Welcome to a seasonal caring podcast where there’s hope for living loving and caring with no regrets. This is Rayna Neises, your host. And today we are enjoying encore episode number two, most listened to podcast of 2022. And that is with Dr. Liz Landsberg. Dr. Liz has been a geriatrician for over 20 years. She’s been the Assistant Professor of Medicine at USC. She trained at Harvard and also was a consultant to the Elder Abuse Forensic Center in San Francisco. With all of her experience, she has put together a new book that she’s just released Living in the Moment, A Guide to Overcoming Challenge and Finding Moments of Joy in Alzheimer’s Disease and Other Dementias. And I’m excited to have her talk with us today and share some of her experiences and a wealth of her knowledge. Welcome today, Dr. Liz. Good to have you.

Dr. Liz Landsverk: 0:55

Well, thank you right now. I’m so excited to talk to someone from my home country.

Rayna Neises: 0:59

I know it’s amazing from Wichita, Kansas. There’s not many people out there who even know where we’re from.

Dr. Liz Landsverk: 1:05

Okay. It’s their loss.

Rayna Neises: 1:07

It’s a great place. A lot of people talk about it, just a Passover lands, but it’s a beautiful place. And we farm the wheat land, just a beautiful place to be. So now in CA.

Dr. Liz Landsverk: 1:19

Big sky.

Rayna Neises: 1:20

Yes, it’s beautiful. You don’t realize how far you can see until you go to other places in the country that you can’t. You’ve been in California for quite a while now. And as a geriatrician share with us a little bit about what you find is most challenging for families.

Dr. Liz Landsverk: 1:37

Well, there’s many things that are challenging, I guess there’s there’s different categories. I think the first challenges are when someone behaviors have started to change, whether they’re in their fifties, sixties, seventies, or eighties, you know, they might get more angry than they mean to, or they’re just not bathing. They’re not taking care of their appointments. You know, they’re having little accidents with the cars. They’re like, oh, it’s nothing, there’s no problem. Or they’re starting to get swindled. You know, that people are calling them and they’re like, oh, I’ll just send this money. And then I’m going to get, thousands of dollars back. And you take them to the doctor and the doctor, does a general exam or listens to them and socially they sound okay. And so you don’t, get a more in-depth evaluation and a diagnosis. And so that person is still at risk. I just saw someone yesterday who basically can’t find your way out of a paper bag. She can’t remember, what medication she takes, what day it is. She doesn’t know what happened the day before. And basically at this point they’re wanting me to do a capacity evaluation. Well, she’s got pretty advanced dementia. Um, But then there’s other people who are like, no, I’m fine. There’s no problem. I have a little Pearl for, those folks. If you have someone draw a clock and have it say 10 minutes after 11, and then have them calculate 25% of $22 and 50 cents. Seems pretty easy when you start to lose your abstract reasoning, which is, sign that the frontal lobes or your judgment is going, that becomes a lot harder. And so when you start to see problems there, it’s like, Ooh, maybe we should go get more of an evaluation. Another problem I see is. If there’s not much money and mom is nasty or mom needs more help or mom’s in a place that’s inexpensive, like an assisted living, but she’s falling. She’s not getting out of bed. She’s not changing her clothes. She’s not bathing. She really needs a higher level of care, a dementia community, or, to be home with family or something. And the family’s like, oh, but we don’t have the money. You know, our mom doesn’t want that, so we can’t make her do that. Well, if someone’s not safe you need to do it. It’s, it’s one of those things. Sometimes it is hard to find a team I’ve given talks to the National Adult Protective Services Conferences. And I’m like, yeah, just go get, a doctor and a neuropsychologist to do an evaluation. They’re like, we don’t have doctors in the area. We have a couple of nurse practitioners. I’m like, oh, wow. So it depends, everyone’s got a county division on aging and they will direct you to the local resources. Also, the Alzheimer’s association often will tell you what the local resources are. I think another big problem is the family conflict. All those things have been brewing for 40, 50, 80 years that really come to for when someone’s failing and there’s money involved. We see that a lot out here.

Rayna Neises: 4:34

It sounds like getting the diagnosis, both for the person who doesn’t think that there is a problem and then also just finding the resources to be able to get that diagnosis. I was surprised I volunteer with the Alzheimer’s association and I was surprised to hear that even when people are diagnosed, 50% of them already been told that they have it. So oftentimes it’s in their records, but they weren’t told that they had Alzheimer’s or were in certain stages. Yes. And so I think a lot of times that communication is a big, big issue. So being able to get the help that you need, as well as get the person on board to get help. And then you were mentioning finances. It sounds like that is a challenge that you run into frequently, someone wanting to spend the money and maybe not having the money.

Dr. Liz Landsverk: 5:26

Right. Yeah, those are, those are the big ones. I mean, that’s not even getting to, what I’m usually brought in for. It’s when someone gets more angry than usual, when they get paranoid, when they, refuse all. And usually they’ve been to the doctor and the doctor’s given them some anxiety pills, some Adavan some Xanax and I help with anxiety and help their sleep. Well, that’s like giving shots of vodka. So basically you’re making these people with dementia, into alcoholics, and then they get, I mean, I’ve worked in city, hospitals and alcoholics, whether they’re on a bender or whether they’re withdrawing, it can be really difficult to work with. And so

Rayna Neises: 6:04

what gets even more confusing is when an elder has got behaviors, either delusions, anger and then how much is the elder and how much is the medications? see that a lot that on top of a lot of doctors are like, well, there’s nothing to do. They have dementia so,

Dr. Liz Landsverk: 6:20

you know,

Rayna Neises: 6:21

sorry,

Dr. Liz Landsverk: 6:23

that’s kind of it.

Rayna Neises: 6:24

So outside of medications, how do we help with some of those behaviors?

Dr. Liz Landsverk: 6:29

Oh, well I think a good way to explain it was one wanted me to come in and treat their mom. The facility said that she was getting angry and irritable and was trying to move around a lot. Well, it turned out they want her to stay in one chair in the same place all day long. And so I told I’m not her. to a better place where they’re going to engage her. They’re going to watch her. They’re going to, get her up and move her around. And they’re like, yeah, we’re not going to do that. We’re firing you and get else to medicate her. But I think, you know, you need to look at, well, what’s going on? Are they too bored? Is there too much stimulation? Are they with like 30 other people? And there’s a blaring TV. Have they been left to sit in a chair all day long? And they’re getting pain, maybe pressure ulcers. Are they wet? Do they not come change them? Are they scared ?Are they delusional? What is going on for the elder? What I really like is, either at home or in a facility where there’s enough staff and elders are engaged with things they enjoy doing. So, I mean, that’s like 80% of it. What I hear and see out here is that there’s a lot of facilities that look like Hilton hotels, but then there’s no staff. So the family like, oh, that looks so nice. There’s no one there, no, take me to one of those rundown places. If there’s people where, the staff are doing activities with the elders and they look like they enjoy being there. And you know, they’re not left to be in bed, to sleep during the day. And they’re up and active, you know, that’s, that to me is a great sign. That’s what I would start.

Rayna Neises: 8:02

And I know with the different types of dementia, that there are definitely some that people have a tendency to be more aggressive with, but majority that’s not a true statement at all. And So many times, like you said, I think it’s blamed on them. Oh, that’s just the dementia when it actually is. Like you said, it’s investigate. I often tell my families that I coach with. You have to put your detective hat and go around and really look at what’s happening to be able to figure out why they’re having the outbursts. I know, as I was caring for my dad, there was always a trigger. There was always a warning before he got upset with me. And once I learned to pay attention to those things, either he was frustrated or like you said, bored. That’s what led to any kind of aggression at all was just not feeling listened to usually for my dad.

Dr. Liz Landsverk: 8:52

That can, that can definitely happen with a lot of people, but there are other ones, you know, where the family is loving and attentive and really kind of, anticipating what’s going on. But the disease makes them just paranoid and angry and nasty, and those people need medication. That is something that I get called for a lot. And the thing that makes me so sad is, there’s a saying that you shouldn’t use anti-psychotics for dementia at all. Well, You shouldn’t use anti-psychotics for someone who’s bored or someone who isn’t sleeping. But if someone is serious to lead delusional, paranoid they think their food is being poisoned. Their spouse is having an affair. You know, someone’s going to try and kill them, or, they’re acting out and being angry at other people are going to hurt other people. Those people should be treated with the more serious psych meds. I mean, if you can give them a little antidepressant, it takes the edge off. Great. But a lot of times you are going to need a little bit of antidepressants, which has its own risks. There’s a 2% increased stroke risk, and 1% increase, sudden death risk or sometimes mood stabilizers like Depakote. And the thing is you can use a small amount of it and take that angry edge off. You’re going to hear, advocates say, oh, you’re just drugging grandma. And that’s never the point. The point is to take the angry edge off. And if someone’s sedated during the day, you’ve got to cut back the meds so that you definitely want to look at the behaviors. And then if you’ve actually worked to support all of that, then you can start thinking about medications not, oh, and that you’ve looked for pain. You know, if you put someone in a wheelchair. They’ve got bad back arthritis. Well, I’m going to be hitting you too. I was like, leave me alone.

Rayna Neises: 10:30

So important because they don’t communicate pain. And I know as my dad’s disease progressed, he really wasn’t able to identify, so you, would ask, are you, is your leg hurting? And he would say no, but then he would limp down the hall and you’re like, okay, something’s wrong? So we’ve got to figure out what it is. And definitely all of us are grumpy when we’re in pain. Right. So it’s not unusual.

Dr. Liz Landsverk: 10:50

Right. My first, my top two treatments for agitation are Tylenol several times a day, every day. And. ice cream, ya.

Rayna Neises: 11:00

I love that ice cream cures, a lot of things. Doesn’t it?

Dr. Liz Landsverk: 11:03

Certainly does well. And, and what you’re going to find is there’s some medications like Motrin, potassium, Aricept, or Donepezil that make you not want to eat. Well, you should get rid of those, but at the same time, if elders are not eating regular meals, I had one guy live on insurance, ice cream for a year and a half. They’re older, frail, and won’t eat, you’re going to die a lot quicker if you don’t eat and drink than if you have ice cream every day. So I’m known for the ice cream diet.

Rayna Neises: 11:33

My dad would be right there with you. He loved his ice cream. We ended up fighting. He was having a lot of reflux issues and we had to substitute a Rice Dream for the ice

Dr. Liz Landsverk: 11:42

Woo. But that sounds good.

Rayna Neises: 11:44

we put some chocolate right on it and he loved it, just like he did his ice cream. So

Dr. Liz Landsverk: 11:48

Good. Well, that’s creative.

Rayna Neises: 11:50

That was his nightcap, every night we had ice cream.

Dr. Liz Landsverk: 11:53

Well, so, and let me say. That’s a much better nightcap than giving alcohol. There’s a lot of people who say, oh, well, mom’s always had her Manhattan every night. And so, you know, I couldn’t imagine changing it. I’m like, well, you really need to. is I don’t want to take away the ritual, but the alcohol causes more irritability and agitation. So you’re just asking for trouble. I’ve been asked to, like work around the fact two or three Valium a day and they have a couple drinks though. We can’t do that, but we can taper it and then keep them busy and then giving them treats, like rice cream sounds wonderful.

Rayna Neises: 12:26

What keeps most families from getting the help that they need do you think, overall?

Dr. Liz Landsverk: 12:31

Well would ask you that, but I will give you my perspective. I think that they might go to the regular doctor and the regular doctor goes, yep. It’s dementia. And here’s some aerosept and that’s all you can do. Or the doctor will say, that’s not dementia, they’re okay, they’re just old. And they don’t really have an idea of where to go next. I mean, I often get called for the people who’ve seen, two or four doctors already and so I think it’s hard to find resources. I mean, our society does not want to talk about being old. Certainly don’t want to talk about dementia. They’d rather talk about supplements to prevent dementia. So there are scammers out there, swindling, I’ve seen there’s this end of Alzheimer’s idea guy where you just do 36 things that’s supposed to cure Alzheimer’s. Well, it doesn’t, I have to take care of these people afterwards and they are charged $10,000 after, six months and with $5,000 with a worthless test and then 30 supplements a day. And it’s, much easier to take a pill than to kind of research as you said, what is the trigger to someone having a difficult time, or what reasoning do they have? Do they understand their finances? Do they understand their medical issues? Can they make those decisions? Should they be driving? So I think it is. And then there are only 3,500 practicing geriatricians in the country of 330 million and our fellowships are not filling up. I think, you know, it’s much more interesting to figure out what’s going on with something when little bits are not working, then just seeing adults with colds and back pains. But a lot of young doctors don’t think of it that way. They’d rather be a cardiologist or a GI doctor and be paid a lot more just to do procedures.

Rayna Neises: 14:21

Yeah, there’s definitely a shortage. I don’t even know that there is a gerontologist at this point around where I live. I know it was something that when my dad was in the Kansas City, Missouri area, when I went looking, we couldn’t find anybody we could get into in less than six months.

Dr. Liz Landsverk: 14:39

Yeah, this is a geriatrician is the medical doctor, like the pediatrician, the geriatrician, the gerontologist is a social scientist, So that people go to medical schools. And if you’re at the VA, you’re probably luckier. So the VA has done a better job of investing in geriatric training then a lot of places. Looked for the memory clinic looked for the geriatric clinic in your medical school, or the VA is what I’d say.

Rayna Neises: 15:04

That’s a great suggestion. Thank you for mentioning that, because I think it is challenging. Number one, to even know that you all have different roles, but number two, to be able to find the one that your questions. tele-health has helped us because there seems to be less barriers in getting to some of the people. Once the initial intake happens. Are you finding that helpful?

Dr. Liz Landsverk: 15:23

I was resistant to that because I like to be there. I like to do the exam. I like to kind of get my sense of interact and he can’t really do that as much but, I started doing telemedicine in California and for the last year I started doing tele-health and, you can do quite a bit. So we, we provide tele-health I’m a geriatrician, you can send labs x-rays doctor’s notes, we’ll have a 30 minute video visit and I will write down report and the the next steps to take your doctor, to help. It’s, it’s been really helpful because often, the big things that I would tell ya Tylenol PM, allergy pills like Benadryl even Zyrtec is not good bladder pills, Detrol Ditra pan not treating pain as a problem use of Adavan and Xanax is a problem. Over-treatment of white blood cells and bacteria in the bladder, just because you have 30 white cells and some bacteria, it doesn’t mean that’s an infection. And particularly you can’t blame all the agitation, sometimes I see it where they keep giving antibiotics, like expecting that’s going to make them nicer and it doesn’t and they keep doing it. And then the poor elder gets the multi-drug resistant bacteria, or they get, a clustered in difficile or a yeast infection. So those, yeah, those are some of the big things that I run into a lot.

Rayna Neises: 16:43

Tell us a little bit more about your book, Living in the Moment and how is it different? There’s so many different resources out there. What made you write it and why is it different?

Dr. Liz Landsverk: 16:54

Well, this is from a practicing geriatricians point of view. So, I’m not the neurologist that’s going to go into the detail of the pathophysiology of how you get dementia. I am here to tell you. What to look for when someone’s having changes and here’s how you do the worker for dementia. It is like what to expect when you’re expecting, except for dementia. It’s kind of step-by-step, from diagnosis to what to look out for, medication wise. What to do engagement wise, what to think about if you have to hire help at home, if you’re looking for assisted living, what to think about with financial or legal situations, what you should do for planning, issues about financial elder abuse. Then a number of vignettes about problems that families have. I find teaching through stories to be very helpful, kind of the interactions and what do I do now? When to think about hospice, kind of from the beginning to the end. I’ve been a hospice medical director as well, and I’ve been boarded in internal medicine, geriatrics and palliative care so I’ve kind of done the whole gamut.

Rayna Neises: 17:57

So offering that beginning to end definitely sounds like it could be helpful for families just to have an idea of where to go and what to look for as they’re going through that. What would you say you think needs to be done differently with dementia in general today?

Dr. Liz Landsverk: 18:12

The first thing is that I think if we really want to do something serious about dementia, we have to do something about the health of Americans, because like 75% of us are overweight. 25% of us have diabetes. You know, there’s a higher risk of high blood pressure, high cholesterol heart disease. Not even looking at the alcohol and cigarette use, but if we had a national program to help provide better primary care to make sure that we take care of these things before they can happen. And then better training for the, the whole health ecosystem to identify it and then understand what the financial risks are. And then to help families figure out how you’re going to pay for support. I think there’s some pie in the sky saying, well, yeah, everyone should have their personal caregiver. And I’m like, yeah, I don’t think that’s going to happen, but what I was thinking doesn’t sound too bad to me is if I had a nice home with like five or six people taken care of by two people that doesn’t sound too bad. There are really bad ones where they just make him sit in the chair all day and that would be awful. Um, but I also work with some particularly, uh, women who are either nurses or just, very good at caregiving. Some nice houses where it’s more homelike and that’s, that’s nice as opposed to being institutionalized, like a nursing home. The other thing I read that hospitals and I just have this knot in my stomach. a lot of small hospitals across the country are closing and I am sick about it. And that’s why I’m trying to have an online platform at Dr. Lewis geriatrics.com. There’s a lot of medical and useful information, and then doing some training for that and then doing tele-health. I am really sad that. It seems that we’re, disinvesting in the health of our more rural community. Which, you know, are the backbone of our society. I don’t have an answer for it. I think I’m distressed to see that medicine has become so corporatized and so expensive and that there’s a lot of people who, you know, they don’t have Medicaid, but they, um, they don’t have enough money to take care of everything they need for themselves, for their health as they’re getting older. And then for their loved ones when they’re old and frail and need support. So. Yeah. That’s a lot, huh?

Rayna Neises: 20:35

It is a lot. I think staffing is the biggest issue. And you’ve mentioned that in multiple different places, both in the facility situation, having enough staff that is trained. Having enough staff at all is a challenge today. Train staff ball game, And I are so many issues with the rural areas and getting the medical help that you need. And it definitely is. Honestly, a lot of it is around not having the doctors to support these hospitals and then the nurses as well as others. So yes, financially, I think it’s a big part of that, but also a lot of them, I know there’s that are closing in Kansas because they don’t have staff. And so it’s very challenging. There’s so much going on in healthcare today that can be discouraging for families. But at the same time, I think it’s encouraging us to get more involved and to really support our elders as they continue to age and we’re talking to caregivers. And so I know that those that are listening to us are stepping up and doing what they can, and I’m always encouraging them to get a team and to bring the extra support around themselves as well. So I think it’s so important to find support beyond just one person trying to do it.

Dr. Liz Landsverk: 22:01

Well, Rayna I mean, what a leader you are to kind of see, see the need and kind of, start rallying the troops, you know, thank you so much.

Rayna Neises: 22:10

Well, thank you. I was a great opportunity to visit with you today. Again, listeners, her book is available on Amazon at Living in the Moment, A Guide to Overcoming Challenge and Finding Moments of Joy in Alzheimer’s Disease and Other Dementias. Dr. Liz, thanks so much for joining.

Dr. Liz Landsverk: 22:26

Well, thank you Rayna.

Rayna Neises: 22:27

A Season of Caring Podcast has been brought to you by Content Magazine. Pre-order available next week. So be sure to check that out at www.Contentmagazine.online. And thank you for joining me. Just to reminder, A Season of Caring Podcast has been created for the encouragement of family caregivers. If you have financial legal or medical questions be sure to consult your local professionals and take heart in your season of caring

*Transcript is an actual recount of the live conversation