Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And in today's episode, Northwestern Medicine Geriatricians come together to discuss age-friendly care and what that really means—how the four Ms, what matters, medication, meditation and mobility, how they guide everyday clinical decisions, and how care teams keep older adults' goals, values, and quality of life at the center of patient treatment.

In this panel we have Dr. Lee Lindquist. She's the Chief of Geriatrics and will be moderating today's episode. Joining Dr. Lindquist will be Alaine Murawski, she's a researcher; Dr. Alex Petrakos, she's an Assistant Professor of Geriatrics. And Dr. Jennifer Woodward, she's an Assistant Professor of Geriatrics as well. Dr. Lindquist, I turn it over to you.

Lee Ann Lindquist, MD (Moderator): Thank you. And I'm joined by some fantastic people here at Northwestern Geriatrics in Chicago, Illinois. And we have some great news. Northwestern Medicine has earned Age-Friendly Care Designation. Woo! Yayas! Yay, Northwestern! Yay, Geriatrics! We here in geriatrics love age-friendly care. We love supporting our seniors and their families. And so, what does age-friendly care mean? What does it mean to you, Dr. Petrakos?

Alexandra Petrakos, MD: You know, I was thinking about this. I think, in geriatrics in our clinic, in our nursing home setting where we practice home care, we always practice age-friendly care. That's what we do. That's why we pursue geriatric specialty. But I think true age-friendly healthcare for me is that every time a patient interacts with a healthcare system. They're experiencing age-friendly care, and that's something that we kind of collectively as a healthcare system can work towards to make care accessible and friendly for older adults.

Lee Ann Lindquist, MD (Moderator): Absolutely. Whether it's you going into an emergency department or if you're going to see your favorite specialist or if you get admitted to the hospital, being treated with age-friendly care I think is fantastic. So, there are the four Ms. Sometimes people throw a fifth M in there. So, there is four M's that we know and love from geriatrics. So, do you have a favorite M?

Alexandra Petrakos, MD: You go first, Jen.

Jennifer Woodward, MD: So, I do so. I'll just say the Ms first. So, there's four: mind, medications, mobility, and what matters most. And my favorite is the mind, or mentation is the other thing people call that. But that encompasses kind of the three Ds we say. So dementia, delirium, and depression. So, it really gets into mood and cognitive impairment. And because I work in a virtual memory clinic, that's really where my interest lies. But I think that those things, our mood, our cognition, they play so well into the other Ms. You know, if we're having issues with cognition, it may factor into our mobility M, it may factor into our medication M. All of these, they just over lapse so much.

Lee Ann Lindquist, MD (Moderator): That's great. That's great. I agree. My favorite M, I love mobility. So, mobility for me, I love getting my seniors up and moving. Whether they're in the hospital, I'm telling them to move around more. Whether they're in subacute rehab in a nursing home, I'm like, "Let's keep going." If somebody asks you to do something, you know, like physical therapy, you say yes, do not decline physical therapy. Always do physical therapy. And I have so many patients that ask me, "How much exercise should I be doing?" And I always say more, which is why many of them hate me. But the more exercise you can do, we really see benefits to staying active as people get older. And when you sit down too much, you just kind of get worse, you turn into fudge.

So, the more exercise we can be doing and even the more exercise we can be encouraging in any care setting, whether it's walking around the floor if you're admitted to a hospital, or encouraging people to walk, you know, to and from clinic appointments depending on where you live. Those are all ways that we can encourage people to be more mobile. And I know one thing that you hear a lot is for medications. We have heard so many times where seniors just say, "I'm taking too many medicines." I don't know if you've ever had family members who've had that complaint. I'll finish. You know, don't worry about it.

Alaine Murawski: I'm sorry. Sorry.

Lee Ann Lindquist, MD (Moderator): So yes, you have had family members. I'll fill in the blank. We're having a good time.

Alaine Murawski: Okay.

Lee Ann Lindquist, MD (Moderator): Our social worker here has had a lot of complaints about people taking too many medicines. But one thing that I think people need to make sure they do, and I'm sure you've encouraged patients that you've known, is to talk to their physicians about whether each medicine is necessary.

Alaine Murawski: Yes.

Lee Ann Lindquist, MD (Moderator): And so, you know, if there's a medicine that they've been taking, you know, since they were 50 and now they're 90, maybe they don't need it because their lifestyles have changed. So, we love de-prescribing, and especially in an age-friendly health system, making sure that people are on the medicines that are the best for them for their age group as well as, you know, ones that are necessary. Because I know among us, we all hate it, we cringe many times when older adults are taking a medicine that somebody gave them that causes confusion, that causes worsening memory loss. And by taking away a medicine, you know, it actually improves their thinking.

So, some of my main culprits are like those sleeper medicines that you see, you know, over-the-counter, like your Tylenol PM, your Benadryl. Those can be so harmful to older adults. And many people think that they're okay because it's over-the-counter. And so, that's medications as well as mobility. That leaves you with the last good one.

Alexandra Petrakos, MD: Right. My personal favorite M, matters most. I don't know. This M has a special place in my heart, I think just because having the opportunity to talk to our patients about what is most important to them. Really, it dictates their whole care plan. And I think, you know, I love being surprised by my patients. We think that we know what patients are going to want. We think we know what's going to be most important to them. And time after time, I have no idea until I have the conversation with them.

You know older adults, it's different than taking care of younger people who are mostly focused on longevity, living as long as they can, trying to stay as healthy and live as long as they can, because there are several patients that I talk to that that's not a priority anymore. And we don't know unless we ask. So, some patients they want to focus on being as comfortable as possible. They want to focus on living to see their grandson graduate from college in the next coming months, or they want to be able to read, you know, their most treasured pastime.

So for me, until I have that conversation and ask my patients what is most important to them, I can't come up with a care plan because the plan has to be in alignment with what matters to them. And we strive to come up with care plans that match our patients' goals. I know all of us here do that. So, I just really love having those conversations and learning about my patients, what is most important to them, so that we can actually come up with a plan that's going to work.

Lee Ann Lindquist, MD (Moderator): And one thing that I've noticed with Northwestern earning the age-friendly care designation is that, in every setting, people are being asked what matters most. Because we have a geriatric emergency department here at Northwestern, and I know we're expanding the emergency department for geriatrics across our health network, which I love. But I love when people get asked what matters most when they come into the emergency room. Because many times people are like, "I want to return home and feel better. I don't want to be admitted." You know, "I just want to be able to make it to my son's wedding," you know, or my grandson's graduation. And I love that people in the emergency department, especially what we call the GEDI nurses. So, the geriatric emergency department nurses, they're actually asking these questions: What makes the most for you? What do you want to do? And I'm sure you've heard people ask about what matters most when you've talked for virtual memory care and for different—

Jennifer Woodward, MD: Oh yeah, absolutely. I think, like Alex said, it's such an important part of geriatrics, it's kind of like the guiding light, the star, like that guides all of our other decisions. Because as we're looking at like mind and cognition, we really want, you know, our treatment to help with their goals and to get them where they're at. So, I think it's really important.

Lee Ann Lindquist, MD (Moderator): And what many people might not realize is that you run a very specialized, awesome clinic. I just love your clinic. It's a virtual memory care. So, you can deliver memory care and you can support people that have memory complaints or they are worried about Alzheimer's anywhere through the entire state of Illinois.

Jennifer Woodward, MD: Yeah. So, our virtual memory clinic is really set up to help improve access. And so, we see patients, we can do evaluation and diagnosis of the different types of dementia. We can do management of dementias, behavioral management resources and support for their caregivers through our social worker. And we can do that all from the comfort of their. So, we do our visits over telehealth. So, they just need to have a smartphone or a tablet or a computer. Family members from out of state can come into the visits. We can connect with them so they can be present. So, it's really helping to improve access to care for patients who maybe have difficulty with mobility or getting in, because they have behaviors from their dementia. So, it's a really nice new, innovative model for care for patients.

Lee Ann Lindquist, MD (Moderator): And I think it's just so fantastic, because we're able to get geriatric care and ask them what matters most and work on the mentation anywhere in the state of Illinois. One of the other things that I'm a fan girl of yours is for your inpatient geriatric consultation and you also have a virtual geriatric consultation in a rural hospital. If you want to talk a little bit about that.

Jennifer Woodward, MD: Yeah. So, partnering with kind of Northwestern to work on this age-friendly care designation, we're doing inpatient geriatric consults. And our consults are seeing older adults and focusing on these four Ms. So, helping patients throughout their hospitalization focus on things. So for example, we see a patient and they say, you know, "My primary goal is to walk my son down the aisle for their wedding." So, we're going to review their medications and take away the medications that might be dropping their blood pressure and causing dizziness. So, we're doing that total comprehensive geriatric evaluation in the hospital setting. And then, we've also partnered with one of our critical care access hospitals in Valley West, and we do consults there for inpatients virtually.

Lee Ann Lindquist, MD (Moderator): I wish we could do geriatric consults all over the world.

Jennifer Woodward, MD: Everywehere.

Lee Ann Lindquist, MD (Moderator): Yeah, just world domination, right? So, if a senior or your favorite senior gets admitted to the hospital, what can their family member do to, you know, get a geriatric consult?

Jennifer Woodward, MD: Yeah. So if they get admitted, they can just ask their primary team that's taking care of them for a geriatrics consult. We would be happy to see them.

Lee Ann Lindquist, MD (Moderator): Oh, that's fantastic. And we're getting a lot. So, I think it's showing a real benefit. And it shows how Northwestern is becoming or has earned the age-friendly care designation. One of the other things here is what innovations or improvements have you seen as Northwestern continues to work towards being a fully age-friendly health system?

And from my standpoint downtown, we have such a great geriatric emergency department. We've got really good inpatient consultation. We've got a home care program. We've got our geriatric outpatient clinic. And I would love if we could take all of these and put them in every region that Northwestern Healthcare exists. So whether it's down coming out of Palos, or whether it's coming out of Central DuPage or, you know, Delnor or up in Lake Forest because we're just starting to spread out. And so, it's great that Northwestern Medicine is really thinking about geriatrics and age-friendly care and putting a major investment in geriatrics. So, I'm looking forward to, you know, how they're going to be hiring more advanced practice nurses to support us in the home care program, in the virtual memory care, in the inpatient. So, what do you think that we could use?

Alexandra Petrakos, MD: I feel like there's been so much growth to your point, and that's so exciting and wonderful. And I do want to see more. I think there's a lot of potential for improvement in transitions to care, which is a huge topic all the time. You know, transitions of care can be quite messy. But they happen all the time. And so, I think having more resources to support cleaner transitions of care and kind of optimizing, having very age-friendly transitions of care, I think would be amazing. And I think that's something that Northwestern is always working towards. It's just that there can always be more work in that direction.

Lee Ann Lindquist, MD (Moderator): Nothing's perfect. I agree with you. So, I'm like, everything that we can learn and kind of like generate more, I think that's wonderful, especially for transitions of care. Because I mean, I've seen so many patients get confused when they're getting discharged and they just need an extra handhold or they need to have a home visit, or they need to have follow-up, you know, virtual care to kind of make sure that things are going smoothly once we get home. Because as much as we like people in the hospital, we like them at home better, because I think everyone would rather be at home than in the hospital. That is for sure. That is for sure. So if you had one message for family or caregivers about supporting healthy aging, what would you want them to hear?

Alexandra Petrakos, MD: I think about having conversations with your loved ones early about what their preferences are so that everyone on the team, everyone can be on the same page as patients age and have more and more medical complications potentially, that we can respect that patient's wishes. I think that having goals of care conversations early and often is a very important part of continued healthy aging.

Lee Ann Lindquist, MD (Moderator): And to build off that answer, here at Northwestern, our research team developed planyourlifespan.org., which I'm biased, but it's an incredible website. Feel free to look it out. And there's no ads. We're not collecting your information and selling it. It's primarily to help people in their 60s, 70s, 80s, 90s kind of plan ahead for what they might need if they ever are hospitalized or if they ever fall or if they ever develop worsening memory loss.

And this kind of goes with the open communication where, you know, what's going to happen to me if I fall and I can no longer live alone in my own home. And so, it actually walked people through. You know, I want to have somebody move in with me if it means I can stay, you know, in my own home longer. "I want to move in with this relative." And many times, we have both seen where the relative is like, "Whoa, I didn't know that was on the list. I didn't know they were planning on moving in with me," you know? And then, "I'd be interested in moving into a senior living community." And it is exactly right that you have to have these conversations with family members, and family members have to have these conversations with older adults so that they do know what matters most. And planyourlifespan.org is an easy way to kind of go through it with your loved one or if you want to as a senior do it, and then pass it on, because you can actually email it to your friends and loved ones so that they can actually see that.

Alaine Murawski: Can I just add one point to that?

Lee Ann Lindquist, MD (Moderator): Yeah.

Alaine Murawski: To add onto that, I think it has to be an ongoing conversation because you might have that discussion. And then, a few years later, that discussion might change or the situation might change. So, it is an ongoing discussion that you should have with your family about what is important to you as you get older.

Lee Ann Lindquist, MD (Moderator): That's awesome. Because we have seen, in our research, we've been following people for like five years now, that people change their mind. And it was fascinating because, you know, before COVID, people were like, "Oh, I could live in a nice retirement community." During COVID, everyone's like, "No, I don't want to be near one." And everyone was like, "Oh, I'm going to live with my relative." But maybe a relative might be getting sick or they're not able to care for you. And now, they're like, "Maybe I do need a senior living community." So, it is returning to them and asking what they want to do and what matters most, even in different care settings.

Alexandra Petrakos, MD: Well, and I love that you mentioned this amazing tool that you guys developed because approaching these conversations can be very intimidating. And it can be almost unpleasant for family members and patients alike, because sometimes people don't want to think about what if these somewhat negative scenarios. And so, having that tool to kind of walk you through it or having any kind of framework or way to approach the conversation is infinitely helpful and makes it much more, I don't know, tolerable or much more approachable.

Lee Ann Lindquist, MD (Moderator): And it takes off the burden from the young ones, the family caregivers, because we've all been involved with seniors that they get admitted or something happens and their thinking is off or something happens and they're very sick. And then, the family member, whether it's a son or a daughter, has to figure out what to do with, you know, their loved one. And they never really received any guidance. And so, they're scrambling to try to find something, find them support. And so, going through something like Plan Your Lifespan, having the discussion about what matters most is a great way of taking the burden off of the next generation.

And in talking about the next generation, one of the things I love—because we're all teachers at some level—is that we're training the next generation here at Northwestern with what matters most and with the four Ms. So, you spend a lot of time with our fellows, with our residents.

Jennifer Woodward, MD: So fellows, residents, medical students. I had a PA student today rotate with us on our inpatient service. And so, we are really focusing on getting them to shift their mindset from a single disease to looking at the whole person and taking into account, like, how do all of these Ms factor into how we're treating their disease. And so, kind of reframing how they're looking at seniors. And so, we're teaching them about these Ms. And then, they can go and teach their other residents and kind of help to better take care of patients,

Lee Ann Lindquist, MD (Moderator): To spread the love of older adult care. And I always laugh because many people don't even realize what geriatrics is. And so, a geriatrician is somebody who has gone through medical school, and then done either internal medicine residency or family practice residency. And we've got internal medicine family practice. Both superstars, okay? There's no difference in my book. Both of them become beautiful doctors who are super smart, and then go on to do an additional fellowship in geriatrics. So, we are the exact opposite of pediatrics. We're on the other spectrum. And we are specialists in the care of older adults. So if you're ever interested in anything that we're doing here at Northwestern Geriatrics, or if you want an appointment with virtual memory care, or if you want a home care visit, or even to see us in the outpatient clinic, the best way to get a hold of us is 312-695-4525. And we'd love to see you and talk about how we can make elder adults' lives better. So, thank you very much. We've got a great team of geriatricians, social workers, geriatricians. Great conversation, and thank you for joining us during our podcast.

Melanie Cole, MS (Host): Thank you all so much for such an enlightening and lively discussion. Thank you again for joining us. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/geriatrics to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.