be doing what I like to call two prescriptions, three referrals and a cloud of dust.
>> Porter: What are some of the danger points you see as your older patients make their way through the system between hospital and home and specialist and your care?
>> Dr. Wasserman: Fragmentation. Not having consistency and having multiple specialists who are not coordinating with each other and I can tell you how many times patients have come to me on multiple medications, each one prescribed by a different specialist. Many of those medications add in side effects that make another specialist prescribe another medication to treat it. So, I think fragmentation of care is the greatest risk to older adults.
>> Dr. Porter: Not only prescriptions for different medications, but in my practice, I would certainly see older adults come in with three or four of the same medicine all prescribed by different doctors.
>> Dr. Wasserman: It gets worse cause when that person goes into the hospital as part of a health plan; many times these plans are changing based on contracts. So, you might have someone go home with three versions of the same medication, and they might take all of them which could be very dangerous.
>> Dr. Porter: Is there a right age to see a geriatrician?
>> Wasserman: Theoretically, geriatricians see people over the age of 65, but I think that varies. Again, if you’re 90 years old and have no health problems – yeah, I would still see a geriatrician if I could. Most 90-year-olds, in general, don’t react the same way to specific diseases as 40 and 50-year-olds, so it's really about recognizing the individual, and I think most physicians are actually quite capable of doing that.
>> Dr. Porter: Thanks, Michael. It’s time for a quick break and a few words about the Merck Manuals.
Whether you’re a parent, a seasoned professional, a medical student or caregiver, the Merck Manuals has the right medical information in the best format and it’s always free, easy to access and readily available for you. Now back to Dr. Porter and the Medical Myths Podcast.
>> Dr. Porter: Now, one of the myths or conceptions that we often heard is that it is always best to stay in your own home.
>> Dr. Wasserman: Yeah, yeah, that’s something I’ve dealt with my whole career, and we all want to stay in our own homes – that is ideal, but we also have to be realistic that sometimes staying in one’s own home might not allow us to have adequate care, adequate socialization. There can be a lot of problems for someone who has advanced frailty and limitations. And over my career I have had many patients where I had to say “look if you move into an assisted living facility or into a nursing home you’re going to have more structure; you’re going to have more socialization” and I will often encounter resistance. But many times when that person goes into that higher level of care, they thrive.
>> Dr. Porter: Sure, when you have someone to talk to and something to do, there are certainly some plusses to that.
>> Dr. Wasserman: I used to have a metaphor that’d I’d use to really compare what we were doing in nursing homes, and it’s that when I was 17, I went to college. I lived in a dorm, I had a roommate, I went to the dining hall every day, I went to class, I had activities every day, and I had the time of my life! But if you’re 85 years old and have a roommate, eat in a dining hall and do activities every day you’re considered institutionalized! And I have trouble with that analogy because why is it okay to be 17 and go through that and not to be 85? And many of the nursing home residents that I interact with are very happy in their environment, and they are very appreciative of the socialization and of the activities and the experiences that they have.
>> Dr. Porter: How about when there is a difference of opinion among family members? I know that I have personal experience with my wife’s family many years ago when her grandmother was needing more assistance. And the family was literally broken apart with whether grandma should stay with her daughters or go to a nursing home and the halves of the family didn’t talk to each other for a decade because of this disagreement. I’m sure that’s nothing new in your experience am I right?
>> Dr. Wasserman: I have encountered that many times and I think the family dynamic issue is one where focusing on person-centered care is the most important thing and if we really focus on person-centered care and help the family really understand what that means we have ways to rework the question to take the family dynamic out of it. What I mean by that is, you might have a daughter who hasn’t seen mom and dad in ten years and had issues and now suddenly come back into their life and have some guilt, and their own guilt is interfering with what mom or dad needs or wants. So, if you’re able to focus the conversation or the discussion of what’s in the best interest of the person- what their wishes are what their needs are, I think you have the opportunity to override some of the individual family dynamics.
>> Dr. Porter: Right, reminding them “it’s not about you; it’s about mom.”
>> Dr. Wasserman: Correct.
>> Dr. Porter: Now, this is a myth podcast, and I’m not sure if this is exactly a myth - that’s that aging is not an excuse to not do everything exactly the way you used to.
>> Dr. Wasserman: No, I think the way I react to that is that in and of itself one’s age shouldn’t really have an impact on what they want to do, what they’d like to do, or what they’re able to do
>> Dr. Porter: That’s a great perspective, can you give us an example?
>> Dr. Wasserman: Probably my favorite example right now is that I was at the Hawaii Iron Man World championships cheering on my friend a couple of months ago. I came across an 85-year-old Japanese man who was not participating in the Iron Man but had completed it which made him the oldest person to ever complete the Hawaii Iron Man which is a remarkable achievement of swimming 2.4 miles, cycling 112 miles and then marathoning 26 miles and completing it all under 17 hours. That is a difficult thing for a 30-year-old to do, much less an 85-year-old.
>> Dr. Porter: That’s certainly an amazing accomplishment at any age.
>> Dr. Wasserman: If you don’t use it, you’ll lose it, and that goes for using your brain as well as using your body. I do say that exercise is the most important thing a person can do at any age and there really should not be a limitation to the amount of exercise that one is capable of doing. Now if I could give a piece of advice to the average 85-year-old, it would be that if they can get a half hour of exercise every day, then that would be wonderful. It is really critical that older adults stay mentally and physically active.
>> Dr. Porter: Is there a particular kind of cognitive activity that is particularly important?
>> Dr. Wasserman: I think the individual has to find what they like, so if you like crossword puzzles, they are a great cognitive exercise, if you like playing games on like an iPad or something there are tons of games to play. I think the individual has to figure that out themselves, but as long as you are using your mind, that is what matters.
>> Dr. Porter: So, it is the same as physical exercise; the best exercise is the one that you’ll do not the one that you won’t do. So, if you enjoy a particular cognitive exercise, then that’s the one for you.
>> Dr. Wasserman: And it is interesting that you say that because since I became a geriatrician many years ago I have turned from a couch potato to someone who thinks that if I’m telling others to exercise then I better do it myself, and that has led me as I get older to competing in endurance sports and doing Iron Mans myself and recently doing an event where over a period of 40 hours I ran and walked 100 miles.
>> Dr. Porter: So how do different people’s priorities differ when they get older?
>> Dr. Wasserman: The only thing that really matters is helping an older adult do the things that are really important to them. So, my favorite example is I might have a patient who has lost a lot of mobility or lost a lot of quality of life and their granddaughter is going to get married in 6 months, and the only thing that matters to them is making it to their granddaughter’s wedding. That becomes their main focus.
>> Dr. Porter: So, what should – should the person seek a medical solution or a lifestyle solution?
>> Dr. Wasserman: I think older adults should avoid medicalizing their care. I think they have to focus on what is important to them, what matters to them and individualizing their health care needs. So, let’s say someone is a diabetic and all they are focused on if their blood sugar levels, but that may limit the things that are really important to them. So, it is really about focusing on the individual and what the individual needs and wants.
>> Dr. Porter: That’s great! Thanks for sharing so many helpful stories and anecdotes with us today. To close, what three takeaways would you like to leave our listeners with?
>> Dr. Wasserman:The first and foremost thing would be to really focus on the person and what is important to them, what their goals are what their needs are. Secondarily, I think exercise is the single most important thing we can tell older adults to do, I often tell people that if I can get people to start exercising regularly then I can discontinue at least one prescription drug and I think we are learning more and more every day about the value of exercising as people get older. I think the one thing I am struck with regularly is the amount of medications older people are on, and most don’t even know why they are on it. They are often given a medication to help a side effect of another medication, and there is very little literature about the use of many prescriptions of people in their 80’s and 90’s and so I think its critical that as we get older, we ask ourselves whether we need to be on the medications that we’re on.
>> Dr. Porter: Excellent advice. Where can you recommend our listeners go to learn more about aging?
>> Dr. Wasserman: The one place I always recommend is the Merck Manual we really endeavor to include age-specific information into many of the chapters. I’d also suggest the American Geriatric Society Foundation for Health in Aging which has a lot of age-specific info on its website.
>> Dr. Porter: Well thank you for that and those two good resources. Well, Dr. Wasserman I really appreciate your time, it been very helpful to hear you discuss some of the major issues about aging and also emphasize the importance of continuity of care and consistency of medication use. I think I can speak for all of our listeners that we’ve learned so much about these issues and how family members can take a more active part in older people’s care. And for more information on these and hundreds of other topics, please visit merckmanuals.com and remember as we say at the Merck Manuals –
>> Dr. Wasserman: Medical knowledge is power, pass it on.