The future of geriatric care
34:49 Share

This is Stanford Engineering's The Future of Everything, and I'm your host, Russ Altman. I thought it would be good to revisit the original intent of this show. In 2017, when we started, we wanted to create a forum to dive into and discuss the motivations and the research that my colleagues do across the campus in science, technology, engineering, medicine, and other topics.

Stanford University and all universities, for the most part, have a long history of doing important work that impacts the world. And it's a joy to share with you how this work is motivated by humans who are working hard to create a better future for everybody. In that spirit, I hope you will walk away from every episode with a deeper understanding of the work that's in progress here and that you'll share it with your friends, family, neighbors, coworkers as well. Peace.

People are getting diseases all across lifespans. It's just how we think about it. We tend to more maybe expect it. Oh, I'm getting X because I'm old. It's what happens. Our body falls apart. But

that's not what I say. So to all my patients, regardless if they're 92 or 35, it's not necessarily your fault. We're trying to understand it. And I have had the experience of learning from so many of my patients over the 25 plus years that I've been a geriatrician that you can overcome so much no matter what age you are. And you will defy even more expectations if you happen to be 95. Music

This is Stanford Engineering's The Future of Everything, and I'm your host, Russ Altman. If you're enjoying the show or if it's helped you in any way, please consider rating and reviewing it. We love to get a 5.0 if we deserve it. Your input is extremely valuable and will help us spread news about the show across the internet.

Today, Deborah Cotto from Stanford University will tell us about the medical specialty of geriatrics. It's very important, it turns out, that both you and your physician don't just blame aging on your medical problems, but get down to the bottom of things. It's the future of geriatrics. Before we get started, a reminder to rate and review the show, particularly if you have found it useful or interesting.

Well, we're all getting older, and as we get older, it seems like we get more medical problems. There's a specialty in medicine, geriatrics, which are doctors who take care of the elderly, and they have a special challenge. After living on the earth 50, 60, 70, 80 years, things accumulate. But you don't want to just blame aging for all your medical problems. And in fact, this can be a failure mode for both patients and their doctors.

Geriatricians are trained to get to the bottom of things and to not assume that it's just your chronological age that has caused you to get cancer or back pain or muscle spasms or anything. Well, Deborah Cotto is a professor of medicine and epidemiology and population health at Stanford University. She's an expert at gerontology, the study of aging, particularly bones and how they relate to your sleep, to your vitamin D and calcium levels, and to your

and to many other aspects of your health. Deborah, what led you to focus your professional work on aging and the elderly? I have to think about the seminal moment, and it actually was when I was 10 years old. My mother was PTA president, and as part of that, she organized our classrooms to go to a local nursing home

where the students would get paired with a nursing home resident to help them with a weekly art project. So I developed a relationship with one of the residents. His name was Ralph. And it was a very pleasant relationship.

I really liked Ralph. I think he had probably some dementia and I helped him with his art projects. And one week I returned, but as I was trying to follow the directions on how to help him do the art project, I made a mistake. And I yelled in the art room, Ralph, I'm getting as senile as you are. Oops.

So the day went on and my mother, upon driving me home, dropping off all the other kids, says to me, do you realize what you just did? Which I had not until she pointed out to me and I was horrified that I was ageist at age 10.

And I think the rest of my time, I was not really encouraged to pursue aging or geriatrics in residency. The chief resident told all of us in the room, don't bother to study for the MKSAP in geriatrics. That's the study guide that a lot of internal medicine doctors use to pass the internal medicine boards. And he said, all you need to know is that older people fall down and

become incontinent and they get demented. Oh, isn't that lovely? Yeah. So I actually followed that direction because you have to read a lot to be able to pass the boards. My score was 4%. And I think even before that in medical school, when the internal medicine doctor was trying to encourage people to pursue internal medicine as a specialty, said, don't worry, you're not only seeing old people.

So there was a lot of negative bias that I was picking up. And I think that at the end of the day, I wanted to really reconsider

our attitudes and that old people are people too and deserve respect and dignity and care. So I think that's what got me there. It's a great, it's a great origin story. And there's so much in that story in terms of what Ralph was experiencing, what his caregiver was experiencing, and then your journey. Okay, so let's, let's do some basic definitions. I think

many people are familiar with geriatrics. Those are doctors who take care of the elderly. And you've written about there's a difference between geriatrics and gerontology. And you actually do both. So can you just give me a quick set of definitions? Sure. So gerontology is the study of aging, the process of aging from ageing

a lot of different ways, social, psychological, medical, health policy wise, whereas geriatricians are clinicians. They are trained to care for older people as they age, to keep them as healthy as possible.

So how would you characterize our understanding of aging? I'm, you know, we all, I think everybody knows that the population is aging in the U S and, and globally in many places. Um, and, and that we need to understand this process because many, many of us have family members or friends who are reaching into their eighties, nineties. I mean, I spent the weekend with a, with a 90 year old, uh, who, you know, beat me at bridge. So what, what is the issue? Um,

And where are we focusing our attention in terms of learning more about taking care of the aging population and the elderly specific individuals? Yeah. So it's interesting because it's a semantic thing. If you think about aging, I think most people focus on old. But in fact, we begin aging almost upon conception, right?

Right. But we don't focus on it because development and growing, that sounds positive. But as we get older, it's it's it's I think most people consider it a natural and universal process. But it has been over decades since.

kind of made equivalent to loss, loss of physical, mental health. Yes. It doesn't necessarily need to be that way. But I think that's what all of us kind of think about. And then we think, oh, well, then what happens next? You know, you kick the can, you know.

So do we... And yet, I know that when people come to you, I'm guessing, and this is part of this is from personal experience, just stuff happens. You know, things happen to me at my age that weren't happening to me 20 years ago. I've learned that I can wake up in the morning with a random new problem that didn't have... At least I wasn't aware of when I went to sleep, and now I'm waking up. And so...

How do you approach a healthcare plan with one of your patients? Because I'm sure they want to have their goals, they have their communities, they want to engage fully, and then just stuff happens that kind of can look like a barrier that didn't exist before. How do you manage that? What's the appropriate kind of mindset when you're going into an interaction with one of your patients?

Yeah, so it's a great question. It's actually the same across the ages. So when I started the bone clinic at UC San Diego, I started seeing people at age 18 all the way up beyond 100.

And it stuff happens all along the spectrum. It's just that when we're younger, we tend to brush it off or not take it as a seriously, or if we have a pain, we ache, but then we, we assume it's going to get better. However, our own expectations, as well as the clinicians who see us tend to put more

they tend to make equivalent the fact that they're having a symptom with the fact that they're old.

So, in fact, last week I just had a patient advocate speak to my medical students who said, you know, he's suffering from cancer. And he basically said when he went to the doctor, the oncologist, who said, you have cancer. And he said, I want to know why. I was a cycler. Everything was fine. And now I found this spot. And the oncologist replied.

answer was, oh, it's because you're getting old. And it's not really true. Yeah. And it's not very satisfying. No. And it's actually, it's a cop out, in my opinion. People are getting diseases all across lifespans. It's just how we think about it. We tend to more maybe expect it. Oh, I'm getting X because I'm old. It's what happens. Our body falls apart.

But that's not what I say to all my patients, regardless if they're 92 or 35. It's not necessarily your fault. We're trying to understand it. And I have had the experience of learning from so many of my patients over the 25 plus years that I've been a geriatrician that you can overcome so much no matter what age you are. And you will defy even more expectations if you happen to be 95 and get through something. Yes.

Okay, great. So you mentioned learning and having a kind of a whole view of the patient. And one of the great things about your scientific work is you're connecting parts of physiology that I don't think people normally consider connecting. So I know you look at bone health, but I also know that you look at the microbiome, the various bacteria that are living in the gut.

And you look at how that can interact with the brain. So now I'm thinking about bones and brains. I didn't always think about those as totally connected. Gut and brain, gut and bones. Tell me about how you've kind of landed on this interesting set of interactions. How did you make these connections? And what do you think they mean about our understanding of health?

That's a great. Some of it is serendipity, kind of the resources that I had available to my fingertips by working with amazing other scientists in the area who are willing to collaborate. I think one thing great about geriatricians is that we really have kind of a big picture take on things.

And that we realize that nothing is simple. We wish it were, but it's just not. And so when we see something, we think about multifactorial causes, right?

So when I've been working with this population of about in 2000, there were 6,000 men who were recruited from different areas across the United States, six different clinical sites. And they were recruited to study the effect of, you know, what are the risk factors for fracture in older men? But they answered no.

a number of questionnaires. They underwent physical function, cognitive function testing and have been followed over the years. And in 2014, they happened to agree, a thousand of them or so, to give their stool samples, which I thought was amazing. I didn't think they would, but they were, because they had already been followed every four months from 2000, they were dedicated. So when we asked, do you mind giving us a sample of your poop? You know, it means- No problem. Here you go. Here you go.

They did it, right? And so the person who thought to ask them for stools circulated an email, do you have any questions that you'd like to ask about this? We're thinking there could be something going on with microbiome and bone. That's why he did it. I see. But for me, I was thinking, well, in clinic, all my patients come into me and they say, doc, I know that you need vitamin D to

to absorb your calcium and how much calcium should I take? And then I was thinking on the other side, well, we know that they're vitamin D receptors all throughout our body and specifically in our gut. And we know that there are millions of bacteria in their gut and there must be some kind of interaction. So that was kind of how it came about. It's my patients asking me these questions and me thinking, well, I

I believe that the microbiome is important and it's probably doing something in there. And that's, and, and, so what did you find? What did you find? What was the connection or the association at least? Yeah. So the association was, uh, blew my mind actually, uh, because what, uh, we did is we measured the vitamin D levels, the kind that the doctor level, um, would measure in the clinic, uh, 25 hydroxy vitamin D, which is supposed to be the stable, uh,

storage measure of vitamin D. Are you sufficient? Are you deficient? What's going on? This is what everybody is measuring. And you hear a lot about vitamin D in the public media. Of course, yes. And it's added to a lot of the milk.

And add it to a lot of milk and people take a lot of supplements. But it's actually the 125 dihydroxyvitamin D that's the active form. Yes. And that's different. Right. That binds the receptor, vitamin D receptor in the gut that allows you to absorb your calcium, et cetera. And what we found by studying the microbiome of these men was that

there was absolutely zero, a flat line relationship between the storage level of vitamin D, the 25 hydroxy vitamin D and the health of the gut microbiome. And by health, I mean,

that there's a good variety, a healthy ecosystem within your own GI tract. Yes. So we, we know that like for, for health, let's just call it healthy poop has a certain distribution of bacteria that we expect to see and that we know is associated with pretty much healthy. Um, and, and,

And you were not seeing a correlation between whether it was the nice looking bacteria or the problematic bacteria that didn't seem to affect the long term storage of vitamin D. But it did affect the active hormone, which was what we saw was the more healthy, the more diverse these older men's microbiomes were.

the better the 125-dihydroxyactive vitamin D hormone was. And that was true looking at different ratios of vitamin D metabolites showing what would make sense. Yep. So would the prediction be that those...

people with the good circulating levels would be less prone to fracture? Would that be the hypothesis? That would be the hypothesis, yes, for sure. Although we haven't seen it in the data. But what we did see is we looked at ratios of metabolism. So those who were...

you know, metabolizing well were more also had healthier gut microbiomes. And that was associated, that has been associated with a reduced risk of fracture. So there you go. And it's a pretty much direct line between kind of bone health and what kind of bacteria are in your poop. Now, if I'm not mistaken, because I did look at some of your work, you also were looking at things like sleep. Am I right? Yeah.

Yeah, because these men were amazing. Thank you to all Mr. Oz participants because they really stuck with us. And I'll just mention the six cities or areas they're from. Sure, sure. So San Diego, where I was, Palo Alto area, Oregon, Portland, Oregon.

Minneapolis, Minnesota, Pittsburgh, Pennsylvania, and Birmingham, Alabama. There you go. That's a nice slice of Americana. Yeah. Yeah. And so these men also answered questions about how they sleep. And there's standardized questionnaires, about 20 questions.

And then they also wore armbands and even sleep at chicken breeding monitors over the 20 years that they've been followed to kind of get a sense of what are their sleep patterns, what's going on. So they had sleep studies done too over time. And so I decided to look at that because I was thinking, you know, sometimes my stomach wakes me up at night, whatever. It must be some kind of association. And certainly, again, we can't,

attribute causality because we're measuring these things at the same time, but there's certainly strong correlations. Those men who self-reported better sleep had more diverse gut microbiomes.

You know, I have to say that as a physician myself, one of the remarkable things I learned very early as a physician is when you ask somebody, how's your poop? Which is a ridiculous question. And like, nobody teaches you how to answer that. But almost every patient knows in their heart, they'll say, no, my poop is good or it

No, I'm having problems. And I'm always amazed at the ability of humans to character. I mean, it's one of the great privileges of being a doctor is that you can ask that question without getting arrested. But now you're putting a little bit of science into it is that, you know, that's going to affect their sleep. It might affect their bones and maybe their fracture risk. It's quite amazing.

Yes. The other, I want to talk about objective measures also to finish that off because sometimes people say, you know, you might be biased. Self-report isn't very good. Men always report that they're taller than they actually are, et cetera. So the idea is these men were these actigraphy monitors or armband monitors. And what, uh, was really interesting to see is that, uh,

those men who had more regular sleep patterns, like consistent go to bed, wake up at the same time, their gut microbiomes were also healthier. Wow. And then now, and you mentioned that this is not causal, but it raises these great questions about, is it the sleep that helps cause a good bowel, or is it the bowel that helps good sleep, or is it more complicated? And so this is really exciting.

This is the Future of Everything. I'm Russ Altman, and we'll have more with Deborah Cotto next. Welcome back to the Future of Everything. I'm Russ Altman. I'm speaking with Deborah Cotto from Stanford University. In the last segment, we got some definitions of geriatrics, gerontology, and we heard about some of Deborah's fascinating work linking bone health to the microbiome, your poop, as well as sleep and other measures of health in the elderly. In

In this segment, we're going to talk about what's the status of geriatrics training in the United States and what are things that physicians should know and patients should know to make sure that they don't make bad assumptions about the causes of their diseases. I wanted to start out by asking about medical education. You're a professor at a medical school.

How is the and you made some mention that even early in your career, you weren't always hearing about geriatrics and you were told in kind of dismissive ways, don't worry about it. It's not that complicated. And yet your own work has shown that it is complicated and fascinating.

What's the status of medical education for our young doctors? And are they getting a better bit of information than you got in your training? Well, that's an outstanding question because since coming to Stanford in 2021, it really dawned on me that instead of a parallel increase in our aging population,

And doctors who are specialized in taking care of older people, it's been actually the opposite. That when I started, there were 10,000 or so board-certified geriatricians in the United States. And when I got to Stanford in about 2021, there were 7,000 or under 7,000. Oh, that really is going in the wrong direction. Yeah.

Right? So then I thought, well, why? What is happening? What happened? And in fact, only about 4% of medical schools has been published online.

offer any curriculum in geriatric medicine. So maybe it's no surprise because there are not enough people to teach geriatric medicine. But also, I think there's a lack of understanding that this might be important for all doctors, because unless you're a pediatrician, you, by definition, will be taking care of someone who's older.

And they're just not. We have six weeks of pediatric mandatory inpatient outpatient exposure as all medical students for many, many years now. And yet that's not mandated in most medical schools.

Wow. I think there is a fallacy. I remember from my own training that it is true that in general medicine, you do have a lot of elderly patients, but that doesn't really mean that you've been trained on the special challenges of those folks. And once I was exposed, I actually took a geriatrics rotation and I loved it. But the number one thing I learned from it was that there was a whole bunch of things that were useful and specific to that population and an approach

that is a little different from how you might approach a 30-year-old. And so I'm wondering, how do you drill this into the medical students? Or how do you gently coax them to understand that there are special ways that you can manage these patients and interact with them?

Yeah, well, being now involved a bit in medical education, even when I got here, it became really apparent that to get a medical student's attention is a competitive process. There are so... I'm excited for our students, but at the same time, kind of horrified because the amount of...

that they have to absorb in the four years is mind-blowing. And so it's a matter of getting the people who are in charge of the medical school curriculum to say, this is important. We will allow you FaceTime with the medical students.

And even though the ACGME or the American College of Graduate Medical Education now has 27 core competencies that every medical student who graduates should know about general principles of geriatric medicine, there's no way to assess if medical students are actually achieving that. But

Fortunately for me, there is one medical student here at Stanford who was very interested in geriatrics. And we have embarked on this project along with the Stanford Longevity Center to assess what is the state of at least Stanford medical student graduates. You know, they're pretty good students. So we created a – we used an old questionnaire. We asked them about –

these questions that seem pretty basic for medical students. And they scored under the passing level for, for what Stanford considers a passing level on exam. But more interestingly, we also had this geriatric attitudes questionnaire and we looked at how the attitudes towards aging correlate with how they did on the exam. Oh,

You want to guess what we found? Well, I mean, I guess I would guess that if you don't care, then you don't know.

Exactly. This was a small sample. We only had something like a 39% response rate in the class of 87. And yet it was so statistically significant, the line. The more positive aspect of views you had about aging, the better you did on the exam. But what is even more exciting, as of yesterday, we have now expanded our collaboration and are using a validated questionnaire developed by my Harvard colleague, Andrea Schwartz,

And to have our administrating to this year's graduating class, not only at Harvard, at Stanford, where we now have a 59 percent response rate, which I'm really excited about, University of Washington and University of Texas. Texas has already sent us back. They got something like 132 responses in their class. Our class is smaller, but the sneak peek is huge.

We're replicating the results about attitudes and score. Right. And only 25% of the students would pass the exam if we use the cut rate of 65%.

But, you know, the great thing, part of me is an engineer. And one of the things that engineers say is that if you can't measure it, then you can't intervene. So you guys are making the incredibly important first step of measuring where you are and where the problems are. And then you'll, I'm sure, you'll design educational interventions to try to raise those boats. Yeah.

Exactly. So it was a roundabout question, but we couldn't change anything until we raised like, you guys say from the ACGME, this is what the expectation is. Yes. And failing miserably. So later in a minute, I'm going to get to some advice for patients and for non-doctors about how they can manage their aging. But what would

be a couple of the key signals that you would send to a medical professional about what they need to know about geriatrics? And I know you said there's 27. It's your whole career. It's totally unfair for me to ask you to. But what would be two of the top things you would want other physicians to be aware of that you that you suspect they might not be aware of?

Well, I can think of a top one. And maybe as I answer that, I'll be able to come back. Great. I'll take the top one. The top one is don't attribute whatever you're seeing to aging. So I can give you very specific examples. I treat patients at the VA. I have a 76-year-old vet. He comes in and he used to walk five miles a day around his beautiful property in the Santa Cruz Mountains. And he's not really a complainer, right? But he just kind of says...

I'm not doing that anymore. And it's basically kind of

I guess bypassed by a lot of different people who may have seen him. And, and then in addition, and I just came off of medical ground rounds where they talked about the importance of bedside exams, clinical exams. I actually listened to his heart because I actually didn't have a resident with me at the time. So I went in, I did my own exam and I said to the man, have, has anybody told you have a heart murmur? And he says, no.

And then I say, well, okay. So I send a note to the primary care physician that I detected a heart murmur. I think, you know, I would suggest that he gets it worked up and he is having a decrease in his physical, usual physical activity. Yeah.

turned out not only did he have an aortic stenosis murmur, which was not actionable on that, I mean, but he had evidence of a reversible cardiac lesion. So he went to catheterization and got a stint. Wow. And it would not have been correct to say, oh, he's just getting older. That's why he can't walk around his beautiful mountain. Yeah.

Yeah, it's just aging. And, you know, this happens again and again. And I think that people and I have another story. So these are great. These are money. These stories are good. So let's hear it. Yeah. So the other story is I sometimes take care of the parents of my colleagues who are doctors.

And one time I see a patient's mother, I'm sorry, a fellow doctor's mother, and the mother complains to me of back pain. So I happened to see the colleague and I said, oh, I saw your mother. It was so great to see her. She has back pain. She told me she had back pain today. And then the colleague says, oh, well, she's getting old. Yeah.

This is a fellow physician. Yeah. And I really didn't say anything, but it's something that stuck in my mind for so long because I'm thinking, well, I don't know. For me, maybe I shouldn't assume too much. Maybe her mom always complains about back pain. And she's just tired. Or maybe it's like the story about the orthopedic surgeons where the kids say, oh, I have this arm pain. And they're like, forget it. Don't worry about it.

You know, it's so usual, but I, it just stuck in my mind that I see a lot of that.

What are some things that you would advise to make sure that you have a kind of positive experience as you age? And you can't make sure, but to increase the probability that you have a positive experience as you age.

Yeah, I love to try to first talk about what we consider in geriatric medicine important as to really listening and understanding what matters for that particular patient. Because different things matter differently, depending. But once I get an understanding of where their goals are, then I usually talk about work. Because

Anything, most things that are really worthwhile in your life, you've worked for. It's not like pie out of the sky and then everything is all true and happy. I mean, those things can give you temporary happiness and joy. But the things that are really durable are things that you've worked hard and you know that you feel that you deserve. So and then I tell them, I feel like no matter where you start, whether you've had a cancer diagnosis or a stroke or whatever,

loss of multiple family members, that you have agency to have a positive outcome, that it can start at any point. But you have to believe that. And that's where the hope part comes in. Great. So hope is great. And then agency is, and when you say agency, I think what you mean is like taking control and not feeling like your other people are always making decisions for you, but to say, I'm going to make some decisions about how I spend my time, how I do things. Yeah.

Yeah, so this is a good point because what I notice often when I get feedback from my geriatrics patients or patients who have seen other doctors, but they come to you for consultation and sometimes they're no longer able to drive or they may have some mild cognitive impairment or even more, the things that they really appreciate about seeing a geriatrician is a geriatrician knows who's the patient.

So no matter where that is, it's the patient who you're taking care of. And to talk only to the person who's driving or managing the medications is not really respectful. So I feel that if I were going to give another second piece of advice- Good, there you go. Is to-

Pay first and foremost attention to your patient. And it's amazing that people can understand even if you think they can't. Yeah, that's fantastic. And actually, it turns into a piece of advice for the patients. Those two things you had for your colleagues as physicians is the patients should make sure that they're being talked to as the primary patient and not

the people who are around them when they make a visit and see if they're detecting a doctor who's kind of giving up on them and saying, well, you're just old versus let's get to the bottom of this. And those are two things that many people would be able to perceive. Yes.

Thanks to Debra Cotto. That was the future of geriatrics. Thank you for tuning into this episode. Don't forget that we're pushing almost 300 back episodes in our catalog so you can spend all day and all night listening to the future of everything. Please remember to hit follow in whatever app you're listening to so that you'll be notified of new episodes and you'll never miss the future of anything.

You can connect with me on many social media platforms at RB Altman or at Russ B. Altman at LinkedIn, Threads, Blue Sky, Mastodon. You can also follow Stanford Engineering at Stanford School of Engineering or at Stanford EMG.

If you'd like to ask a question about this episode or a previous episode, please email us a written question or a voice memo question. We might feature it in a future episode. You can send it to thefutureofeverything at stanford.edu. All one word, the future of everything. No spaces, no underscores, no dashes. The future of everything at stanford.edu. Thanks again for tuning in. We hope you're enjoying the podcast.