A Holistic Approach of Caring for People with Dementia (with transcript)
Dr. Michelle Dhanak is an MD and has been in clinical practice for almost 25 years as an Internist and Geriatrician. Dr. Dhanak has extensive experience caring for people living with dementia. She believes in a holistic approach and the importance of partnering with patients and their families. Dr. Dhanak joined the ElderConsult Team in 2017.
Frank Samson: Welcome to The Aging Boomers. I'm your host, Frank Samson. Of course, on our show, we discuss so many of the issues facing Boomers, their parents, and what we know is an aging population, which I'm smack in the middle of.
Also just want to thank everybody for all their support. Our listeners are growing each and every day, and it really is just people sharing the podcast with others, letting their friends and family know. Certainly most of our listeners are just listening on iTunes, iHeartRadio. Many are listening on our free app. Keep up to date on many of the great guests that we have interviewed throughout the course of the show.
We have another great guest with us today I'm very excited about. We have with us Dr. Michelle Danick. Dr. Danick is a MD and has been in clinical practice for almost 25 years as an internist and geriatrician. She has extensive experience caring for people living with dementia. She believes in a holistic approach and the importance of partnering with patients and their families. Dr. Danick joined the Elder Consult Team in 2017. So, Dr. Danick, thank you so much for joining us on The Aging Boomers. I really appreciate it.
Dr. Danick: Thank you for having me.
Frank Samson: I know that I've had the pleasure of meeting you personally and hearing you speak. It was wonderful, and very informative. Now, I know I mentioned at the very end of your introduction that you joined an organization in 2017 called Elder Consult. So, tell us a little bit more about Elder Consult and how it maybe differs from a standard medical practice.
Dr. Danick: Elder Consult Geriatric Medicine was started by Dr. Elizabeth Landsverk about 10 years ago in 2006 because she just couldn't find the kind of practice that she wanted. So, she created it, with the intention to care for elders in their home and specifically focus on people with dementia. So, Elder Consult, unlike a traditional practice, is house calls, which is the heart of geriatrics. We see people at home, wherever home is for them, whether it's living in their own apartment, their individual home, or assisted living or memory care.
And that allows us to have a better sense of who they are and how they're managing day to day with their particular village of caregivers, family, friends, facility staff, and private caregivers. We travel all over the Bay Area.
Frank Samson: That's wonderful. And that's so needed, especially with families that are going through this with a loved one with the stress and all that. Do you become, in a sense, their physician, or are you more of an advisory and work together with their physician?
Dr. Danick: The great thing about this practice is it's very flexible. We can work as a consult where we go and we advise the primary care physician. Or we can work in a more expanded forum where we are on call for that individual and we do their prescriptions and we still communicate closely with the family and their primary care. But we can take a more active role in their care, or we can actually become the primary care physician. So, it's really up to what that individual needs and what is gonna be the best fit for that patient and their family.
Frank Samson: That's wonderful. We have listeners, of course in the Bay Area where we're based, but we have listeners all over the country, all over the world. Do you do any remote type of work, via Skype or anything like that? Or is it really more in the Bay Area where the practice is?
Dr. Danick: It's definitely a hands on practice. We're not virtual. And that’s because we're often dealing with people with very complex conditions and challenges, and it would be very hard to accurately manage their conditions without seeing them and being able to do things like take blood pressure, see how they are interacting in their environment, etc. There may be a role for some virtual patients in the future, but we haven’t made steps in that direction yet. I've done some virtual practice when I was practicing in New Zealand, but not very much. You have to know your patients really well before you can do that.
Frank Samson: Right. So when I did your introduction, I mentioned you as a geriatrician. Some people have heard the term pediatrician, which is obviously a physician that works with children. Geriatrician is kind of working with the elderly. I assume that's correct, right? I mean, I know that's correct, but maybe you could expound upon that a little bit and that area of specialty.
Dr. Danick: That's exactly right. A geriatrician is someone who's trained typically in internal medicine, but it can be somebody who's done family practice. But the key is that there's advanced training after they complete their residency. So, in the United States, it's anywhere between one and three years depending on if you want to get sort of sub specialty training. But generally the fellowship is one year at an academic center.
Geriatrics is all over the world. So, I got my fellowship certification in New Zealand, which is where I was practicing for 10 years. In the United States, a lot of internists practice as geriatricians because, as you know, there's an aging population and there's very few geriatricians in the United States. There used to be 12,000. There's now only 6000. So, there's an incredible shortage of us. So, many internists sort of get their training on the job, but they don't have that specialist training, which I find is extremely valuable in just giving you a much deeper understanding of what are the issues that are so very key in management. It's the icing that helps really recognize the problems that occur in an older population and get on top of them early.
Frank Samson: With us, everybody, with the aging population, I guess I'm kind of perplexed by the fact that what you said, and I knew this before you said it, that there is a decline actually in physicians specializing in geriatric medicine. Does the medical field need to do something more from a marketing standpoint to get people to specialize in this? Personally I don't understand why not, because if somebody opens up a practice and specializes in this, I think they would probably be pretty busy with patients because of the tremendous need. So, why do you think this is happening and what needs to be done?
Dr. Danick: I really think that some of the problem is that there's so few practices like what I'm in. The heart of geriatrics in the home. When I talk to physicians and they hear what I do, the most common comment is, "Wow, that's really interesting," because it's so much fun. But there aren't practices like what we have. It's incredibly unique throughout the United States. I also think that geriatrics is very underpaid, like most of the primary care specialties, so most geriatricians either have a more traditional private practice where people come to see them, or they're a medical director in a nursing home.
I think it doesn't appeal to the young doctors oftentimes. I noticed the difference when I was in New Zealand that how many people were interested in becoming geriatricians because there were so many more jobs opportunities available to physicians when they finished. Also, it took Dr. Landsverk 10 years to find me as a partner because many of the geriatricians choose to remain in academic centers. So, there are geriatricians available, but they're doing research. We need to research, and the work they’re doing is essential, but we need even more people who are out working in the community.
Frank Samson: Yeah. I would think that it ... Could a general practitioner who's not a geriatrician get certified? Even though they may have been in practice for a while, is there incentive for them to get additional training to specialize in it?
Dr. Danick: I think a lot of people go to conferences. That's how we educate ourselves. And you know, there are incentives, because for example, the California medical board says that if 25% or more of your practice is a geriatric population, you have to have a certain number of educational credits. So, people do educate themselves through conferences, but I certainly found that having a more formalized experience in a geriatric practice gave me a much better understanding of the content.
I can see that there's just principles of geriatrics that are difficult to understand. Even though I see a lot of people who are cared for by very skilled internists, there's just things that they miss. They just don't quite realize the important of proactive management. And that's kind of the key. When we get into our population, which is oftentimes extremely complex, you need somebody who's got a skill set and has seen people like this over and over and over again. So, that's why that specialist, that's why you go to the specialist, because they have a level of experience with a certain population and they know it.
Oftentimes, that's sort of where physicians can run into trouble. So, who do you go to? And especially for the people with dementia, or other complex or challenging behaviors, when you intersperse that with all the complex medical conditions that interface with the dementia, it can be hard to sort out.
Frank Samson: Yeah. Let's talk about that. What would you say are some of the most common problems that you're dealing with in the elderly? And I guess as a follow up question, what are some of the more common problems and what could help our listeners who have loved ones or maybe listeners that are getting older themselves. What can they do to make a difference in helping prevent some of these problems?
Dr. Danick: This is really my passion, which is early recognition and management of common conditions that occur for people as they're aging. One of the primary ones is the beginning of not necessarily dementia, but cognitive changes. Your greatest risk for dementia is age, so as Baby Boomers are aging and as we're living longer, we know that if you're 85, your risk for dementia is somewhere between 25 and 50%. But once you get up into your 90s or middle 90s, it gets up into 60% or higher.
This is regardless of genetics, which is always people's questions. It's just that your greatest risk is age. So, it's proactive management. Instead of having the stigma of memory loss as being something that we try to hide or we're ashamed of, it's recognizing that we have ways to manage it, and not necessarily with drugs. Just recognizing that this is very common for older people and that if we get on top of it, we help people to manage the strategies and give them the supports, they won't end up in that crisis of unpaid bills, elder financial elder abuse, all the things that happen to people that are devastating in their lives. That precipitates a spiral of hospitalizations, illnesses that could've been avoided.
So, cognitive changes are one of the ones that often we as geriatricians get called in for, because when you look at what are the things that threaten someone's independence, there's three primary issues. It's cognitive changes. It's losing your ability to walk or reductions in mobility. Falls, not being able to get around as well, and urinary incontinence, etc. And when you have one or more of those conditions or problems, and especially if you have all three, it becomes increasingly difficult to stay independent. And it makes sense.
For family members who are trying to care for somebody, people will say, "Oh my goodness. Yes, I recognize this." When I have all three of those things, I can't take care of that person at home anymore, or I can't support them to be at home anymore. And if I don't have money for private care givers, then what are we gonna do?
Frank Samson: That's the big challenge.
Dr. Danick: It’s a big challenge. And you can ... if you start getting on top of those things early, the minute somebody falls, that's a red flag as a geriatrician, to begin to say, "Why did that person fall?" That's an indication that something's changing in their ability to kind of balance, their ability to stabilize themselves. It could be the loose slippers that they have always worn, but now they just can't pick up their feet as well.
So, it isn't just "a mechanical fall". There's changes. There's things we can do to help them. We can do balance and strengthening exercises. We can look at their footwear. We can look at all these different things. One of the most common things is people's blood pressure is too low, and the blood pressure medicine that they've been on for the last 20 or 30 years, now when they stand up and they walk around, their blood pressure's too low. But they aren't telling people that they feel dizzy when they stand up. They're just falling over.
So, there's lots of things that the geriatrician thinks about and that we can educate families to think about so that they ask their doctors and they're proactive about saying, "Hey, my mom had this fall. What can we do to prevent it? Does she have osteoporosis? Has she had a bone dexa scan? Has she been treated? Can we prevent a head fracture?" I see a lot of people who have had a fracture 10 years ago and by the time I catch up with them, they've had the hip fracture, which is the end, oftentimes, the end of the road to independence. But it could've been prevented if that osteoporosis had been treated earlier.
Frank Samson: Yeah. I know and you're touching on it already, but I know you believe in more of a holistic approach of caring for people with dementia. Can you kind of explain that approach and how it differs from maybe a more traditional approach?
Dr. Danick: Well, geriatrics is by nature holistic. And what we mean by that is that you can't just go and look at the individual's "diagnosis". "Oh, this is Mrs. Smith and she's got coronary artery disease. She had a heart attack two years ago and she's got hypertension and high cholesterol and now she's had a stroke." You have to look at all of who Mrs. Smith is, because if Mrs. Smith is 90 and she's had all those conditions, she very well and most likely has a little bit of memory impairment. She may not be walking as well. We have to look at all of her physical conditions. We have to look at her mental health and cognitive health to understand how that's interplaying, because maybe the reason that she's having these problems is that she can't remember to take her medication.
Then we have to look at her social system. What's going on with her socially? How is she supported? How is she managing at home? What are the other things that are impacting her health? Has she just lost a friend and is she really depressed, and that's why she's not managing her medication? And what else is going on and sort of how does she feel about her life? How does she manage her stress? How does she manage her spiritual health? And how does she manage the changes in her life that can often contribute to things like loneliness? And how do you feel happy in your life as an older person?
So, we have to look at what I call sort of the four pillars of health. Physical health, mental health, social health, spiritual health, that these are the things that we touch on when we do our geriatric assessments, which are called the comprehensive geriatric assessment, and we look at all those and we look at the interplay of all those things. And then we ask the individual, "What's important to you?" Because for them, it may or may not be that heart attack. What may be important to them may be very different, and it's trying to understand how do we incorporate the goals and the values of that individual that change over time.
And you and I know as we age, what we thought was important to us at 40 is very different at 60. And let me tell you, it's very different at 90. And it has to be readdressed and reevaluated. That’s probably the greatest issue that I see, is that people are cared for based on their medical conditions as opposed to everybody pulling back the lens and saying, "Who is Mrs. Smith today? What's important to her? How is she managing?" So, what geriatrics is about, it's not about chronological age, it's not about diagnoses as the focus, it's about function. How is Mrs. Smith functioning in her day to day, and all of what her day to day is, her social health, her spiritual health, her physical health, her mental health. And how do we then take care of her and manage the conditions that are impacting her function?
Dr. Danick: So, it's a totally different view of how you care for the person. And really to understand it, you have to see the person at home. I mean, you don't have to, but you're gonna get a way better picture.
Frank Samson: Exactly. Exactly. Boy, I could talk to you all day and time's flying. We do have a couple minutes here, and I know you'll do your best on this one. For those listening that are dealing with parents, or a loved one, whether they're in a difficult situation right now or not, what suggestions do you have for them knowing they're not professionals like you. I know there's no clear cut answer, but could you try to help people look for certain signs that may say, "Hey, that's not normal"?
Dr. Danick: That's a great point. The most common places I hear about, "Oh, it's just normal aging," is memory. People say, "Oh, I'm just forgetting words. That's normal." So, there is normal aging where our brain doesn't work as quickly and we can't process as much, and we don't multitask as well, but we are able to make decisions. Your decision making capability doesn't change with age. You may not be able to come up with the names of things as quickly, but you can eventually come up with them. Especially if you're not stressed.
But where people start, the cracks in the veneer are things like not remembering to take your medication, forgetting to pay bills, not remembering appointments. When family members notice that, that's the beginning of deficits that are going to get that person into trouble. They're not going to be able to manage their day to day existence as well. It doesn't mean it's necessarily dementia, but it means that we need to have a recognition that there's issues that are coming up and strategies to manage them, and then we'll prevent a problem in the long run.
What I commonly see is when that memory and those particularly short term memory problems begin to happen, the older person starts to become anxious. They are spending a lot of time trying to remember things and that anxiety impacts everything in their life. So then that impacts their memory even more. If we can support them and recognize that this isn't something to be ashamed of, but it does need to be managed, it's more than normal aging, that's one of the most important things. Early diagnosis and recognition of cognitive changes, whether it's mild cognitive impairment, which is some short term memory loss that the person is noticing, but isn't having a major impact on their ability to function day to day, or whether it's dementia.
And then the second thing I would say is changes in mobility and falls. It's not normal aging to fall. And then the last thing is people need to look into delirium. Delirium is acute brain failure. That is when the loved one suddenly becomes confused, and that can be from an illness, it can be from a stroke, it can be from a change in medication. That is often under recognized and under treated. And if people have recurrent deliriums, or oftentimes even one severe delirium, their brain doesn't come back at the same level and their function doesn't return to where it was.
So, in my eyes as a geriatrician and for most geriatricians, it's a geriatric emergency. Needs to be recognized and treated. And the treatment is understanding the underlying cause and then correcting that.
Frank Samson: That's great. Great advice and boy, we've got to have you back because there's so much more to talk about. But before we sign off here, please share with our listeners how they could get in touch with you or Elder Consult, they want to learn more. How would they go about doing that?
Dr. Danick: One of the best ways to learn about Elder Consult Geriatric Medicine is to take a look at our website. We have a tremendous amount of educational information where people can learn about dementia, they can learn about medications. They can learn about a lot of the things that I've talked about, and they can review a lot of the talks that Dr. Landsverk and I have given, and that's at www.ElderConsult.com. Or they can call our office if they're in the local area. We cover all the way from Carmel to Santa Rosa, and I go east as far as Antioch, so we're all over the Bay Area. And the phone number is 650-357-8834. There's someone in the office Monday through Friday.
Frank Samson: Great, great. Well, thank you so much, Dr. Michelle Danick. Check out, they do have some just tremendous information on their website. Check out at www.ElderConsult.com and I want to just thank you so much for joining us on The Aging Boomers. Thanks so much and I want to thank everybody out there for joining us as well. And as I said, just go on your iPhone or Android phone and call, download the free app and listen to these shows. Share the information with your loved ones. Just be safe out there and we'll talk to you all soon.