Chapters Transcript Video Gait, Gadgets & Getting Older: Tales of a Geriatrician Yes, there is a role for geriatrics, um, and geriatric partnership with many surgical and medical subspecialties. Oncology is a great example. Um, so specifically somebody who's diagnosed with cancer, number one, we wanna know what their goals are. So again, what matters to them? What do they want for treatment? Um, or if they're at the end of life, do they want treatment? And these are difficult conversations to have. Hi, I'm Lindsay Carrillo, director of business development at UCI Health. Hi, I'm Doctor Sunil Verma, ambulatory Chief Medical Officer, as well as a trained laryngologist here. Welcome to Physician Huddle by UCI Health. I'm really excited today to be joined by Doctor Lisa Gibbs. She's interim chair and professor of family medicine and the division chief of geriatric medicine. She also plays a large role in our organization, population health. Welcome, Lisa, to the podcast. Thank you. I'm happy to be here. Doctor Gibbs, tell us a little bit about your clinical role at UCI. So I have been here for over 20 years, um, as a practicing geriatrician, um, I have a background in family medicine first and then I completed a one-year fellowship in geriatrics. Um, soon after I joined the faculty here in geriatric medicine, um, and I've worked in the senior health center, uh, ever since. Uh, first, um, the majority of my work was clinical, uh, but now, as Doctor Verman notes, I've been moving more into the administrative role as well. Tell us what makes the senior health center here separate or different than uh other organizations here in Orange County or even here on the UCI campus. Yes, the senior health center is a very special place. Um, not only do we have our geriatricians working there as a group, all focusing on the care of older adults, um, especially on the complex care of older adults as people reach into their 75 plus years. Uh, but we also have a team there which with allied professionals, so we have psychologists, social workers, pharmacists, we have nurses that are very focused on the care of older adults. Uh, even a geriatric psychiatrist. Uh, so we're well suited to really cover the comprehensive needs of all of the complex patients that come to us for care. And one of the um one of the areas that you focus with on your, on your patients, one of the many areas is on the risk of falls. And you know, this is something that at least in training, I was only something I thought about honestly in the inpatient side. Um, but in reality, and I think this, this as, as I start to think about my parents' health, um, and I start to think about my older patients' health, this is a much more of a reality. So what is it about, what is it that you're doing in this space? What does the team do and and How much does it actually matter? Right, uh, thank you for asking. So falls occur because They said that's a culmination of a lot of systems that are that are in decline or that are starting to have difficulty with. Um, the fall is sometimes, you know, like I said, the culmination of Uh, it's a warning flag. So there are a number of issues why falls are important. Number one, a really bad fall and change the course of one's life. A hip fracture, um, a wrist fracture, um, some people fracture two sites, right? And it's very, very difficult to come back from that. Um, however, we know that those in the community fall every year, at least 13% of older adults, um, and so we want to prevent that fall that changes the course of someone's life, and we know that the highest risk for that fall is the previous fall. So we're really focused on preventing any fall. Many people come to us because they're bruising or, or they have, uh, you know, lesser injuries from falls, um, and they recover and they may have many of those. um, but you know, at some point, you know, it could potentially lead up to a major fall, uh, at which someone then can no longer go home and take care of themselves, or perhaps, um, one part partner is, is taking care of someone else with dementia and then they're no longer able to take care of. You know, their spouse with dementia. So it, it affects multiple lives potentially, um, and so we try to recognize those risks. As a trained geriatrician, we're always thinking about falls syndrome, how people walk, uh, we have gait and balance assessments, for instance, that we do with everybody that comes through our door. Um, balls is one of the things that we focus on with occupational therapy, with physical therapy, and so forth. Uh, so, uh, yeah, can't say enough about that importance of trying to prevent that one fall that will define the rest of your life. Doctor Gibbs, we were talking about even something as simple as footwear, right? Like the summer sandal, and how that could really be very serious. What do, what kinds of things do you see when patients walk in? Right, well, especially here in Southern California. I mean, people love the sun, they love to be out, they love to wear their sandals, um, but what I've noticed, and then I actually attend a Falls clinic, uh, is that people walk in for their falls assessment with open-toed shoes, with sandals. You know, and the first thing we do is we look at their shoe wear and we're like, You know, I'm sorry, this, this, this won't work. You need reliable, stable close toed shoes uh that won't, you know, cause you to trip on something. So something as simple as that could really be the difference between a fall and not a fall, right? Um, so you're right, it's, it's just they don't expect us to be making comments about what they're wearing, but that's one of the first things we do. Well, and then the implications of, you know, like you mentioned, they get a fracture or they end up in a nursing facility and, you know, potentially maybe they never go home again. Mhm. Absolutely. Yeah. And many won't go home again. Many will never get back to the level of function they had before they fell, and many of them will actually have higher mortality in the 1st 6 months. What is the right type of patient to be seen in the senior health center? I know personally, I take care of a lot of individuals in the age range and they'll ask me, you know, uh we love the surgical care we received at UCI Health, really want to think about establishing my primary care here. I actually don't know where to necessarily send patients. We talk, we're talking a little bit about probably the, the more sick patients, the ones with multiple medical um morbidities, if you will. But what is the right type of patient to be seen in the senior health center? Or is it just is it just an age-based thing? So we um we try to avoid, you know, really focusing on age itself because for us, age is a physiological condition. I mean, aging is a physiological condition. Uh, so age for us is arbitrary. Uh, but if you're looking really for somebody who may be starting to have a number of complex issues even at 60. Um, we're happy to see, to see, um, those patients. Uh, there are a lot of folks that wanna age healthily, so they wanna know how to age so they can prevent the, the dementia. They can prevent the fall, they could say active as possible. Um, so we also do a lot of preventive work in terms of, you know, looking at how you age. I mean, really, how you age should be something that people start considering in early middle age. Well, it's, it's certainly, it's certainly a hot topic right now, and, and it has been, but I think it's gaining steam about, you know, what should we be doing in our 40s and 50s to prepare ourselves, you know, the, the amount of attention now to increasing muscle mass, um, you know, with within the 40s and 50s is really something that we hear about a lot. Um, also just a lot of the mental and mind games and and preparing one's brain to always stay active. Maybe you can comment on a couple of those and and Or should we be concentrating on this? What is the sign showing and what are you seeing in your own patients? No, great questions, um. And I also, before I answer that, I also want to say that when, when we see a patient, especially for the first time, we try to envision that patient 2030 years, 40 years down the line. What will be that vulnerability, what will they look like? What do we really need to think about what we're caring for them now? Um, so what you're describing, um, So 11 great example is dementia. We know that up to 45% of the risk factors for dementia are modifiable. What if we started modifying those risk factors in the 40s, right? So some of those, some of those easy ones would be hypertension, cholesterol, you know, reducing those vascular risk factors. We know that most of the patients with Alzheimer's have mixed dementia. So they have a combination of not only Alzheimer's, but they have vascular dementia. What if we took away that vascular dementia? We could probably prevent a lot of other cases, um, exercise, mobility, so exercise and nutrition, I mean, we learned about those in kindergarten, some things never change, and those are the things that we can modify most easily. Activity, exercise, nutrition, uh, reducing the risk for diabetes for sure. Diabetes is a huge risk factor as well. Um, so all of the things we learn about, you know, we just need to become really good experts at behavioralism and how to really change people's behavior through our primary care, and that's, we are, we are, we'd like to think of ourselves as experts in in behavior change as well. What is special about this patient population? You started family medicine, that's where you got your, you know, first few years of training. What drew you to this geriatric population and how do you have to function differently as a physician? Uh, I think what drew me was the, the complexity. Um, in fact, we practice in a paradigm of the four M's, uh, mind, um, wellmentation, mobility medications are what matters to our patients, which is what drives us, really what matters to you, what brings you joy. But along with that is a 5th M called multicomplexity. And while a lot of doctors run from complexity in the in the way that they run from a a medication list of 20 medications, they run from a you know, a medical history list of 10 conditions, we actually run towards it because we actually like to figure out how to prioritize that, which medicines we can take away, and for us it's a if it's just a different game. Um, so the, the complexity, I love the medicine. Um, I, I really enjoyed neurology, psychiatry, and humanism, and I think geriatrics is just a wonderful combination of all of those things. And then I was really intrigued by a lot of the patients I saw in family medicine, um, cause the older people can tell you stories that younger people can't. Right, um, they can tell you things that they would like they will have a different relationship with you that younger people won't. They'll be more brutally honest, um, they'll tell you what they think. They'll tell on each other, you know, the two people in the room will often, you know, air their grievances out. I know that one. You become a marriage counselor too? Yeah, so I found them to be really fascinating in terms of, you know, their life stories and, and so forth and what they've lived. So you, you just, I think you just mentioned taking, looking at the medication list and and sort of sorting through that. How, how do you manage that and, and yeah, I think you mentioned you've been taking medications away. Um, that's something especially where we live in Southern California, you hear so much about patients not wanting to be on medication, uh, nationally we're hearing so much about over reliance on medication, and now you're talking about taking them away, which really fits into really where we are as a society. How do you do that and what's the importance of it? So, uh. One of our joys is taking medicine away. So we, we, we describe ourselves as the only the only medicine specialty that loves to take medicines away, not give medicines. Yeah, so yes, uh, you've hit upon something really important. So we were very good at knowing when there are medication interactions, contraindications. Uh, there are a number of medications on what we call a beer list that are not indicated for older people just because of their association with confusion, with falls, with interactions. So, so we're very good at. Spotting those, um, and, and you're right, a lot of people come to us because they really do want to whittle away at their list of medications. And number one, it's really hard to track sometimes, you know, people bring in with their charts, you know, I'm supposed to take this before breakfast, this after breakfast, this before noon, and 5 before I go to bed, it's just. Too much. So we really do try to help them simplify that regimen as well. Full-time job just to manage all these pills that they have to take and, you know, like you mentioned, uh, a whole laundry list and schedules. Um, what are some of the frequent flyers? What are the things that come up most often that you're saying, this is not right for this population? What's, what are the top ones that you really don't recommend for these older patients? Well, one of, one of the categories would be sleep medicine. And over the counter sleep medicines. Uh, many of them have a very strong anticholinergic activity, which again causes the confusion, the falls in older people. So, and, and over the counter medicines in general can be, can be dangerous when they're added with all of the prescribed medications, not to mention all of the herbal supplements and all of the other um things that people take, including CBD. And marijuana and and everything else. So we have to take a look at everything and it's the combination of what people are taking and so forth. So we try to get people on sleep hygiene first, of course, without medicine. We try to do everything without medicine if we can, if it's indicated, with something like sleep. Um, and if that doesn't work, then we pick safer alternatives for them. We've talked in the past about the importance of integrating geriatric medicine into other subspecialties, for example, oncology or even possibly cardiology. So tell us a little bit about that because at least in the oncology example, right, cancer is something that is, is increasingly common in the older individual. And so how do you care for that patient in a special way that's probably different than someone, you know, in, in, in midlife, if you will. Yeah, so, yes, there is a role for geriatrics um and geriatric partnership with many surgical and medical subspecialties. Oncology is a great example. Um, so specifically somebody who's diagnosed with cancer, number one, we wanna know what their goals are. So again, what matters to them? What do they want for treatment? Um, or if they're at the end of life, do they want treatment? And these are difficult conversations to have. Um, you know, secondly, we will look at the medications and then we will consider things like chemotherapy and their interactions with the medi medications that they're on. Uh, we'll consider again those additional risk factors for falls that might happen because somebody's on certain medications or certain Therapy, uh, perhaps, you know, medications that may cause nausea, uh, may cause weakness, may cause frailty for the time being, you know, we look ahead to see where those problems are going to happen, um, with that treatment, uh, for cancer. Um, and then, of course, you know, really advocating for someone to stay mobile, increase that mobility. Um, if someone has already some cognitive dysfunction, for instance, in the older old, you know, then we'll take a look at the effects of chemotherapy, radiation, or any of the cancer, you know, treatments on their mind. Uh, and we know some chemotherapy agents actually cause what we call a brain fog, so we would be the ones that would look after, you know, their mind as well as their body. We talked before about how, you know, geriatric medicine should really be woven into any specialty console, you know, orthopedics, they're probably dealing with people with joint issues or potentially fractures. I mean, here we have an ENT sitting with us and, you know, I'm guessing there's issues that, yeah, I mean, look at orthopedics, especially those patients that have fallen, you know, have had um hip repair. Or have had a history of trauma? You know, so we've had some interest from the trauma surgery uh department as well to refer patients to our Falls clinic. But yeah, I agree. I mean, any patient that's undergoing treatment for chronic disease and a subspecialty, um, Will benefit from a geriatric consultation. Well, one of the areas that, you know, where our patients mix as a laryngologist and as a as a geriatrician is patients with aging voice and patients that have that inability to project their voice or that they sort of run out of air. And what we see is associated with that is often atrophy of the vocal full muscles and so that can be exacerbated when there's other chronic conditions such as Parkinson's disease as well. And really uh uh you'll see focus in that area and so the treatments that we're able to offer our management including therapy, but then also surgical options like injection laryngoplasty, where we inject filler into the vocal folds to give them that longevity of the voice, and that's something that improves their ability to be heard by other people. Oftentimes they're in a relationship with somebody else who maybe has has some hearing loss, so that helps from a safety perspective as well as a communicative perspective, and allows them frankly to function in society better. Because when you're in that, you wanna have a good quality of life when you're when you're all of us do, but it's really important at that age, and so I think being able to team up with the specialists, I imagine that's a lot of value, not only to your personal career, but then also to the patients we all treat. Right. Uh, for instance, we have a geriatric comprehensive evaluation clinic called HAPs, um, and, uh, one of our oncologists, you know, sends everybody over for a prehabilitation assessment before he does, um, any type of uh procedure, um, specifically stem cells. So, uh, You know, I think as we look, um, I've also had conversations with anesthesiologists, cardiologists, um, uh, nephrologists for sure. So I agree. I mean, really, we can find anytime you have an older adult who has chronic disease, who's getting care from subspecialist, um, we can look after their overall. Well-being and their functional status, like, are there any treatments that will benefit or not benefit their functional stat because at the end of the day, the functional status is what keeps them independent. I would imagine this is also a pretty big patient population here in Orange County. Is that fair to say with the demographics here? Yes, um, the older adults are one of the fastest growing demographics in Orange County. Um, as we look towards the next 20 to 30 years, we see the younger population actually decreasing in size, but the older population increasing dramatically. Wow, that's really incredible. I know you touched a little bit about on uh diabetes, which you mentioned can lead to Alzheimer's, you know, obviously an indicator for a lot of other issues, but there's cases where you're actually pulling back on some of that treatment, right? Cause it can cause low blood sugar or, you know, you're telling me about that. Well, right, so one of the, the major complications for older persons with diabetes and leads to hospitalization is hypoglycemia. So we actually liberalize the treatment of diabetes a little bit more than sometimes the endocrinologists do because we try to. Avoid that low sugar level because we're looking for that. We're looking for that because we know that's a trigger for hospitalization. Um, so that's true. Uh, we have standard guidelines from national organizations which allow us to really liberalize the A1C threshold up a bit, um, up to 8 rather than 7, you know, for the benefit of the not only the treatment, but the complications. You mentioned some things that maybe you weren't dealing with 20 years ago. Obviously, you know, uh, cannabis legalization, a lot of supplements, a lot of, you know, TikTok recommendations on what you should be taking. What are some of the more interesting trends that you've seen kind of bubble up that maybe you didn't expect to be dealing with. I think even sexual health is a very big part of quality of life for individuals in this age group. Yeah, that's true. And for that, that's we, we have many of our patients we partner with urology and gynecology for many of our patients for sexual function and sexual health. Um, in terms of, you know, what we, what we. Maybe didn't expect before. Again, I think marijuana, uh, CBD are probably the biggest ones. I mean, some people don't realize that there is a little, a slightly higher risk of a heart attack, uh, when using marijuana, um, because of the constriction of the blood vessels, um. You know, some of the CBD uh formulations like topical ointments and creams and so forth, don't seem to have too much side effects. So, you know, we just, we just wanna be judgmental so people will, will let us know what they're using, so we can be a better judge of, of, uh, medication safety. Um, so yeah, I mean, um, and people are more willing to tell us these days. Maybe that's the difference. Like we've always had marijuana and we've always had CBD, but patients are really now I think a lot more open and telling us what they're doing. What kind of questions do they come to you with when they're thinking about this, or maybe just telling you for the first time? Uh, they are They don't ask us as much as they tell us. And I think that's the case with a lot of herbal, herbal medications and supplements. Like for, you know, a lot of it's not regulated. You can buy it easily, uh, people just decide they're gonna try it. Um, and sometimes people come and say, hey, I'm, I'm thinking about this supplement. What do you think? Will this interact or do I need vitamins or, you know, X, you know, X, Y, and Z? What, what about it? But many people come to us already with like a 5 to 10, um, lists of herbal supplements and then they wanna know if they're, if these are helping them or if they're interacting with the other medications on their list, um. So I guess it goes both ways, but, um, but oftentimes I think people don't think there's any danger to these herbal supplements and over the counter medicines, which is a mistake, but I understand why people think that way, cause it's easy to get and you don't need a prescription. So it must be safe, it must be safe in it and wow, a lot of people are spending a lot of money on these supplements, money that they really don't have, um, so that's another thing about as well. You know, a lot of these commercials on TV are pushing um. You know, I won't name names, but a lot of these medications to, to, to help people think clearly or prevent dementia, you know, but they come to us and we say, OK, but look, here's the science. There really isn't good hard science behind this, so, you know. That's what I need to tell you, so you can make your decision, but, you know, in most cases, we wouldn't recommend it. So you've been a leader in this field, um, you mentioned that you have almost a dozen physicians within the group or a dozen providers within the group. What's changing? What are we gonna see change in the future? Where do you want to see the program grow? So we are ourselves, well, first of all, I think the medicine's changing quite rapidly as it always has, um. So we're looking at advances, I think in a lot of those areas that we touched upon, you know, cancer treatments, stem cell treatments, so forth and so on. I think one of the things that we we advocate for is that older adults are part of those clinical trials. Because otherwise, you know, in, in historically older adults have really been left out. They're too complicated, right? If you want to study the effects of something, you don't want to choose a 90 year old with 3 other comorbidities because it's gonna be hard to prove your statistically prove your point. But we're at the point now where we need to, we need to really advocate, um, to have older adults be part of those clinical trials, um, so that's one of our, our missions. Um, we want to embrace, you know, the bench to bedside treatments. We want to be part of translational medicine, especially here at UCI. Um, and in our division, we are, um, we are going to be starting and jumpstarting a research arm of our division. Uh, so we're, we're in the process of doing that now and love to be able to collaborate with all of the researchers in AG Cross College of Health Sciences. Um, so yeah, we have a lot of plans. That's impressive. Um, what role are you seeing technology play in your patients? I think we all know someone in the boomer generation who's a little bit glued to their phone and scrolling like we all are, but how's that really changed your conversations with your patients? So we, we think it's an opportunity for digital medicine. Um, we think it's an opportunity to teach people self-management of chronic disease. You know, through the watches, through the apps, uh, we actually developed the first template here at UCI so that people could take information from their digital device, through their MyChart into the EMR so we can track their blood pressures and so forth. So certainly tracking for chronic disease management, we think it's an opportunity because more people are already familiar with phones and watches and they're more willing to download apps. And use them. So, you know, we're dealing with the generations now that have worked in businesses, they've had computers, they've had phones for a number of years, so it's not so much of a of a leap to say, OK, well, now let's use this for medicine. Um, so I think that's, that's a major opportunity as well as AI. I think AI in the future, uh, would love to work with AI in terms of detecting fall risk, preventing falls, you know, um. you know, detection and a number of different things, so. Yeah, be able to, uh, you know, recognize risky behavior, uh, identify factors that are associated with it, and then potentially limit those in those individuals, so that would be nice. Mhm, absolutely, yeah, yeah. Last question here, what do you wish other physicians knew or better understood about geriatric medicine or their geriatric patients? I, I wish that other physicians would um really still acknowledge that there is a certain, there is a lot of different knowledge and expertise needed to care for older adults. I think a lot of people still think that it's, it's adult medicine, but it's, it's really not. We, we feel like we can care for patients in a much better way because of the expertise, the knowledge and the skills that we have, um, and we feel like patients have better outcomes. Um, so I think over the years historically, geriatrics has had, uh, uh, maybe a difficult time just describing itself, what we do, you're nodding there, um, but there is a real role, just because we're not, we're not fancy really, you know, we don't have flashy instruments, we don't do procedures, uh, what we do is a lot more nuanced but necessary. And as people age, then they really realize what value we have for them and their lives and their families. Um, so, I wish, I wish and I hope that we continue to gain that acknowledgement. Absolutely. Thank you both so much for being here today. This has been Physician Hoddle by UCI Health. Thank you for joining us. This was an episode of the Physician Huddle podcast by UCI Health, produced by Brett Shaheen, Angelika Yagubi, and Victor Ting. For more episodes, information on clinical trials at UCI Health, or to refer a patient, review the show notes or visit clinicalconnection. UIhealth.org. Created by
