Joey Wahler (Host): It's more important nowadays with people living longer. So, we're discussing primary care for seniors. Our guest is Dr. Pavitri Dwivedi. She's a geriatrician and primary care provider at UM Baltimore Washington Medical Group Adult and Senior Care Team. This is the Live Greater podcast series, information for a Healthier You from the University of Maryland Medical System. Thanks so much for joining us. I'm Joey Wahler. Hi there, Doctor. Welcome.

Pavitri Dwivedi, DO: Thank you so much for having me.

Host: Great to have you aboard. We appreciate the time. So first, at what stage of life or age should someone start thinking about senior-focused care? And I wonder if that's something of a moving target, so to speak, because of the fact that with people living longer. Seventy or 80 or 90 doesn't look the same for one person as another, right?

Pavitri Dwivedi, DO: Absolutely. Well, I'm going to have my bias answer. And I think everyone should have a geriatrician, but the Medicare definition of geriatrics is 65 and older. However, that may not necessarily be true for everyone. Like you said, everyone's needs are different. Every patient is different.

So, I have a practice where I see patients who are 49 and older because there are patients who are in their early 50s, 60s who have a lot of complicated complex medical history. You know, that might need a little bit more wholesome comprehensive approach. So, I think if you are someone or if you have a loved one who may have more medical needs, who may have more hospitalizations and might be looking for that comprehensive approach, you should absolutely seek a geriatrician like myself.

Host: I was going to ask you next, in a nutshell, how would you say senior care differs most from traditional adult primary care? You mentioned the word comprehensive there a couple of times. Is that it? If so, tell us what you mean by that.

Pavitri Dwivedi, DO: So, one of the things that I always talk to my patients and families about And what I hear from them is, "Well, my doctor does not have enough time for me." And I think a lot of us hear that more often that not. So, I feel like one of the benefits of seeing a geriatrician is getting that extra time.

So when I do my first initial established care visit, I have an entire hour. So in that hour, I have my time to not just talk about their medical history, but really understand the patient for all the other things outside of their medical history. So, we talk about the dog that they have. And we talk about, "Hey, where did you go to school? What did you do before you retired? Are you happy with retirement?"

So, I think when I talk about comprehensive care, I'm not just talking about the medical care, but also what makes this person for who they are And what they are. So really putting the patient in the center of the visit, and also including the family and the loved ones who are at the visit. So, it's almost like more of a discussion approach than, you know, me telling them, "Hey, you have chronic kidney disease and these are the medications we're going to do and go see a nephrologist." Like, that's not what we are doing here.

And then, when I see them for a followup visit, again, I have a full 30-minute slot where I can actually take a minute to see if the recommended things from the previous visits were actually completed. And if not, what are some of the barriers that did not allow them to do that?

Host: So you're really treating the patient, not just the condition, as physicians sometimes like to say, right?

Pavitri Dwivedi, DO: Absolutely. And I don't think, when it comes to older adults, you can have a generalized approach. I think every patient truly is unique. Everyone ages differently. Age is not what we see in media or we see in our community or our society. It's very complex. It has its beauty, but it's not a similar trajectory for everyone.

Host: Absolutely. So that being said, what are some of the common health changes that people experience as they move into their 60s, 70s, and beyond?

Pavitri Dwivedi, DO: So, a common term that we use in our practice is geriatric syndrome. So, that is patients start talking about, "Hey, Doc, I just feel like my legs don't feel like they used to before" or "I think my wife is telling me that I have hearing loss, but I don't think I do." So, there's a lot of cognitive changes, there's a lot of sensory changes that are happening. Even the way one may have diabetes versus another patient, it's very different how these diseases present. And everything is almost Interrelated. So, not everything is, okay, this patient has diabetes and that's all they have. There's a lot of loops and there's a lot of factors that go into it.

So, I think, as you get older, things are getting a little bit more complicated, And we really talk about the basics. "Hey, when's the last time you got your eyes checked out, or when's the last time you went to the dentist?" Because these are the things that you don't usually think about. But as you get older, you know, it's almost like there's a cascade of events that keep happening. And a lot of my patients also say, "Hey, I feel like all I do is go to the doctors." And you really want to start focusing on the basics and making sure that we're doing that preventative approach so the situation does not become crisis mode.

Host: And so, when you mentioned this cascade of events that takes place, if there's a lot going on, how can patients and their families know when the time is right to consider a senior care specialist like you?

Pavitri Dwivedi, DO: Absolutely. So lately, I've been seeing a lot of patients who have a great primary care doctor. And a lot of the primary care doctors are saying, "Hey, maybe you should go see a geriatric, maybe this medication list needs to be looked at from a different lens. Or maybe the way your diabetes is managed, maybe we need to see if there's any additional approach that can be taken here to help you resolve this."

So, I always say anyone who has, you know, as I talked about, very complex medical care patients who may need a little bit of extra time, patients who are in that transition of care, where now the families are saying, "This is getting a little hard for me to take care of grandmother. Like, what are my options? What are my resources?"

And I think a geriatrician can help you really identify that. And it's not just saying, "Okay, well, there's an assisted living facility, you should go there." It's, "Okay, well, there are all these options. What's best for you? Where do you see yourself in the next 10 years and the next 15 years? And is this something that we can help you with?" So even after my patients who move into these assisted living facilities or nursing homes, they still come and see me from time to time making sure that, you know, their nutrition is good, their weight is being managed, their medications are getting taken as they're scheduled or is there something that they can come off safely?

So, I think there's a lot of factors that go into these visits. It's not just, "Hey, these are your options. Have a good day." I think it's not as black or white. There's a lot of gray area when it comes to taking care of older adults.

Host: How about the main benefit of having a care plan focused on aging? I would imagine a lot of it just has to do with the benefits that one gets typically from seeing any specialist, right?

Pavitri Dwivedi, DO: So, that's interesting that you brought that up because a lot of the patients, and we're talking about patients in their 80s and 90s, you would think that someone sat down with them and talked about their goals of care or their care planning. But I can say like at least 70% to 80% of the patients that I see for the first time, no one has talked to them about their goals of care discussions or, "Hey, if you were to fall and they call 911, do you want to go to the hospital? And once you get to the hospital, what are you okay with. And what are some of the things that you don't want to do anymore?" And these are pretty challenging discussions. It's not that, you know, you're just not filling out a form and signing it off.

A lot of times, what I do is I say, "Hey, listen. This is what the form is. Why don't you take it home, sit down with your loved ones in your comfortable setting in your home, and you guys can have a discussion," because this might be the first-time they're talking about this, right? And you don't want to do it in front of someone that you're just meeting, even if it's a provider or a physician.

So, I think that allows them some time. And then, once they do that, I have a visit just especially to fill the form out and still have a discussion. A lot of times, they'll check things off and then we go over it like, "Well, it's not what they show on Grey's Anatomy or The new doctor show that's out right now," because reality is very different. And I think it's important to have these tough discussions ahead of time. So, it improves your quality of life that you're not worrying, "Hey, if my mom ends up in the ICU. What's going to happen?" So, I think it really prevents those fears. And it really puts the responsibilities on the family members that the patients truly want to make those decisions.

Host: I'm going to ask you more about family members and their role in just a moment. But first, how can older adults stay independent, which is so important to them, and healthy, of course, for as long as possible? And I wonder as part of it, a big part, what you were just talking about, the fact that sometimes the most important things at these ages are avoided. A lot of it is just accepting how old you are, where you are in life. And that it's important not to ignore things for too long, or they can become more serious than need be, yes?

Pavitri Dwivedi, DO: Absolutely. I can't even count how many times people come to me and say, "Hey Doc, can you just gimme a memory pill?" or "What can I do? Like, is there a magic pill?" There's no magic pill, right? There's all these supplements that are out there. There's these vitamins, and there's no like actual evidence that tells us that they work. Like, there's actually no data showing that, if you take this for a certain amount of time, you're going to be good.

So, I think what I really talk about is where is the patient today? And we can't go back 10, 20 years ago, but what can we do going forward? So, I really talk about the basics. How much sleep are you getting? Do you get good quality eight to nine hours of sleep every single day? If not, how can we help you with that? The next is, "What's your diet like?" Because a lot of times, you know, we say, "Well, eat Mediterranean diet or eat low carb, high protein." But what does that mean for this patient? Is this something that they're able to do? Are they even able to swallow? Or do they have teeth, right? There's a lot of those factors.

The next part is how do you keep the brain active? As we get older, people retire. You know, you're spending a lot of time watching TV. But now, studies are coming out that passive behavior such as watching TV or scrolling on your phone actually increases your chances of dementia. So, what can we do to keep that brain engaged? What are some of the ways you're spending your day? So, I really talk about, "Tell me about your day-to-day." What are you doing?

The next is staying active. There's this recommendation of 150 minutes of exercise. Well, even if someone tells me to do 150 minutes per week, that sounds like a lot of time. So, I say, "Well, did you do today? Well, how did you move today?" So, I think really breaking down things from day-to-day instead of giving generalized recommendations help a lot.

And I think one of the best things anyone can do is staying social. You have to find a way to stay connected to people. That's one of the best thing you can do for yourself. They have enough data which shows, you know, cognitive health and socialization has correlation. And that also is something that they talk about in those Blue Zones documentaries. Go out there, have a community, build a community.

And one of the things that I always say is I ask my patients, "Can you name three people? If something were to happen, who are the three people you would call?" So, I think instead of using these big, generalized recommendations, really break it down for that patient specifically and give them more patient-specific advice and solutions and not just expect everyone to do the same.

Host: Well, you mentioned there, who you're going to call, right? And speaking of that, what role would you say caregivers or family members play in caring for older people, especially when at times tough decisions, as you pointed out earlier, do sometimes have to be made and often as you well know what the patient wants and what their loved one wants for them can be two different things? That's challenging, right?

Pavitri Dwivedi, DO: Absolutely. One of the things I do is when I walk into the appointment, you have to sort of read the room. You know, why is the patient not talking and why is the caregiver making all the recommendations? And is this person fit enough to even take care of the patient or do they want to play that role? A lot of times, my patients will tell me, "Oh, I have three daughters." And then, I ask, "Okay, from the three daughters, who calls you every day? Or Who do you reach out to when you fall down?" Because a lot of times, we assume, like, because there's family, there's going to be support. That's not necessarily true. I think support can be different for different people.

And then, once we identify that caregiver role, we also have to identify, well, what does burden for them look like, right? What does it mean to be a caregiver? Is this something that they even understand? Like, you know, if the patient has dementia, well, that's going to progress over time. And do they have all the resources that they need to feel equipped to help the patient and their personal needs as well?

So, I think the caregiver role changes a lot. It evolves a lot when the patient is living at home versus if the patient moves in with them or if the patient moves into a facility. Because if they're at a facility, then they're playing more of an advocacy role now for the patient. They're providing that emotional support. So, it may not be more hands-on care. They're still very involved being that middle person between the patient and the facility. And sometimes when the patients have to move in with these family members, that changes the dynamics too. Well, where's the patient staying? Are they in a different suite or are they part of the home? How's that dynamic and how's that personalities and all of that working out for both sides.

Host: Then, in summary here, Doctor, you've done such a great job of breaking all of this stuff down in some very effective detail. But what's one overall step that people joining us can take today to prepare for healthy aging? If they can do just one thing, what's job one?

Pavitri Dwivedi, DO: I think one thing you have to do for yourself is accept that aging is inevitable. We're all going to age whether we like it or not. So, it's better to find that doctor that works with your goals of care, that works with your medical history, that has time to look through your medications. And I hope you find that person sooner than later.

Host: Well, folks, we trust you are now more familiar with primary care for seniors. Doctor, great advice indeed for all of us. Thanks so much again.

Pavitri Dwivedi, DO: Thank you so much for having me.

Host: Absolutely. And to schedule an appointment with Dr. Dwivedi or a member of the University of Maryland Baltimore Washington Medical Group Adult and Senior Care Team, please visit the link in the show notes. And to listen to more Live Greater podcasts, please do visit umms.org/podcast as well as YouTube or your favorite podcast platform. If you found this episode helpful, please do share it on your social media. I'm Joey Wahler. And thanks so much again for being part of Live Greater, a health and wellness podcast, brought to you by the University of Maryland Medical System.