Medical Issues and Problematic Behaviors Facing Older Adults with Dementia

Welcome to the Living to 100 Club Podcast. Here's our host, Dr. Joseph Casciani.

Hello, I'm Joe Casciani, your host for the Living to 100 Club Podcast. Our conversations are all about aging well and doing what it takes mentally and physically to live longer and healthier. Our guests share insights and recommendations about successful aging, stories of perseverance, and inspiration about our future. Today's program more than meets this goal. We actually are following last week's podcast on modifiable risk factors for dementia. In today's program, we also explore the topic of dementia with our guest, Dr. Elizabeth Lansverk. Our guest is a geriatrician in San Francisco who provides house calls for the most difficult-to-treat behaviors in dementia. Dr. Lansverk has written a book, Living in the Moment, for the care of dementia for both families and professionals. What do families need to know about its progression? How best to communicate with a person with a dementing condition? And what do people misunderstand about dementia? Where do medications come in? Is, and is there a misguided use of nutritional supplements promoting its cure? We'll talk about this and more today. First, a little background. Dr. Liz has over 20 years of experience in providing medical care to the elderly. She's board certified in internal medicine, geriatric medicine, and palliative care medicine. Dr. Landsberg founded Elder Consult Geriatric Medicine. A house calls practice to address the challenging medical and behavioral issues often facing older patients and their families. Dr. Landsberg was an assistant professor of medicine at University of California, San Francisco, an adjunct professor of medicine at Stanford University, as well as consultant to the San Francisco Elder Abuse Forensic Center and hospice medical director. She is currently the medical director for Silverado and Kensington dementia care communities, as well as on a scientific panel for the Alzheimer's Association. Dr. Landsberg graduated from Stanford University and trained at Cambridge Hospital, Harvard University, and Mount Sinai Medical School. As a house calls geriatrician, she collaborates with local physicians to address the needs of complicated vulnerable elders to alleviate pain, agitation, and discomfort through the utilization of geriatric and palliative care techniques. Dr. Landsberg, welcome to our program.

Well, thank you. I really appreciate it, and I appreciate the work you've done. I mean, first in your first career and now in your second career, and they're both hugely important.

That's great. Thank you very much for that. Yeah, I'm glad to have you on this program. I'm looking forward to our conversation. I always like to open by asking our guests to tell us briefly about the journey that brought you to where you are today. You've covered a lot of ground, as I did in the mini bio, but tell us, uh, you know, synopsis of how you got to where you are today.

Well, you've, um, kind of outlined the arc. Um, I started out after finishing my training in academics. And, you know, it was interesting. I enjoyed it, but I found that there were a number of things that we weren't trained to really address. You know, we were limited on what medications we should use. And when I trained at Mount Sinai, I trained with some really good geriatric psychiatrists. And, you know, the biggest problem is that there aren't good studies to tell us what to do. So I wasn't kind of getting to put a lot of that into practice. So I opened up my house calls practice and I haven't had to advertise. I was just inundated with people like, fix my dad, fix Mr. Jones, and here's someone who's going to get evicted. I just took care of someone who was in an academic hospital for 5 months.

Wow.

I mean, so I think I had pivoted. I was like, wow, this is really interesting. And so, I did that for 18 years, and then I was like, yeah, I can do this, but I work with a few hundred families at a time. And now, I want to see, well, what else can we do? So, I'm most interested in having a platform at— I got rebranded as Dr. Liz because no one can say Landsberg or remember Landsberg. So, I'm Dr. Liz Geriatrics, which basically sounds like an elderly sex therapist, but And so I have a lot of good information there. I have blogs, I have videos. I'm on Facebook doing a High Noon with Dr. Liz every Saturday. I'm on YouTube. I have a book.

Yes. Living in the Moment. Yes.

Which is pretty much like What to Expect When You're Expecting for dementia. We're doing training modules for elder care professionals to get CEUs about agitation, about pain, about keeping people moving, about when do you need occupational therapy. What is it? Overtreated UTIs. Just, we're working on many of those. And then we're also doing telehealth, which is the video visits. So I've kind of pivoted and I'm realizing that, you know, this isn't really a Don Quixote quest. This is more a Fitzcarraldo quest of trying to pull the ferry up over the Andes.

Of course.

And I'm not sure it's going to work, but I'm going to try because there's only 3,500 practicing geriatricians in the country. I am closing my house calls practice within 2 months, and I'm only doing telemedicine for the folks I've been working with and then telehealth. So that's where I am. It's exciting and a little terrifying because, you know, in, in the Bay Area, people know me and they know what I do. And so I've been really busy. And out in the big— in your world, communicating to the bigger national and international audience, I'm just this little voice over the side. And sometimes I will get interviewed by the reporter from AARP about the book. And I want to say, yes, I take care of the stuff that's really difficult, like dementia before it gets diagnosed, that most doctors don't want to touch. Financial elder abuse, untreated pain, agitation that's mistreated, and people who've got way too many medications and stuff like that. But they're like, I don't know if we want to talk about this. Let's talk about what brings joy. And so they just make it sound like anything else, like I'm another dementia activities director. And then the article got buried online. You can find it. You just go to AARP, Elizabeth Landsberg, Living in the Moment. But it got buried within 2 days. So, you know, I am very appreciative of the opportunity to talk about the messy— I, I think I've distilled it to let's talk about the messy stuff that, yeah, uh, people suffer with and no one wants to talk about.

The gritty side. Sure. Yeah, yeah. So, um, you're touching a lot of different areas, a lot of different vehicles to provide services, uh, telehealth and writing and your Facebook group and many different avenues. And I agree, there's a lot of voices and we're all kind of, I don't know, kind of singing together. So what do you enjoy? What do you enjoy about this work?

It's just amazing. So I think it's very hard to communicate what we do and why it's different. But I have a video on the website about Bruce. It's easier to find on Elder Consult. But if you go to videos, Dr. Liz Geriatrics. So, Bruce is a great example of what— why I do this. So, he was a man who'd been a very successful executive, but then he had a heart attack and stroke and just got very distressed. And they started treating him with psych meds, and then he tried to jump off the Golden Gate Bridge, and they put him in a hospital.. And then they made the family pay for nursing care 24 hours a day for 2 weeks, which is illegal. And then they just upped his psych meds and then put him in a nursing home. So that's when the wife reached out to me and he couldn't walk, he couldn't talk. He was bedbound and just kind of couldn't even say a phrase. And I looked at the meds and went, this is a mess. And so a lot of times when everyone's anxious or not sleeping, they get Ativan or Xanax. And those medications, you know, I even see academics say, oh, well, you know, you use them when you need to. And I'm like, no, no, no, no, no. So we tapered that and we started changing some of his other medications. And he started eating, walking, and went home. And a few months later, he went on a cruise to Alaska. And then within 6 months, he was back as a deacon serving Christmas Mass.

Yeah, yeah.

So, you know, that's dramatic. But there are so many times when someone's been too angry or they're not sleeping or they're really paranoid and the family's like, oh, you know, we just have to put them somewhere, or they're in a facility, you know, and they just want to sedate. I was thinking, oh no, we, we doctors don't sedate. And then I was talking to a psych resident at one of the academic institutions locally, and then like, yeah, we use the sedating medications. I was like, trying to sedate them. We're trying to take the angry, paranoid edge off so they can enjoy. And that is the message I'm trying to get out. In addition to people like Bruce, who was in a hospital— I mean, it's stunning. He was in the hospital for several months, but they made him pay $50,000 for 2 weeks of care. Outside of the hospital before he went to the nursing home. So his care was probably a couple million dollars. And if someone gets admitted to the hospital for agitation, the average length of stay is 60 days, which is crazy because you and I know that there's this push to get heart attacks out after 3 days, but no one wants those people. And the cost is $600,000. So if you get the meds right, you can cut the stay at about 4 or 5 days. I have several communities that I work with that can handle these folks. Get the medications right, they can be alert, engaged, and calm. I mean, I have one guy who, you know, he's too sedated, but he, if you pull things back, he starts swinging at people and trying to climb over the 10-foot fence. You know, I will get the meds right, but I don't have them yet. So 95% of people can be better. They can be calm, alert, and engaged. I don't cure that dementia unless, like Bruce, it's just from the wrong use of medications. Sure, that can happen a lot. So that's why I do this.

Yeah, yeah, I can see that. Untangling all the complicating factors here and really seeing some successes, some breakthroughs. Just a week ago, I had a psychologist on my program who talked about all these modifiable risk factors for dementia. We know there's primary degenerative, but there are secondary dementias. And many of these causes, like medication or nutritional deficiencies or other factors that can mimic the confusion and behavior, aggressive behaviors and disorientation. So, it sounds like you're doing a lot of that yourself with these different cases and really helping to untangle the complicating diagnoses. Yeah.

So I look forward to seeing the program on preventing dementia. I mean, I'm disappointed to see that there are some doctors who have kind of cashed in and have tried to tell people like, oh, you will cure your dementia with turmeric or K2, or take all these supplements. And out in this area, they've got people thinking that they have to spend $10,000, $5,000 for all these blood tests that really don't affect outcome. And then I've had patients being given 30 supplements a day and then going to see these expensive functional docs to look for the root cause. When basically, if we had a plant-based diet and took care of our blood pressure, our blood sugar, our cholesterol, our weight, didn't smoke— actually, unfortunately, resveratrol is not a treatment for dementia, so we have to very much limit alcohol. And then exercise 30 minutes a day, we can cut our risk of dementia by 50%, which I think is fabulous since my mom had dementia in her 60s. So I'm like, cool.

Yeah, yeah, yeah. I've seen that. I've seen that same research. Lancet Commission out of the UK is showing 40% of these are dementia cases are preventable. Yeah. With these lifestyle factors that you described. So when we do have a legitimate, not legitimate, but when we do have an individual who presents with different symptoms. What should families know about detecting dementia? What do you—

That's a very good one.

Yeah.

You know, so the quickest way that I look at people is I look, I listen to the symptoms, and then I look at their medical problems, and then I look at what medications they're on. So like if they've had head injuries, if they were a boxer, if they were a football player, if they'd been in a car accident and had a head injury, if they fell and hit their head. You know, those are the sorts of things that I worry about. The medications can often make people look worse, particularly any sleeping pills, whether it's over-the-counter Unisom, Tylenol PM, or anything like Restoril, Ativan, Xanax. All of those can make people, you know, misperceive what's going on, make them more irritable and agitated. Even antidepressants, sometimes Paxil. So, all of this stuff is on my website, drlizgeriatrics.com/medications, and in the book and those sorts of things. But I make sure that the medications are taken care of correctly. And then, you know, I'll do the screening. And this is where you come in, you know, the Mini Mental Status Exam, the 30-point question of, you know, what's the date today? Where are you located? Do this 3-step You know, proceed, uh, task.

Yeah.

And then, you know, write a sentence. So that's a screen. Um, or the MoCA is even better because one of the changes is that you have a field of letters and numbers and you go from a letter to a number to a letter to a number. So it's a little bit more abstract. What I've seen is talking about like financial elder abuse, the misunderstanding that, you know, it's not a hard and fast test. That, you know, I've seen even in academic review books that if you get more than a 24 out of 30 in a mini mental status exam, you don't have dementia. Well, as you know, that's not exactly true. You could have a 30 out of 30, and if you have damage to your frontal lobe or your risk assessment area, the frontal temporal area, you could lose all your money because you've lost your risk assessment. And that's when you need neuro— geroneuropsychologic evaluation, which is, you know, more in your wheelhouse. You know, that's 4 or 5 hours worth of detailed work to really know what's going on. The caveat I see there is that sometimes I've seen these people go through like the academic interdisciplinary team and they have, you know, 5 different disciplines talking about this person, but they haven't cleaned up the medications first. So I think the first thing I would want to do is clean up the medications, do the, you know, do the evaluation, check for thyroid, B12, folate, and head CAT scan at least. So, you know, if it's a stroke or if it's a head injury or if it's a tumor, you want to know those things. And then you figure out where you are. And sometimes you can find that through the Alzheimer's Association. That is something that I will be doing as telehealth. I won't be the doctor, but I will do a geriatric assessment to give to the doctor. So, you know, there's I see a lot of hesitation from doctors being scared to say something that might get them in trouble. So a lot of times the doctor won't help out, which really leaves the elder vulnerable to financial abuse and the family kind of high and dry. It's like, well, you know, Mom's driving and she can't remember paying her bills and she won't let anyone help her. And like, what the hell do we do?

Sure. What about some of the signs, clinical signs of forgetfulness or language problems, word finding? Do you, can you?

If someone, you know, like I'm over 50, I can't remember all the movie stars and the rock stars from my youth. Sometimes when I'm kind of multitasking and I walk into the room, I'm like, what the hell? But I can get my work done. I make it to my appointments. I pay my bills. Those are the big things. If you start not remembering people close to you, not remembering your way to church, if you go to church every week, you know, things that you should be able to do. If you're an accountant, if you can't do simple math, if you find people, you know, a quick and dirty test that I do, because I think, as you know, the way that we miss dementia is someone socially sounds okay. So the doctor kind of says, you know, how's it going? Oh, fine. Any problems? Anything? No. Is there anything you're worried about? No, I'm doing fine. I'm driving, I'm, you know, taking care of my bills. I'm doing everything.

Yeah.

And so one of the things I do is have them draw an analog clock and say, make it say 10 after 11. Or actually, a neuropsychologist says 11:10. It's like, okay. And there it's a bit more abstract because sometimes they're like, Where do those two hands go? Do they go on the 10 and the 11? You know, to get it to the 2 and the 11 is a little bit more abstract. And then I have them calculate what's 25% of $22.50. Again, not really hard. And I use this as a way, you know, it's not the Mini-Cog. The Mini-Cog is to be given three words to remember, to draw a clock, and then remember those 3 words. And that's got a pretty good sensitivity. I like doing this because if someone can't— and definitely, I want your perspective of it because this is more your wheelhouse again. If someone can't do a simple calculation, then they're not going to know if they're being swindled with a reverse mortgage or if some stockbroker is wanting to put them into something risky. They're not going to be able to check check the math. And so I often do those. And then I— the other thing that I ask is, because some people get their back up if you start asking the straight-up Mini Mental Status Exam, they're like, I don't need that, I'm fine. So I often teach them, you know, 4 things we can do to prevent stroke, you know, take care of your blood pressure, sometimes take a baby aspirin, increase your exercise, you know, don't smoke. And then we'll talk about something else and I'll say, okay, so what are 4 ways we can cut down the risk of stroke? You know, if they can't tell me anything, that's concerning.

And then I—

it makes it easier. I— and I'm not a psychologist. I'm a bit of a chicken. I'm not great with people with early dementia. And there are some people who are wonderful, who are really empathetic and kind of can talk about it really directly. I feel kind of uncomfortable. I mean, my mom had it and, you know, I sometimes worry about myself. And so I don't talk about dementia because people tend to get defensive. I talk about looking for little strokes. Because that's not as threatening.

That's good.

But the outcome is the same. And if someone can't do these things, I don't say you've got dementia, this is a problem. I say, oh, you know, parts of your brain are working because it's true, because socially we can have an interaction and, you know, they can sound very in control, but then they can't take care of the details. And so I say, you know, I think there's just some areas that you need, you need help with the details. So we, you know, I say, you know, and driving's one of those. And so I think it's a good idea to get a driving test because I'm a mandated reporter and I'm going to report them. That is hands down, if you're going to do something, you take away the guns, you take away the car, because those are the two ways that someone can get hurt and you'll be liable. And, you know, God forbid someone can really get hurt or die. So, you know, those are my first criteria.. And then I'm like, you know, to really detail what's going on, I think we should get some more in-depth testing to see what's working and what you need a little help with. And so I find that that works for me.

Sure. Yeah. So there's, I like that expression about your, you know, maybe little mini strokes and, you know, your brain's not working so well. It could be a vascular dementia or it could be just a kind of primary degenerative dementia.

Right. But I find people are like, I don't have dementia. You know, so I—

A lot of denial. Yes. Yeah.

That's how I approach it. I mean, you know, I'm, I do my best.

Sure.

Yeah.

So a family member that's concerned, adult child, son or daughter, seeing dad maybe getting lost when he goes out driving or can't find the car. That's a concern. I mean, maybe a single event, not so much, but a pattern. Yes. If there's a pattern of these events, or someone was defining the difference between can't find your car keys versus not knowing what the key is when you're holding it in your hand.

Well, there's that, but then there's a lot of people who are in the gray that might have a fender bender here, or they might get lost. No, they're like, no, I'm fine. Or they might graze something. And the other things that I try and do is like, you file down the key, you pull the spark plug. I mean, aren't there any spark plugs? Anymore. You, you say, oh, the car has to go into the shop. Yeah, but I had one woman where they, they did that, and then she looks so good she, she couldn't remember from one day to the next. She was in her 60s and had alcoholic dementia. She slipped her caregiver, she took a cab, she went to the rental agency, and they gave her a rental car.

Of course.

Oh, you know, you got to be creative and you got to be—

yeah.

You got to be ready to be flexible.

Do you think the different types of dementias really matter? Early stages, frontotemporal versus vascular?

Very much. Very much. I think vascular is more difficult to work with than Alzheimer's generally, because particularly vascular, you know, people with Alzheimer's kind of get a little more fuzzy and a little bit more withdrawn. And they might not be as interested in their family or their hobbies and those sorts of things. And I found that it's easier to get them into a day program. But people with vascular dementia, they're like, I'm not going in with those people. They're crazy. I'm fine. And they're the ones who are going to be at home and go, I don't need any help. Where the daughter is spending all her time making sure that mom has food that's already cooked because mom can't cook anymore, mom can't drive. But she doesn't want anyone else but her daughter. And she's like, I'm fine. I don't need any help. I'm not going to have a caregiver. I'm not going to go anywhere because she's got her daughter. So that's tough. Then there's the Lewy body dementia, which is— there's different flavors of tough.

Sure.

Which makes it more interesting. The Lewy body folks can look okay, but then they can get paranoid and angry and accusatory, particularly if you give them anticholinergic meds. It can make it worse.. And they often have Parkinson's. The Parkinson's meds can make them more delusional and paranoid. And so kind of teasing things out, what I like to do is cut down all the medications first and see what's left over before we start putting on medication to treat agitation. There's the frontal dementia, which is fascinating in that they have good, good memory but have lost their judgment. There's a primary progressive aphasia where they start to lose their ability with words, which is easier to see. But it's the loss of judgment and risk assessment that, you know, can really send families and providers around the bend because someone can, you know, socially sound fine. I had one guy who the daughter was having a tough time. He was in assisted living. He was being sexually inappropriate. He was stealing. He was going out and getting drunk. He used to be like a straight-laced engineer. And the doc, you know, he went to his doctor and said, I want Viagra. And he looks so good. The doctor gave him Viagra. It's like, oh, that's No, that's not what this guy needs. And then we went to court. You know, I'd done the evaluation. He just— and I said, Joe, you know, you don't have Alzheimer's, but you have trouble with impulse control. He's like, yeah, okay. And so I was trying to tell the, you know, the court-appointed lawyer, don't say dementia, say impulse control, because that's pretty much what, you know, frontal dementia can be, where you've lost your judgment, you've lost your risk assessment. And you're just all over the place and you need help putting that together or keeping that contained so you don't get swindled, so you don't get hurt, so you don't hurt someone else. And so in court, the lawyer said something like, so, Joe, you know, do you admit that you have dementia? And I'm like, oh, he goes, I don't have dementia. I'm like, call it impulse control. Anyway, he, um, he, uh, wasn't conserved for a couple more months, and then they finally, you know, they did more testing and finally figured it out. So, it's pretty fascinating.

Yeah, yeah. Denial is a big part of the picture, right? I mean, very difficult, and it's very easy to mask the underlying cognitive decline. I mean, as you say, they're very socially appropriate. Someone with Alzheimer's can say the right things on the surface, but if you scratch a little bit below the surface, you see that there's there's a lot of loss.

Well, and the thing that I often hear from families is, you know, dad's being such an asshole, he's just being difficult. And I think what I see a lot is they're not aware of it. I mean, if particularly if they have like vascular dementia, they think you are the problem because they have anosmia, or the, um, as Rumsfeld says, the unknown unknowns. They're not aware of what's not working. And so I try and work around it, and I kind of go where they are and talk to them about the things that they can relate to and just talk about, you know, a little help here and a little help there. But, you know, you've been a very strong, you know, independent person, and we want to, you know, support you in that.

You mentioned the push for, or the press for nutritional supplements and a lot of recommendations for different drugs, or not drugs, but different supplements, nutritional supplements. Are there any that help, or can they kind of minimize these symptoms? We know they're not going to reverse them, but can they minimize them?

So like the latest craze is the microbiome and leaky gut. You know, when I heard several MDs making hay on basically what you need for a healthy microbiome is plants. You just need fiber. You don't have to buy psyllium. You don't have to buy probiotics, prebiotics. And I think some doctors try and scare people, MDs, I'm saying, into thinking, just to thinking, oh, I'm going to have poop in my blood. How gross is that? And I need to have this to protect it. And it's not fair. So B12, I've seen thyroid. I've seen the issue with turmeric and omega-3s. Those decrease the risk of stroke. But if you're already like my dad was going to take turmeric and he was on warfarin, I'm like, Dad, don't do that. You're more likely to bleed. Stop it. So basically, no, the folks I look to are the Shirzais because they have the actual medical studies that have been done. You'll see that a lot of these doctors selling supplements don't have randomized controlled trials that have been published in medical journals. There's one doctor who has some 36-point plan and basically says, like, Mrs. Smith had a job and was driving, and then she got dementia and she couldn't go to her job and she couldn't drive. And then she did my plan and then she got all better and she went back to— and it's like, that's not a study. They talk and say that they have published studies. Well, they have descriptive, but it's described by them. And I am offended. You know, we have taken an oath to do no harm. I'm offended in taking advantage of people in a situation when they're very scared and selling them magic beans instead of what can help, you know, of a vegetarian diet and exercise. So there is one other area that I see that I wish we doctors would do differently. It's the agitation in dementia. You know, I'm sure that you probably saw that a lot in the facilities. And the thing that's so heartbreaking is that if someone's in the hospital and they got delirious, and there's a big debate on whether you should use antipsychotics. So delusions and paranoia are called psychosis, and antipsychotics used to be really horrible, used to be held all— I've seen a few people like on Stelazine or Thiothixene and Trilofan. Not too many anymore, but now it's Risperdal, olanzapine, or Zyprexa and Seroquel are the common ones. But if anyone's been on that in the hospital because they've been delirious, and actually antipsychotics can help clear the delirium if you take care of all the other stuff. The nursing homes don't want them because they get a black mark for anyone who has antipsychotics.

Sure.

And assisted living doesn't want them because they're like, ooh, you know, they're going to be a problem. No one takes these people. It's just, it's heartbreaking. And, you know, if I find I spend 40% of my time taking people off sleeping pills, you know, the Ativan, the Xanax, because they start, you know, giving it occasionally and then people become tolerant to it. You know, you can probably get away with taking Ativan a couple of times a month and not get in trouble.. But if you start taking it a couple of times a week, then you start— particularly elders with dementia start withdrawing. And then they're like, oh, well, we better give it every day. And then they keep giving higher and higher doses. And then you made a whole mess just from that. I've seen problems from not treating pain, you know, and treating pain even from some fractures with Ativan or mood pills, you know, because of the agitation related to the pain instead of treating the pain. And this fear of narcotics for anyone. I will say that I am disgusted that there are doctors that will write out scripts for 150 Norco or OxyContin or who are just paid to give out these pain pills. And those people need to be shut down.

Sure.

What I often see is bone-on-bone arthritis on someone who's got moderate dementia, who really can't go through a big surgery.. And so they give them Motrin or Naprosyn. Those medications increase the risk of heart attack, stroke, kidney failure, GI bleed, hypertension, and heart failure. And so I start with Tylenol, you know, several times a day, but then I'll use a half of a Norco twice a day for serious pain, you know, bad arthritis pain. And often if you take the pain away, you don't need the psych meds. So I'm really upset. And I hear a lot from academics that, no, they become tolerant, so you can't do that. Well, that's not true because I've got elders that have been on it for months and years. They don't know what they're on. You know, if they get sedated or they don't seem to need it, I always try and take it off and replace it with a little Tylenol. But I'd much rather treat agitation by treating the pain than try and treat the pain with the psych meds where I'm just sedating them and they're still in pain.

Don't you get the treating the agitation, sometimes you get the paradoxical effect, so it increases that restlessness, the akathisia. Does that— do you see that?

So Risperdal affects her Haldol, Cymbalta, you know, this phrase about using Cymbalta for pain because they're trying to avoid narcotics. But I see it amping people up. There's a serotonin reuptake inhibitors and then the serotonin norepinephrine reuptake inhibitors. And those are, you know, someone is calling like Effexor rocket fuel, and that's similar to Cymbalta. So you can overstimulate people. So there is a paradoxical effect, but with the benzos, the category of Valium, Ativan, Xanax, Klonopin, is more that they start taking it more often. And it's the— with particularly like Xanax is the crack of those pills where it's shorter acting and twice as powerful. And so you can start withdrawing between doses. So I think I— my experience has been occasionally it's paradoxical where you give it to them for the first time, they get more agitated. But more commonly is they've been getting it for a while. I had one lady who only got Restoril, which is a sleeping pill in that category, for 3 nights in the hospital. She had dementia. I'd gotten her meds all settled out. I had to take her off Cymbalta, and then she got discharged. They just stopped the sleeping pill. She was raving. She was delusional. She was paranoid and very much awake at midnight. I had to go over there. It was from the withdrawal from the sleeping pill from 3 days.

Wow.

So you slowly have to get them off. And that's been my practice, is I slowly get them off. And sometimes it can take 6 months to a year if they've been on a lot of medication. And so those are my biggies. That's what I've been doing for the last 20 years.

Yeah, you've been immersed in that. So what do families do if they're looking for a specialist, someone like yourself with those kind of skills to untangle all the medication mixes and undesired side effects. I mean, where can they go? Where do they find someone? As you mentioned, we're shortage of geriatricians. Geriatricians have been short. Yeah.

Yeah. So I mean, even in our area, there's just a shortage of primary care, which is heartbreaking because that's where I started. I would say look to medical schools, to the geriatric division. Call the Alzheimer's Association. Actually, surprisingly, the VA has done a better job of collecting geriatricians. So, if there's a geriatric clinic at the VA, that's a good idea. You know, then I've got my book, I've got my website. We do telehealth where I can give a geriatrician's perspective to bring back to your doctor. And, you know, I'll opine about what I see for cognitive function. And say, well, I think you might need X and Y. I mean, I don't overreach. I'm like, if there's concerning things, but it's not really clear, I'll say, I think it's good to get neuropsychologic testing. Or, you know, more often it's like, I think you ought to stop the bladder pills are really anticholinergic. I see a lot of women on those. Detrol, Ditropan, Sanktura, Vessicare, you know, or allergy pills. Zyrtec is not safe. For elders. So, um, those— okay, that would be where I'd look.

That's helpful. Thanks. Um, we'll get to, um, the context, uh, in a second, but tell us about your book, Living in the Moment. How do readers benefit?

Yeah, well, it's pretty much like What to Expect When You're Expecting, and I've read The 36-Hour Day. Um, this is more user-friendly. This is Yeah, like what to expect when you're expecting, starting from the beginning when you start seeing changes in behavior but don't have any diagnosis, what to think about, what is dementia, what kinds of dementia are they, what parts of the brain affect what function. And I have lots of little stories about family interactions and, you know, to kind of illustrate the points that I'm making, talking about how to do the workup, what they should be doing. That you can't just do a quick mini mental status exam and say, oh, that's dementia, and that's all you get. Good luck. Basically, I talk about the different medications that can affect cognition and well-being. I talk about a lot about behavior problems and how to address those. Then we talk about the coping day to day, how to how to think about caring for someone with dementia, where to look for help, techniques to use, when to think about assisted living, how to look at assisted living. I mean, I see so many times when if it looks like, you know, a Hyatt, people are like, cool, I want mom there. And I'm like, no, no, no, no, no. You know, you need places where, A, you see the staff. There's someplace where I can't find any staff member. Bad idea. Where the staff are engaging with the elders. Where they're not lined up watching a screen and where the staff is available to you. So, those are the things that I like. And then we talk about advanced care directives, setting things up financially, and then finally talking about hospice, what to look for in hospice. And there's a more recent development. I think private equity is buying up a lot of hospice, so you got to be careful. I didn't know that. That they're trying to cost cut a lot. And I talk about, you know, what you should expect from hospitals.

What a great resource. What a great resource. You've got it all there. Living in the Moment. It's available on your website and on Amazon.

Available on the website, Amazon, IndieBooks, Barnes Noble, Target.

Yeah. And your website is drlizgeriatrics.com or elderconsult.com or both.

Dr. Liz Geriatrics. I am retiring Elder Consult because I'm retiring doing house calls in person. Although I'll be doing telemedicine visits, and then I will be doing telehealth.

Great, great. So, drlizgeriatrics.com. Well, it looks like we're out of time for today, Liz. Before we wrap up, I just want to remind our listeners to visit my website, livingto100.club, sign up for our email list, and download a free copy of my 9 Tips to Make Living Longer Enjoyable. While on the website, be sure to peruse our library of blogs and podcasts. And finally, if you're interested, reach out to me to schedule a presentation for your group in person or online. I think there's value in helping older adults feel inspired about their future. So, Elizabeth, thanks very much for being a guest on our show today. I really appreciate it. I know our listeners appreciate it as well.

Well, thank you. This has been terrific.

Great, great. Yeah, you're welcome. And thanks to everyone for listening to our program. Hope to see you next time.

Hey everybody, Jared Sebaste here, host of Retire Repurposed. This podcast is dedicated to help people transition into fulfilling and purposeful retirements. Retirement is a big life change. In fact, the two most dangerous years of a person's life are the year they were born and the year they retire. Few people could just flip the switch from working a career 30 or 40+ years, retiring on Friday, without methodical steps to living what we call a repurposed retirement. To listen now, search Retire Repurpose on your favorite podcast platform, Senior Resource, or Life Audio.