Dementia with Agitation...Now What? (with transcript)
Elizabeth A. Landsverk, M.D. is a triple board-certified Geriatrician, Internist and Palliative care physician, with extensive experience in addressing complex medical and psychosocial issues in the older individual. Her expertise is addressing complicated medical and psychological conditions, with particular emphasis in dementia and agitation, helping her to improve systems of care for the most challenging patients.
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 the Boomer generation, their parents, and what we know of course is an aging population. I just want to thank everybody for all their support. Our listeners are growing of course each and every day. That's because of you, because you're sharing it with others. That's how we're getting the word out. Thanks to all of you for supporting us.
Frank Samson: I want to remind everybody that today's show is sponsored by Senior Care Authority, a senior placement and elder care consulting organization that has a national network of professionally trained and experienced local advisors to assist families. They'll work with you in determining the right path for you and your loved one and discuss various long-term care options, whether it's in-home care, assisted living, memory care, or you just need an advocate, somebody to get advice from, and you'll be able to talk with somebody locally in your area, and advisor in your area. For a free 30-minute consultation with an advisor in your area, you can certainly contact Senior Care Authority at 888-809-1231 or you could go directly to the website at www.SeniorCareAuthority.com.
Frank Samson: I'm very excited about today's guest. I'm always excited about our guests, but I'm especially excited about today's guest because she's local in our area, in the Bay Area here, and very, very well-respected. Her name is Dr. Elizabeth Landsverk. She's a triple-board-certified geriatrician, internist, and palliative care physician, with extensive experience in addressing complex medical and psychosocial issues in the older individual. Her expertise is addressing complicated medical and psychological conditions, with particular emphasis in dementia and agitation, helping her to improve systems of care for the most challenging patients. Dr. Landsverk, a pleasure to have you on The Aging Boomers, and welcome.
Elizabeth L.: Thank you, Frank, and thank you for this wonderful service you're providing to families across the country.
Frank Samson: Thank you. We enjoy what we do. It gets tough, as you know. It does get tough at times. We appreciate everything you do as well. I just wanted us to start out, because when I did the introduction, certainly you're a doctor, an internist, but your specialization is a term that not everybody's familiar with, and that's a geriatrician. They may have heard about a pediatrician, but maybe not everybody's heard about a geriatrician. Explain what a geriatrician is. We've got people listening from all over the country. If they wanted to talk to someone like yourself or somebody in their area, how do they go about finding someone with that specialty?
Elizabeth L.: It's great that you mentioned the pediatrician, because just as the pediatrician's a physician specialized for children, a geriatrician is specialized for elders, folks over the age of 65. A physician needs to go back for more training one, in my case I did two years of extra training at Mount Sinai in New York City. I think it gives me the extra perspective on the challenge that we face as we get older, besides making sure we take care of blood pressure and cholesterol and that sort of thing. We also look at function. We look at risks of osteoporosis and fractures and falls. We look at the effective medication and what we need to do to help keep elders more independent and enjoying their life.
Frank Samson: That's great. I'm putting you on the spot there, but do you know, is there a website somebody could go to or to find who ... I'm sure it's not a common type of work that people do, so how does someone go about finding a geriatrician?
Elizabeth L.: You're right. There's 600,000 physicians in the country. Only 6,000 are geriatricians. They tend to be concentrated around universities. If there's a medical school near you, in the school of medicine, they usually have a division of geriatrics. That would be the first place that you might look. Also, accessing the Alzheimer's Association, if someone is specialized for care in dementia, often they have expertise in caring for elders as well, although you are gonna find a lot of people calling themselves geriatricians, including emergency room doctors. It seems to be popular. There used to be 12,000, and now there's only 6,000. I think it's because of the way that Medicare reimbursement works.
Frank Samson: That's a shame, because we need more geriatricians out there, don't we?
Elizabeth L.: We do.
Frank Samson: I know you have specialty in dementia. I want to just hit on some basics, even though we've talked about this several times on the show. We can't do it enough, because we always get new listeners, and they're learning. Before we get into some of the more detailed information, just tell us more about some of the dementia basics, maybe just what is dementia, different types of dementia. Why don't you just give us an overview of that, if you don't mind.
Elizabeth L.: This is a very interesting time. Back when I started training, we thought of dementia as a problem with memory, are you oriented times two or three, do you know the time, the place, the situation. Now we're realizing that your memory might be okay, but it's other parts of brain function that have declined.
Elizabeth L.: Let me describe why this is a problem now. It used to be that not that many people encountered dementia. In the 1960s, the average lifespan was only 60 years old. Medicare was a pretty viable government program, since less than half the people could access it. Now people are living into their 80s and 90s a lot, and the incidence of dementia increases to 30 to 50% when you get into your mid-80s, so we're starting to see more dementia.
Elizabeth L.: The classic view that it's someone who has poor memory, can't take care of themselves, can't get dressed, that does occur with a number of folks with dementia, but you could also have dementia that can be crippling and have your memory okay. You could have a decrease in function of your risk assessments or your judgment or your reasoning.
Elizabeth L.: The different parts of the brain, depending on where you have damage, is gonna determine what kinds of cognitive problems you have. If it's in your hippocampus, which is what hits Alzheimer's the most, it's poor short-term memory. If it is something in the back of your head called the parietal lobe, that is a problem with sequencing and you're not able to recognize that, say, if you sit down to the plate of food, that is a signal for you to eat, or that you should put on your socks before your shoes. It's the order that you do things in.
Elizabeth L.: The frontal lobes are the most challenging in that if you have damage there, then it could either change your mood, you could get really angry, or you could be acting socially inappropriate. You could lose your inhibitions. You could be sexually inappropriate, where someone never would've done that 20 years ago. You lose your ability to judge risk.
Elizabeth L.: The door-to-door roofing salesman says, "Oh lady, you got a problem with your roof." In the past you would say, "Now wait a minute. No, I'm gonna call my contractor and see who he suggests." As your judgment declines, you might say to this person who just knocked on your door, "Oh okay, you can fix my roof."
Elizabeth L.: That's where a lot of the financial elder abuse comes from, either in person, or now, not only can they access elders for abuse by phone, but also by internet. The Nigeria scam. That's a good example of losing your risk assessment in that. I think they still say Nigeria Bank, "Send us $1,000 and we're gonna wire you $1,000,000," I think they say Nigeria because they want to weed out all the people that might be skeptical down the line. I think a lot of people have heard about Nigeria bank scams. It's the loss of judgment. Socially, they can look okay, and that part is the most dangerous, that said. That's the general kind of dementia.
Elizabeth L.: Dementia is not a particular disease. It is a constellation of symptoms, like heart failure. Heart failure can be either from high blood pressure or from heart attacks or that sort of thing.
Elizabeth L.: Similarly with dementia, it can either be from Alzheimer's, which is the protein deposits from the brain, the plaques and the tangles that gum of the works and make the brain not work as well, versus vascular, which is more common with folks with diabetes, which is teeny little strokes that can cause parts of the brain not to work as well, depending on where the strokes are, versus Lewy body dementia, which is associated with Parkinson's disease, and that has more mood lability and delusions and paranoia, or frontal dementia, which is just the frontal lobes don't work well, and you again either have lost your inhibitions and you're acting inappropriate or your judgment is way off.
Frank Samson: That's a great overview. Thank you for that. I guess when someone hears dementia, they think, "All right, no cure," but there are certain types of dementia that may actually be reversible, not many, but is that correct, there are certain types that could be reversible?
Elizabeth L.: If you have memory problems or thinking problems that interfere with your day-to-day care, I'm in that middle-aged category and I'll walk in the room and go, "Wait a minute, why am I here?" or, "Where did I put my keys?" That's not so much of a problem. The problem really comes to you can't function at work, you're forgetting to take your medicines to the point where it's causing problems with your health, you're not making it to appointments, you're changing in the way you interact with your loved ones and others, that you need to have a workup.
Elizabeth L.: The workup includes a scan of your head, a CAT scan looking for little strokes or tumors or something like that or a bleed in the head, and you also need to check the thyroid and you need to check B-12 and folate. If any of those are off, treating those can make your thinking better. These days, anything that you can do to take care of your heart takes care of your head.
Elizabeth L.: Actually, your Boomer audience is the folks who need to be working to decrease their risk of dementia now. When you're in your 70s and 80s, dementia's scarring one way or another. There's not much you can do when you're 70 or 80 to completely reverse things, but if you're 40 or 50 and you're 30 pounds overweight and you've got high blood pressure and your cholesterol and got some diabetes, that's when you really want to be taking the steps to get your weight down, get your blood sugar down, exercise.
Elizabeth L.: Actually, the only proven treatments to decrease the risk of dementia are exercise and then taking a baby aspirin. Any advice I give on this show is just general, and you always need to run it through your doctor. For many people who have cardiac risk factors, taking a baby aspirin can cut down the risk of more little strokes and thinking problems down the line.
Frank Samson: That brings up another question. I know you're very involved and we as an organization are very involved with the Alzheimer's Association and have great respect for them and what they're doing. Their goal is to get a cure for Alzheimer's and various other types of dementia. The reality is that we're probably, unless there's something you can enlighten us on, but the reality is that we're probably a long ways off for a cure. When I say a cure, I'm talking someone who is diagnosed with it, that it's almost like they have a flu and they take some medication and now they feel better. We're a long ways off from that, I believe, based on people I've spoken with. Certainly you can enlighten us on that.
Frank Samson: You started to talk about can it be avoided. Especially the Boomer generation, like you said, you mentioned the baby aspirin. What are some other things that, I'm not sure if they're proven totally, but what are some other things that people need to, should do, to decrease their chances of any type of dementia?
Elizabeth L.: That's a really hot topic these days. There are folks who say they can cure Alzheimer's. They're saying things like coconut oil is a good idea, that there are certain amino acids one should take, certain specific diets, and/or high-dose vitamin C, the chelate mercury. Unfortunately, nothing has been proven in randomized controlled studies.
Elizabeth L.: I think it's important to speak to that a minute, because when studies appear in a journal, you could say, "Oh, okay, if it's in the medical journal, it must be true." There's a big difference between having a case study where the person who is treating is also the person evaluating, such as, "Mrs. Smith was having trouble with her memory and she was at work and she lost her driver's license and then we did this treatment and then she got her driver's license back and she could work again." You need a independent person to evaluate how folks are doing. You need to look at populations from the beginning of the treatment going forward to see if there's really a difference.
Elizabeth L.: A good diet of a lot of fruits and vegetables, avoiding a lot of saturated fats. I think if I was gonna get rid of one dietary item, it would be sugar. I was stunned to find out that Coca-Cola, a 12-ounce can has 12 teaspoons of sugar. Cutting down our sugar, having a good Mediterranean diet, not having as much meat.
Elizabeth L.: It was interesting when Cuba was cut off from funding, when the Soviet Union went down. Their incidence of heart attack and stroke really decreased, because they didn't get as much meat and fat.
Elizabeth L.: We do have evidence of what really can help. It's just not as much fun as taking a pill. We don't have any quick pills, so the Diet Coke and the chocolate cake scenario is not gonna get us through. We have to have our fruits and vegetables and go out for our exercise.
Frank Samson: That's good suggestions. I know you deal, and we as well, but you especially deal with some very, very difficult cases. We've had various people on our show over the course of several years now on various subject matters, and there's various theories out there, and some say don't treat people with dementia with medications, and then there's other theories as well. Then you're dealing many times, in situations which I know you have dealt with, with agitation, where people become abusive to their own family members, and maybe they've never been abusive in their lives at all in their past. We're having to deal with a lot more of that today. It probably keeps you pretty busy.
Frank Samson: I don't know if it's a particular question, but maybe just your philosophy on medications, on family members who are confronted with someone who is becoming very agitated, maybe becoming abusive, how do they deal with that? I know it's a loaded question, but I'll let you try to tackle it.
Elizabeth L.: Actually, it's not. That's what we geriatricians do. I for shorthand call it the geriatric protocol. It actually simplifies this quite a bit. I've definitely seen a number of cases where there's been a struggle for years and years to try and take care of this person and the agitation, but if you use the protocol, it works just about every time.
Elizabeth L.: What you need to do is first you need to get rid of the wrong medications. I was pretty shocked to find that my own father was taking Tylenol PM at sleep. There's nothing wrong with taking a little Tylenol if you have aches and pains. In fact, it's one of my top favorite medications for treating agitation, after ice cream. It's the PM, it's the Benadryl, it's anything anticholinergic that makes people more confused and agitated. Just to iterate quickly, the nerves talk to each other by using choline. As Alzheimer's progresses ... Are you there?
Frank Samson: Yeah, I am here, absolutely.
Elizabeth L.: Great. I thought I might've lost you. As the disease progresses, the nerves die and they produce less choline. If you give these medications, and the most common ones are the antihistamines, the Benadryl, the Zyrtec, and let's see, I don't use these too often, a better medication is Claritin, Atarax is another common one, or Meclizine is used for dizziness, those are all very anticholinergic, or if someone is not sleeping, the over-the-counter sleeping pills really need to be avoided, such as Unisom, again, the Benadryl, anything PM you have to avoid.
Elizabeth L.: The category of medications for, quote, "anxiety or sleep," such as temazepam or Restoril, especially Alprazolam or Xanax, which I found is the fifth-leading prescription in the country, everyone from kids to grandmas getting it. It's like the crack of medicines in the Valium family that are called benzodiazepines, the crack of benzos. It's twice as powerful as Ativan, and it's shorter-acting. It gets people hooked quickly, and then it's hard to come off of. People can be more agitated just within a few hours of getting the dose. It's usually given three times a day. I just saw a woman where they just give it at night for sleep, and she's really agitated by the afternoon and the evening. I have to slowly get her off of that medication before I can help with her behavior.
Elizabeth L.: We get rid of the wrong medications. Then we treat pain. What I'm hearing a lot these days is, "Oh, we should never use narcotics for anyone." I'll get back to that in a minute. They're going to things like Motrin and Naprosyn. I've gotta say, if I have a headache or something like that, I love my Motrin, ibuprofen, but for elders, it is proven to increase the risk of heart attacks and strokes, it can cause kidney damage, it can cause heart failure and fluid retention and GI bleeds. It's not really safer.
Elizabeth L.: What I like is the long-acting Tylenol. People are like, "Oh, Tylenol, you could have liver failure." You definitely should not use more than 4,000 milligrams a day. I rarely use more than 2,500 milligrams. There's this new preparation long-acting Tylenol where you can take one tablet, 650 milligrams at breakfast and at dinner, and that takes a lot of the pain away.
Elizabeth L.: The issue is it's like, "Mom doesn't complain of pain," but if you talk to them it's like, "Yeah, mom had really bad knee arthritis. She was taking Motrin and Percocet before she got dementia, but now she doesn't complain about it," but mom's hitting the caregiver and won't go to dinner, it might be that you need to treat pain.
Elizabeth L.: If the Tylenol doesn't cut it, and there's a medication called gabapentin. There's not great studies for that one, but it has less side effects. Orthopedists are using it to help with arthritis pain and after joint replacements. It can also help with nerve pain. It's cheap. Talk to your doctor about it, again. If that doesn't help the serious bone-on-bone arthritis pain ... Excuse me, you were gonna say?
Frank Samson: No no, I'll let you finish. I just had a followup question. Go ahead.
Elizabeth L.: If that doesn't take care of serious pain like bone-on-bone arthritis, a little bit of, it used to be Vicodin, now it's Norco, a half a tablet a couple times a day. Particularly with my folks with dementia, they don't know what medications are taking. We doctors are charged to, quote, "do no harm." I think it is harm if someone has serious pain and you're not treating their pain but you're giving them Ativan and antipsychotics and such to try and control behavior that comes from pain.
Elizabeth L.: The biggest problem I see with narcotics in elders is untreated constipation. I've seen a couple people who have had such bad constipation that they've perforated their bowels. That is dangerous.
Elizabeth L.: I think we need to make sure we're addressing the pain. Then if people still have agitation, behavioral problems, there are a bunch of other psychoactive medications, where I could probably talk for an hour about just that. At my website, ElderConsult.com, there's a lot of information about, I have a whole page on psychoactive medications, about what they can be used for, and also the most common side effects.
Frank Samson: I'm glad you mentioned that, because I was gonna do that before we ended our show, make sure people know your website. That's Elder Consult, C-O-N-S-U-L-T, dot com. That right?
Elizabeth L.: Yes. What I'm trying to do there is-
Frank Samson: Let me just ask you, because what you just talked about the last couple of minutes was extremely enlightening to me, I've heard certain pieces of it before, but it goes back to the beginning. Here's the thing that makes me a little nervous about all this. When we were talking about geriatricians and the small amount compared to the number of physicians out there, small amount of geriatricians, and I don't want you to knock your peers, but do you think that especially those that are becoming agitated, do you think the doctors are trained enough to be able to give this type of guidance that you've been talking about? Should they know this, or is it a challenge in the medical system, which is having an effect on so many people out there? Hate to put you on the spot.
Elizabeth L.: No no no. I think about this a lot. When I was in training at Mount Sinai, I spoke with Bruce Vladeck, who ran HCVA, which used to be the head of Medicare and Medicaid. I was trying to understand how the funding is. There aren't geriatricians because they don't make as much money as other doctors, full stop. It's not a sexy area of medicine. I think it's the way things should be done. That's why geriatricians are more people that want to help. They're closer to social workers than the cardiac surgeons. We do this because we think this is important work to do.
Elizabeth L.: At UCSF, the regular internal medicine residence, where I was an assistant professor, they get one month of training in geriatrics total. It's not seen to be important. Then understanding the medications is also not addressed.
Elizabeth L.: One other bit I want to put in there about the medications is these poor patients with Parkinson's disease, the medications used to help them move increases dopamine. Schizophrenia has too much dopamine, so people can be delusional and paranoid. They can be having behavioral problems just from their Parkinson's medications. If you give antipsychotics, which can make them less psychotic or delusional and paranoid, it can make the Parkinson's worse. It is important to have specialists that are aware of this.
Elizabeth L.: I think it's a big cultural thing. We're not ready for it. What I'm seeing in the hospitals is they're getting dinged if people stay too long. They get better reimbursements for procedures than taking care of elders with pneumonia. It's a societal issue that we haven't addressed yet.
Frank Samson: Boy, I could talk to you all day about this. Would love to have you back. There's so much more to talk about. Just to give suggestions to maybe family members out there who maybe have a loved one who's recently diagnosed, maybe they've been diagnosed with MCI, which for people who don't know what that is, it's malcognitive impairment, or maybe they've been diagnosed with dementia, maybe early stage, just to make sure that their loved one is on the right track, what do you suggest they do? Who should they contact? Who should they be dealing with? What type of a doctor? Talk to us. Give suggestions to those family members.
Elizabeth L.: For the issue of when to diagnose dementia and protect folks from financial elder abuse, I've given talks at several financial conferences, and I'm saying you need neuropsychologic testing, which is more extensive testing. People are raising their hands going, "We don't have that where we are." It opened my eyes that across the country, if there's only 6,000 geriatricians, not everyone can see a geriatrician.
Elizabeth L.: What I would say is just about everywhere there's the Alzheimer's Association. They are a wonderful resource. They know the resources in the community. I would find a local physician who works with elders a lot. Also, the Alzheimer's Association often has a list of who's most savvy about that.
Elizabeth L.: I would find a good support group, because you can feel really isolated and not sure what to do, and often other families that have gone through can, A, relate to it, and B, be a support and give you ideas.
Elizabeth L.: I think the most important thing for someone who has been diagnosed with dementia is it's not a death sentence. It means that you need to change your approach to life, but you need to still go to church, still be involved with your garden group. You might need someone to drive you there. It's important to stay physically active, make sure you're walking, because actually exercise has been the one thing that has been shown to decrease the progression as well. Avoid those medications that can make you more agitated or confused. Those would be the things that I would suggest.
Frank Samson: Great. Dr. Elizabeth Landsverk, thank you so much. Check out her website, a lot of great information on it, at www.ElderConsult.com. Thank you, Dr. Landsverk, for joining us. Again, as I said, we'd love to have you back. Wonderful information. Thank you all for joining us on The Aging Boomers. Just be safe out there, and we'll talk to y'all soon.