The complex and broad-ranging needs of older adults can be difficult to meet in the primary care setting – or by specialists seeing them for a single disorder. Geriatrician Maki Nakazato, MD, explains how geriatric medicine can help – including through comprehensive evaluations and access to senior-specific resources. With the dearth of evidence-based guidelines for this population, experienced geriatricians have exceptional value. Whether the patient is a robust octogenarian looking to preserve their independence or a frail 60-year-old with multiple comorbidities, a geriatrician can check for physical, cognitive, psychological and social deficits; provide medication management; counsel patients on diet, exercise, sense of purpose and other factors that support healthy aging; and make referrals. What's more, they can explore what matters most to an individual patient and focus on reaching those goals.
Alright, so, um, so I'm Macky, um, uh, and just a little bit of background about myself. So I did, um, family medicine training, um, in Philadelphia, the community hospital, and then after that I, uh, finished a geriatrics fellowship. At Stanford. And then last year, um, after that, I finished um my palliative care fellowship at Virginia. So I'm just starting to be a geriatrics attending. I just started at UCSF in um October, so I'm still kind of new as the attending, um, and Uh, I think I got some of like the topic requests after I kind of proposed this idea for the lecture, so, um, I was gonna really kind of just give you an overview of like what we do in geriatrics, um, in the hopes that that might give you a sense of like when to refer to geriatrics if you need, um, uh, or which type of patients. Um, so that's kind of what I'm focusing this lecture on. Um, and just to kind of start my story, like when I started my fellowship, like I knew that I wanted to take care of older adults, but I don't think I truly knew what Really geriatrics really meant or what I was really getting myself into. All I knew was that I wanted to like learn more about how to take care of older adults, and I thought, you know, I've seen my family medicine attendings, of course they were taking care of older adults, you know, really, really old ones, and serving the medical director as medical director as well as just, you know, providers at a at a nursing home. Um, and so I know that it's possible, of course, for family medicine and um internal medicine doctors to take care of this population, but I thought that maybe there's something, there must be something, um, since geriatrics fellowship used to be a two-year fellowship, now it's a, a one year fellowship, um, but something there, um, that I, you know, that there's something to learn more than what I learned in family medicine. So I thought I would try to kind of maybe show you a little bit about um what I learned. Um, and, and kind of give you a sense of what we do in geriatrics. Um, So the learning objectives we're just gonna reflect about geriatrics and the care of older adults, and um I wanted to give you an overview of what is geriatrics or what I think it is, and what um geriatricians do. Specifically, I guess what I do um in terms of like taking care of healthy older adults who want to age well. And also just like your more complicated older, older adults usually, um, that I think you usually traditionally think of when you think of uh as a geriatric patient and of how we do a comprehensive geriatric assessment and maybe do like 4 or 5Ms of geriatrics. And then I'm hoping that from that we can extract when to refer to geriatrics. All right, so I do just kind of wanna start with the story again, these are, these pictures are not of real people of um that I met, they're just pictures that I was hoping that it gives you a little bit of visual cues, um, but they're all from the internet. Um, but when I was a 3rd year family medicine resident, I met, um, there uh there was a 100 year old patient who came in with her daughter. And it was kind of like a, a sub-acute visit, I think. Um, she wasn't actually my patient, she was actually one of my co-resident patients. And um I don't think she like they had specific complaints. It was something kind of chronic complaints, um. Uh, but I just remember during that visit, the daughter was really, really distraught and she was, um, wondering like, you know, she knows her mom is 100 years old, but why is, why are all the providers saying that, like, um, all of her problems are due to her age and, you know, isn't there anything more that we can do, or how does she, you know, age well. Um, and that, that seemed to be like the most, the primary, um, concern for the daughter that day. Um, and I didn't really as a like a, as a, as a resident, um, I didn't really know, like I thought that, yeah, some of the aches and pains that she might be experiencing is due to age, but um, I didn't really have like any specific recommendations. All I could do was kind of just listen to the daughter's complaints and kind of just um pass it on to um my co-resident to follow up um a little bit more closely. Um, but this kind of also, you know, Maybe it was one encounter that made me want to know a little bit more about geriatrics. Um, and I hope I, I shared also this story because, um, I wanted you to take some time here to just think about like, what do you think of when you think of older adults, especially your older adult patients, and what are your experiences with them. Like, maybe you have some more experiences as me, um, as a, as a 3 year resident, though. All right. Um, so what is geriatrics? So this is actually a Wikipedia definition. I wanted to see like what how people define geriatrics, just, you know, in the common lay world, and I thought it actually did a pretty good, uh, a pretty good job. Says it's a medical specialty focused on providing care for the unique health needs of older adults, and the term geriatrics, I thought, uh, originates from the Greek gerum, meaning old man, and naiaris meaning healer, and it aims to promote health by preventing diagnosing and treating disease in older adults. And I also continues to say that this care may benefit those who are managing multiple chronic conditions or experiencing significant age-related complications that threaten quality of daily life. Um, geriatric care may be indicated if caregiving responsibilities become increasingly stressful or medically complex for family and caregivers to manage independently. So I thought, I, you know, I bolded some of the words that I thought was kind of important in this definition. Um, and I think the second part, um, of this, I think that's really the kind of geriatrics that we think about, but I think again, we sometimes forget that as our role as healer, um, in geriatrics, we also try to prevent um disease and promote health, um, rather than just kind of diagnose and continue to treat the chronic problems that these um older adults are facing. Um, so I kind of wanted to start by kind of talking a little bit about, um, that part of geriatrics that I think tends to be a little bit forgotten, um. So, aging well, um, And this is one of the focuses that I do in my clinic and my consult clinic, not the primary care clinic. Um, but this is, um, I'm, I was just looking literally for a picture of a 100 year old lady on Google, and I met this, I heard, I came across this story. um, so this is Miriam Todd. She was on the Today Show, um at some point, and you can visit this article if you're interested. Um, and she, uh, this, I thought that this article really kind of did a great job kind of summarizing what aging well meant. Um, this 100 year old woman was still working, um, at her like family business of trying to sell furnitures, um, and as you can see, I think the secrets to her aging well was, you know, lifestyle things. So she still still cooked her own meals. She's, she made sure she was eating plenty of fresh fruits and vegetables, and that she had a colorful plate every meal. And as you can tell below too, she was also exercising, and she had a positive outlook on life. Um, so, uh, I thought that it's interesting that, you know, this, um, we think that she became a story because, you know, we think it's incredible that a 100 year old is able to live like this. Um, uh, but wouldn't it be amazing if this kind of became the norm and not the exception, that people did age well like this, and I think as a culture, Americans, you know, we tend to see aging in a negative light. Um, and so we kind of focus more on the losses and things that we come across with aging. But, you know, obviously there's people like this who's 100 years old and can age well and live a good quality of life. And I feel like if we thought that this was more of the norm, then maybe as a resident, when I met my 100 year old lady who came in that day, I would have never thought that it, you know, that some of the difficulties that that patient was having was just due to her age, and maybe I would have, you know, had more creative ideas of how to help her. Um, so just kind of going on, um, to try to talk about aging well and kind of what goes through the patient's minds, uh, and as well as I think our thought process too about aging biology. So aging does, like, we do have a negative, um, over, you know, view of aging because aging usually does result in a loss of function, a loss of homeostasis, and, you know, it increases our vulnerability to disease. Um, but again, the onset rate and extent of the aging process, it's heterogeneous between individuals. It really is different, um, as well as across the different organ systems within an individual. Um, so I think the big point here is that, you know, your physiological age, which is, you know, the, the age, the manifestations of the changes of aging that you have that's affecting your function at the whole person level or at the organ system level, that's actually really different from what the chronological age is. So, you know, you can have a 100 year old person who is pretty healthy, um, and doing pretty well. Um, And this again, it's just a little bit more about the organ systems changes with aging, um. You know, your brain volume does get lower, you know, um, your heart function is reduced, the lungs don't work as well, the, you know, the gut doesn't, um, work as well. Um. So there are differences, of course, in this um aging population. Um, and it's not just that that the patients are dealing with, but also the psychology of aging, that all these changes, it does, uh, you know, change how older adults view themselves, especially after retirement, um, uh, you know, well, after they start developing some problems, definitely, but also, um, after retirement when they kind of lose their, um, sense of purpose, um, if they've been somebody who's really busy with working and haven't had a chance to think about their life, um, you know, aging could be, um, uh, I think it could be a difficult time. Um, but again, uh, you know, most of the people that I see, um, uh, especially the Americans, like, you know, um, uh, the older adults really want to be, to maintain independence. That is really their goal for most of the time. They want to to be able to live and function independently in society. That requires a lot of, like, you know, physical, cognitive and psychological health for that to all be um uh working well for them to be able to do so. Um. And some of the challenges that the people, you know, who are um aging, it's maybe a matter of attitude. Um, sometimes people have like a negative again, like perspective on aging, um, but, you know, if you don't focus on the losses, um, uh, you know, you might be more satisfied with the life that, uh, they're living. OK. And, you know, with normal aging, even if you have some, you know, cognitive changes that is still in the normal range, then older adults, they're able to adjust and make accommodations to maintain their quality of life and independence. Um, uh, so, you know, it is possible, again, like if they're not, you know, having a lot of dementia, severe dementia, um, or, uh, cognitive, otherwise like cognitive impairment, they are able to adapt, um. And also as as you age, you actually gain more experiences, things that people call crystallized abilities that help you compensate for some of the negative changes that occur with aging. So, all this to say that again, that healthy aging is possible, though, you know, we don't need to necessarily look at it at it um in a negative light. Um, and, you know, it might just be mean that, you know, you might not be able to do the same things that you've done before in the same way, but you might just have to figure out a different way to um to do it, and you still might be able to, uh, function independently. Um, so in healthy aging, you know, there's 5 domains, promotes health, prevents injury, and manage chronic conditions, optimize the cognitive health, physical health, and mental health, and social engagement. Um. So, you know, it's really important for um for patients to make um active efforts to adopt, like, new activities and engage in cognitively stimulating activities, um, for healthy aging, physical activity, exercises, not just good for like cognition or for your physical health, but also for cognition. And also your emotional mental health, and socialization also, you know, prevents cognitive decline, and it kind of um helps us maintain meaning and connectedness with others, or gives us um a purpose. Um, and these kind of like lifestyle factors that can account for about 10 years' difference in life expectancy, um, if they're doing it or not. Um So again, like, um, uh, at my um clinic at OSU, one of my part uh responsibilities is that as a geriatric consultant, Um, in the integrative medicine clinic. Uh, I do, uh, I am starting these group visits, um, about aging well, and we really focus here on like diet, making sure that, you know, again, they are eating lots of vegetables and fruits, um, making, and also some protein so that they can maintain muscle mass, um, exercise, the type of exercises that they should be doing, again, to build muscle and to maintain it, but also for balance. Um, we talk about the importance about socialization, as well as making home adjustments because most of these older adults do want to stay in their homes. So what, what, you know, what kind of creative ways we can do to um make them be able to stay in their homes, maintain a sense of purpose, um, we can talk a little bit about self-compassion. And also, um, kind of, uh, go through about advocating for, for yourself, um, to help kind of navigate through this um not so friendly complex healthcare system that we have. And I think that's kind of the way that I see that that geriatricians really try to promote healthy aging. Um, And you know, I feel like these are the things, yes, they seem simple, but these are the things that, you know, again contribute to a good quality of life um and and longevity, and I wish I had known these things so that I could kind of offer these things to that 100 year old patient that I saw as a resident or help guide them, because I think these are all different categories of things that she could have worked on, and I could have made recommendations had I known. Um, so that's all really to say that there are things that we can definitely talk about, um, or, you know, can make recommendations to your older adults who are kind of, who are aging well. There's, you know, but, um, And they're they're, they're doing pretty well. Um, and then, but what about the older adults, right, who are, um, not doing so well, um, the, the older adults that we generally think of, um, as our geriatric cases, like how, how do we deal with this complexity? So, I think, you know, um, generally when we think about these complex older adults, we do tend to think about like the, like, you know, they have these geriatric syndromes that geriatricians are used to kind of treating, um, like frailty, functional decline, you know, they're usually at risk for falls, maybe have some urinary incontinence, malnutrition, um, cognitive dysfunction. Um, pressure ulcers, hearing and vision concerns. Um, so we do as geriatricians, we do focus on these things. Um, and for us, I did put up a little picture about um function because function is really um key in seeing how, how well that patient is doing. So the, both the ADLs and IADLs. Um, And yeah, so I think um I wanted to go over the comprehensive geriatric assessment. I think it's especially important in patients who are your, you know, complicated geriatric patients who have plenty of comorbid conditions. It's really important to do on the comprehensive geriatric assessment. Um, I don't think that, you know, the traditional medical assessment that we do is really enough, um, uh, and you have to like kind of Uh, with the comprehensive geriatric assessment, what it really consists of is, you know, we have a cognitive assessment, we also do psychological assessment about mood. We, uh, look at their social function, um, as well as their uh social history to see what their living condition is like, what kind of like, um, uh, you know, needs that they might have in terms of housing or transportation or financial concerns. Um, functional assessment, like I said, like how independent are they? What, uh, what, what do they need help with and why do they need that help? Um, is it due to cognition or is it due to like physical limitations? Um, A medication review for sure, both prescribed and over the counter medications. Um, uh, a lot of these uh geriatric patients tend to be on, like, they like to try to do supplements, so try to, um, review those for um any kind of interactions, um, and also try to like just reduce polypharmacy. Vision and hearing and nutrition, like, are, are they having any um unintentional weight loss? Um And kind of doing that comprehensive geriatric assessment, I always think about doing a 4 or 5M geriatrics uh summary, because that helps me give an overview picture of that person. And so the 5M's of geriatrics, it's mentation, mobility, medications matters most in multi-complexity. I usually just do like a 4M summary without the multi-complexity, but really just the 1st, 1st 4. and I think by categorizing it like this, um, it gives me a sense of the person as a, as a whole that I don't, I don't get by just looking at, um, just the problem-based um assessment and plan that I have for them. Um, and again, it's really important I think to have that kind of holistic picture of that patient where you know about their social situation, their environment, the supports that they have, their function, how they're thinking, and how they're walking, because, you know, that really one of the toughest things I think in geriatrics to do, at least for me, is like this concept of shared decision making. Of how, you know, a lot of the care is based on, you know, it's just deferred, um, in the guidelines to shared decision making. And that's because there's not really much evidence-based medicine for these older adults. Um, there's not a lot of studies that really do um study older adults, and most of them are excluded because of their comorbidities, and it's kind of hard to study them. Um. And so, you know, I think for these cases, whether it be something as simple as like, do we continue screening for breast cancer or like other cancer screenings, there's really no one right answer, um, and we probably really don't know until you kind of look at hindsight, like maybe we should have done this or not. Um, but again, uh, having that more holistic picture of that person, I think helps with Um, helps us kind of make recommendations to do this shared decision making for that patient and individualized care. And again, to do that, you really need to understand the patient's goals and preferences as well, um, and understand their function. Um, and I think, you know, it seems like everyone at One Medical is aware that, you know, it's hard to do this, but there's a lot of help in the sense that there is an interdisciplinary team. Um, you don't always get to see everybody face to face, but there's the other specialists that are taking care of the patients. There's the nurses and pharmacists and social workers. Um, as a geriatrician, we have um a social worker in our clinics, and that's been very helpful. Um, some programs also have like a, a pharmacist to review their, the medication. So again, that can be very helpful. Um, and I definitely rely heavily on the physical therapists and occupational therapists that are working, uh, as well as the speech therapists that are working alongside these older adults and, you know, other psychologists and nutritionists as well. Um, but I think, you know, a word of caution, it's great that we have all this team working, um, but I think, uh, one of the responsibilities of the primary care doctor is to kind of keep track of all the good work that, you know, these people are doing, um, and kind of keep in mind how of the big picture of how people are functioning, which can be kind of difficult to track, but I think it's important cause The older adults usually are not really able to track it themselves. Um, So now I, I wanted to kind of just go through a case of a patient that I actually saw, um. Uh, and I, my hope is that by going through this case, it, um, I can kind of show you what kind of geriatric review of systems I do, um, uh, in a visit, um, like how I form a 4M 5M summary, um, to kind of, uh, come up with this, uh, you know, with the care plan, the ultimate care plan for a patient, and I'm, I'm hoping that, you know, at least this gives you an idea about, um, What some geriatricians might think of um when they see a patient. So, I have patient JV, um, he is an 80 year old male coming in for a new patient visit. Um, And really important thing in geriatrics is a lot of like document review, so you do a pre-charting, and in general, you see that he doesn't seem to be getting much regular medical care. Um, and you also find that he has been without housing for a period of time. Um, so there's really not too many notes in that's available in the chart, but one of the things that you do see is that he presented to the ED in September for a toothache, was given a course of clindamycin, and recommended to follow up with a dentist. Other things that are notable in his history. He has a history of depression after his girlfriend had passed away. Um, has other history of insomnia and history of alcohol abuse. He also has a history of diabetes, CKD, hyperlipidemia. His last A1C was 9 in April, um, and, uh, from the chart review, you think he's probably, that was him take with taking metformin 500 twice a day, glipizide 2.5 daily. Um, he has some other past medical history too, but I'm just going to, you know, say that those are the things we're gonna focus for this presentation. So JB comes to the office and um the staff kind of immediately warns you that he's extremely disheveled. His clothes are visibly soiled and may smell of urine. Um, when you walk in, um, he has a bag of medications with him that does look a little dirty, um, And it does not look organized. Some of the medication bottles in the bag, um, they're actually open and so there's some loose pills mixed with some other pills in the bag, um. Uh, and, you know, and just because he has the medications out there, um, and you don't have much history on him, you start by reviewing the medication bottles, um, and you notice that, you know, many of these bottles, some of them are like, you know, um, pretty full. The bottle of metformin that you know, uh, that you see is, it was filled 3 months ago and yeah, it's still pretty full. Um, and he does endorse, when you ask about him, he does say that he doesn't always take the metformin, although, um, uh, before the visit, he may have told the, the nurse that he does take it kind of regularly. Um, And you kinda go over the medication list. There's some medications that he's not taking because they were just never refilled or he lost the medications. Um, and just kind of continuing the visit, the new patient visit, you then just ask about his medical history, some of the things that you ask about is his diabetes, especially because he comes to you and says that one of his main concerns is that he's thirsty all the time and has urinary frequency. He doesn't know why he has this. Um, uh, when you ask more about the diabetes, he just says he does not really check his blood sugars as he lost his supplies to check his blood sugars, and he's not really interested in checking it religiously. Um, for meals, he gets meals on wheels, um, he does like ice cream, he's really interested in seeing a nutritionist for exercise, he walks his dogs, uh, his dog, um, uh, maybe daily. And just about dental halls just cause it came up in the chart review. He did not follow up with the dentist. He says that all his all of his teeth have broken off, and he's basically using a blender to be able to eat his food, um, but thankfully no weight loss. And continuing again, depression and insomnia. He's on mirtazapine 15 mg at bedtime. He's off the Lexapro, um, or he's tried different medications in the past, and he's not on Lexapro because he developed hyponatraemia, not on Wellbutrin because it was not effective, not on doxepin because um of orthostatic hypertension. Um, and he tells you he's actually doing OK in terms of um of his mood. Um, because he's in a new committed relationship, but it's not with, um, it's with a real person that exists, but it's not real in terms of like physical, it's just in his dreams. Um And so, you know, you'll review his other medical conditions too, but we'll move on to the review of systems. This is exact this is kind of um the template that I use for geriatric review of systems for um for my patients. Definitely ask about memory, um, cognition, and he, he denies any problems. Mood kind of talked a little bit, but he can be lonely, chronically Remron helps. nutrition, again, he's blending his food, no weight loss, sleep, he's sleeping OK, doesn't have any pain. Um, urination problems. We talked about the urinary frequency and nocturia, constipation, he's OK. He's having good bowel movements every day. No problems hearing, vision, he does, he's seeing OK, but he hasn't seen an eye doctor recently. Um, dentistry, we kind of already talked about mobility. He walks without an assistive device, um, no falls thankfully recently, and his support system is really just a friend and maybe Santa Rosa and a friend that he lives with. Um, and what matters most is that he says that um he's been trying to, uh, doing some writing that he hopes to publish, and he also wants to kind of reconnect with this kind of love interest that he had and is having this, um, I guess, imaginative relationship with right now. Um, going through his social history, so he was homeless for a period of time, but now he does have housing, so he lives with a friend in a two-story house and dog that seems to be owned by, maybe co-owned by his brother who lives in Virginia, but his brother is thinking about maybe planning to sell the house, and if he does sell the house, the patient is not sure where he'll go. He might go out of the country, he might go to a different place in the country. He's really not sure. Um, he does have a college level of education. He likes for hobbies, he likes writing, loves to take his dog to the dog park. No alcohol use currently, was a former smoker and he does smoke some pot once a week, um, to help him with his writing and thinking. Um, and he's not currently sexually active, although he said he would like to be. And then the function, he's actually pretty functional, um. Uh, you know, he's, uh, managing his finances, and he was working on his medical application actually. Um, driving, he, he does drive, not currently because he lost his car, but he's planning on getting another car. He's managing his meds, you know, and ADLs he's also able to do except for some of these urinary accidents that he has, um, but he's been able to keep himself dry without depends. So, I guess, you know, it's a lot of information that we get um in one visit, and this is, you know, your first time meeting him. Um, and, you know, I just wanted to pose to you, um, the question like, just take a moment, what would you do for this patient if he came into your clinic? Um, And for me, I don't really know, um, but if I, I feel like if I, if I was a family medicine resident, I think um that what I would have done for this patient was I don't think I would have been able to really get all of that history at one time, but I would have probably immediately recognized that his diabetes is probably not controlled given his complaints. I don't know if I would have had time to check his medication bottles or even thought to have checked his medication bottles. Um, but, you know, I would start with checking his labs since he didn't have any recent labs. Um, and, you know, once the labs are back, I may have increased his regimen, um, or I might have sent him to endocrinology. Um, I may have also connected him to psychiatry because of the depression and problems of, you know, having tried other medications and um just in the future if he's having problems. and I might have placed a referral to dentistry, so I think maybe as a family medicine resident if I had seen this patient in a normal family medicine like appointment time. Maybe that's kind of as far as I would have gotten. Um, it's my guess. Um, but as a geriatrician, I think, again, the biggest difference is that I have more time, um, to get his full history and his full picture. And also, I do have a little bit more resources in that, um, I do have a social worker um as part of the team, which I did not have as a resident, and we also have embedded psychiatry. Um, so I, I was thinking, you know, you know, referring to him to social work and psychiatry for that, uh, part of the plan. Um, so I knew that in, you know, as a geriatrician or as a physician, I guess that in general, his diabetes will not be well controlled, but given all of his social problems, you know, his problems with housing, and not to mention I guess he had lost, um he didn't have electricity and heating for some time at this current housing. Um, I wasn't really sure, as well as his medication, he's not taking it regularly. I wasn't really sure if he would be able to follow up on recommendations um without additional support. I'm not, I wasn't sure at this point, is it maybe memory problems that's affecting him? Is it his emotional, uh, you know, history that's making him not able to Um, do, you know, medication management. I'm not really sure what the reason for the noncompliance is, but besides those things also, you know, Um, uh, for, uh, his social housing situation, I wasn't sure if he would be able to, he would be able to, you know, take his medications appropriately or even like test, um, for his blood sugars appropriately. Um, so I think at the time I placed a referral to social work to help him get medical, um, and because I really didn't know what he was doing at his home and I had concerns about his home, um, situation. I thought that we'll start with him getting Medi-Cal, and then once he has that, he might be able to get home health and IHSS so that maybe those caregivers can help can help us, give us a better idea of how he's managing in the home, as well as kind of like, you know, having the social worker also reach out to um to get collateral from his um from the person that he's living with or his brother who's living in Virginia. Um, who he has, you know, questionably, I don't know how much of an interaction he has with him. Um, and this is just an, uh, you know, what I wrote for my forearm summary for, um, for this guy, and it's just, uh, to give you an idea of what I do. So, um, so mentation again, I wasn't sure, um, he doesn't have any, he says that he doesn't have any problems with his memory, but given his difficulties with medication management as well as self-care cause he's disheveled, um, I wanted to try to do a MOCA to see if there's some kind of cognitive impairment the next visit. Um, and I thought that maybe his cognition might be affected by mood, given his history of depression and his current kind of like sexual fantasies and, you know, that. And so I was, uh, I think I considered doing the Jerry psych referral but did not place that day. Medic medications. I thought I would check um maybe his past medical records. He was on some supplements that I thought we can consider stopping um and really for him I thought that keeping his regimen simple is really best. Um, mobility, um, he doesn't have falls, but, uh, you know, looking at his gait in the office, it was very slow and hesitant. Tug was 17, so he is at risk for falls, um, and I'm thinking maybe he does have some neuropathy in his feet due to diabetes, as well as alcohol history. So I was thinking maybe we can consider PT for strength and balance in the future, um. Maybe it's like when he's a little bit more uh stable and might be able to do PT. Um, and that matters most. Um, I thought because he identified that, you know, finishing his manuscript was really important for him, um, I thought, you know, we try to support his cognitive and social needs so that he's able to do that, and because he wants to express some loneliness and wanted to connect with this, um, this past kind of love interest. I, I wasn't sure if we we'll be able to do that, but I thought, you know, we could Uh, think about increasing his socialization to help him feel less lonely and maybe less kind of um focused on this, uh, this love interest. Um, so then I just recently actually had the subsequent visit with him. Um, so his labs came back, his A1C is 11. Again, not too, not surprising, um, but, and again, because I wasn't sure how much he's taking his medications, I decided to kind of do the dogma of geriatrics of going, uh, starting low, go slow, so decided to continue his regimen for now and make sure that he's taking it regularly. Um, uh, ask, oops, sorry. Ask him also to try to like, you know, set up reminders so that he could try to take his metformin um every day, twice a day, maybe ask his roommate, um, so that he can remind him. I also ordered some blood glucose monitoring supplies, just the basic stuff, just to see if he's able to, if he's able to keep, you know, keep track of it and not lose it. I did do a MOCA and it was 26 out of 30. Um, so I, you know, I think, um, his inability to self-care doesn't seem like it's really necessarily due to cognitive impairment, but it might just be due to life's choice. Um, so I thought maybe his mood might be impacting his choices. So at that point I placed a referral to Jerryy, um. And you know, he did have some confusions, I think um in between he had picked up some medications that like he should have stopped taking, namely the Lexapro, and he's like, he's, I'm not taking them, but I picked them up. So again, the plan was to, you know, reduce polypharmacy and keep his medications and regimen simple. And um I aligned what matters most to him to make his lifestyle modifications to try to kind of motivate him to make these lifestyle modifications and try to take his medications. Um, and I said, you know, good control of the diabetes is good for your sexual health, um, and also maybe like reduce the risk of stroke so he can continue working on his writing. So, um, in summary, so this is actually um a summary that I found um from AGS, a much better kind of summary than the Wikipedia one probably, um, about, uh, what a geriatrician does, but really like providing patient centered care that optimizes function and, um, you know, and well-being. Um, you know, integrating the patient's goals and values, um, prevent, diagnose and manage geriatric syndromes, provide comprehensive medication review, um, and coordinating healthcare and healthcare transitions, but, you know, I hope I was able to kind of show you maybe that what we're doing this by going through the, the case. Um, And then this is really my last slide. I think, to me, I think geriatrics is a medical field where the heart really matters, and you have to have a lot of patience to be able to kind of sit through and go and listen to all of them, to to the history that um these these patients bring. Um, but I do think it's like an an art in addition to the medicine science because of this like more shared decision, um, concept. And I do think that we are all capable of doing this type of care. Um, it took me like a fellowship, you know, to realize this. Like I, I feel like in fellowship, I gained that additional lens by looking through the, uh, the forums, um, that I feel like I, I see the, the people in a different way than, um, the patients in a different way than, uh, without that. But I think it's, um, you know, possible to to do that with practice, maybe taking a few courses, um. Uh, and just developing your practice. I just think that the limiting factor, though, um, in our healthcare system is probably mainly time. And so that I would say, you know, if you're thinking about like referring to geriatrics, um, I would, I would suggest that you do refer if you have a very complex patient with, you know, lots of comorbidities or someone who does have some cognitive impairment like dementia or Parkinson's where, you know, um, it might just take a long time to get the history or for them to come to the clinic appointment, um. Um, you know, where you know that the 20 minute office visits just, just don't do, um, don't do you justice and providing care for this patient, but also not, uh, you know, to the patient too, um, because they're just too complex and 20 minutes is not, it's just not enough time. Um, uh, you can also think about referring a patient if, uh, to geriatrics if you feel like they just have, uh, you need, you need a lot of um help with coordinating the complex care that they have. Or maybe if you're just like running out of ideas about what you um like what you can do for the patient and the, you know, and the patient feels that there's something more that can be done, um, you might consider referring to geriatrics. Um, and that's kind of really my last, my last slide. So, I hope that this was kind of helpful in the sense that again, like you could kind of see by going through the case like what I think about for my complex, um, geriatric patients, uh, you know, what I do for them in terms of like review systems and the assessment and my summary. Um, that I come up with them, um, as well as again, like, you know, but don't forget the, the healthy younger, um, older adults too, that there are things that you can do to promote, especially like lifestyle things to take care of them. And I think, you know, they are very appreciative of the, you know, some of these more simple advice that you can give to them, um, because most of the times they do feel kind of um sad that there's nothing to do or that people just tell them. Um, there's nothing much to do, and that's not necessarily true.
