 We're back, we're live, we're doing community matters, we're doing aging and grace today with Dr. Warren Wong. And Warren is a physician and been involved in elder care, geriatric medicine for a long time like decades and decades. And right now you're at Straub. That's right. Yeah. And that's fabulous to know because we care a lot about geriatric medicine, we care about aging, we care about all the issues around aging, not only in the medical community and the social structure of the state, but in the implications in every way, how does it affect things. So, Warren, welcome to the show. Thank you for coming down. Yeah, Jay, can I just say something right up front because just in case the audience is interested. I'm at Straub but I actually am not in the clinics per se, so actually people can't make an appointment to see me. I do some work in nursing facilities and I also do some administrative works. Okay. Well, tell us about your practice. What is it like? Who are you servicing? It's really interesting because of course older people get sick and there's a lot of pressure in the healthcare to control costs. So nowadays there's a lot of use of skilled nursing facilities where after a person's in the hospital they would go to a skilled nursing facility to have rehabilitation and that's generally covered by Medicare with some Medigap insurance or a program such as Medicare Advantage, Akamai Advantage or Senior Advantage within the Kaiser system. So a lot of times people will spend a relatively short amount of time in the hospital and a longer time in the skilled nursing facility and sometimes people know that their benefit allows for a certain amount of time. It's actually not true what the insurance allows for is a certain amount of time in the skilled nursing facility as long as they're continuously getting better. But what we've noticed over time is that the skilled nursing facilities are taking more and more complicated patients. Like when I started, you know, we gave one IV antibiotic a day, that was about the limit of what a skilled nursing facility could handle. Nowadays we have in the skilled nursing facility it's almost like a hospital. You know, people will get IV antibiotics two or three times a day. Some places have infectious disease consults going there. Really? And lots of pills. Way too many pills, you can be sure of that. I mean, you know, it's a full-time nursing job just to make sure all the pills are given and dispensed. But a lot more time is spent by a lot of people in skilled nursing facilities and in fact the statistics are that most everybody, once they become a senior, will probably end up spending some time in a skilled nursing facility. Yeah, no more at home. What about the old notion of aging and grace at home? Is that less these days? Well, you know, I actually have some mixed feelings about that. You know, I think aging in place is a very popular notion. And I think the concept of not being institutionalized, not going to a nursing home, that's where this aging in place comes from. But it's a mixed blessing because I've seen people who age in place and you know who their best friend is when they age in place? They're a nurse. No. Oh, they're not in the nurse. The nurse is never there. It's a computer. The television. You got it. It's not the computer. They're best friend is the television. It can be actually extremely isolating to age in place. So I think that the notion of aging in place is good in sometimes very supportive environments where you live with a larger family, a multi-generation of, that's fantastic, you know. And I think that is the alternative. But it's going out, though, isn't it? Yeah. Family is going nuclear. Right. So it's a little bit less possible. But people are starting to have different ideas about where they live. So actually, it's quite an industry in Hawaii to have senior housing complexes. There's many, many of them, Plaza, Hawaii, Kai, Arcadia is the original. Are there enough of them? Well, it's definitely an expanding market. And you know, I used to think about, ah, I'd never want to go there. You know, this is like a permanent cruise ship. You know, you're on a cruise ship for the rest of your life. All your meals are delivered and you have entertainment. But I've actually seen an evolution in these senior housing situations in which some younger and younger people are starting to say, you know, this is pretty nice. And it gets to be more of a community environment. And little communities are starting to develop. And people can still become, be very vibrant and active in that. Of course, you know, there's a huge amount of variation, but I do want to get back to the point that aging in place, you get what you asked for. And you know, some people have some rose-colored glasses about how wonderful it is to be living at home. I used to make home visits all the time. Oh, that's good of you. And when I made home visits, I didn't have to know the address. I would just say that's the house, because the house is in collapse. As you get older, it's a big task to maintain a house. And so you'd walk into the house and everything is just very convenient for the older person. But it's a mess. They always talk about doing away with clutter, right? Because clutter is bad for old people, but at the same time, it's also convenient for older people. You don't want things in shelves or whatever. You want right in your line of sight. So there are some pluses and minuses to aging in place. I think, optimally, is to plan for aging in place, have good relationships with your children, or a lot of older people now are thinking they relocate to live with their children and things like that. Well, money, money, money. I think it's a euphemism when you say aging in place. It's cheaper that way, isn't it? And it'd be better off if you had resources or insurance to take care of you in a facility where it wouldn't be like a cruise ship. And so, I mean, are people in Hawaii able to do that if they want? Or is it just that we have a kind of a group of people who just don't have the money for it? Yeah, I think there's a huge number of people who actually don't have the money for that. Their home is their only asset. And it's an asset that they have, but they don't have much income coming in. Some people just living on social security, and then it becomes very difficult. And then to live in that house, obviously, is less expensive for them than to live on social security. It's actually a pretty big commitment to saying, well, I'm going to sell my house, take the money from that, and kind of live on the income. You don't want to do that. Well, it's kind of hard to figure out. Am I going to have enough money? And where am I going to live? And this house is really nice. But with the amount of money that I can spend on, I'm going to live where there's no public transportation, no community. I think that is a difficult concept. But actually, it kind of depends on all kinds of situations. So let's just say you're a really, really old frail person. And you're really at your last chapter in life. And you just want to stay at home. And you need a lot of care. You need care throughout the day, getting in and out of bed. You know, it's depressing. That's really expensive, isn't it? Well, that is, you know, it's more expensive than the care facility. I tell people that is the most expensive option. And if you have that kind of money, you can do that because that's more expensive than a nursing home. You know, that's easily $12,000 a month to have people providing care for you 24 hours a day. Are they available in Hawaii? Because I know people looking for them for a long time can't find anybody. Well, you know, it again comes down to money. If you have the money, it's available. And there's a lot of private pay nursing agencies coming up in the state of Hawaii. Almost invariably, there's a minimum of three hours at a time. And you know, a lot of people, even people who are very wealthy, they just don't like the concept. Why should I pay for three hours of care when all they're doing is sitting around and watching TV and looking at me and then helping me out once in a while? Well, I'd say that's true, but I also tell the patient, well, you're not going to be able to find an agency caregiver for fewer than three hours at a time. And it's also true that if that person is not around, you're actually not safe being by yourself. So that's a discussion I've had for decades with people. You know, people always talk about, well, I'm just going to find somebody on my own. And my response to that is, well, good luck. I mean, because some people actually do fantastic. But a lot of people try it and find out, oh, this happened, that happened. And I mean, there's always the potential for abuse. Yeah. Oh, yeah. That's true. We've heard many stories about that. So the thing about it is, I don't think younger people realize that when you're home alone and you're elderly, you are in decline. And it becomes more possible that you will fall down, more possible that you will have some sort of accident, more possible that you will have dementia, Alzheimer's. And right after this break, Warren Wong, I would like to talk about dementia and Alzheimer's, because I know you practice in that area. And I want to give people a handle on what that experience is like, not only for the patient, but for the family and for the physician. We'll be right back after this break. Freedom. Is it a feeling? Is it a place? Is it an idea? At DiveHeart, we believe freedom is all of these and more regardless of your ability. DiveHeart wants to help you escape the bonds of this world and defy gravity. Since 2001, DiveHeart has helped children, adults, and veterans of all abilities go where they have never gone before. DiveHeart has helped them transition to their new normal. Search DiveHeart.org and share our mission with others. And in the process, help people of all abilities imagine the possibilities in their lives. We are back. We're live here in Community Matters. I'm Jay Fiedel. We're talking about aging in grace or with grace, as the case may be. And we're talking with a geriatric physician. We're happy to have him. Warren Wong MD practices, at least part time, its travel and does lots of other things, including entrepreneurial things, which we're not going to talk about today, maybe another show. But Warren, you deal with people who have dementia. You deal with people who have Alzheimer's. And it's tragic, but there's a tremendous need for physicians and medical staff to help people in their waning years, because people always wane. At the end, there's always an end. So can you talk about, tell people out there, what is dementia? What is Alzheimer's? What's the difference? And how does it affect your life? Yeah, so I think that we'll start off with the question of what is dementia and what is Alzheimer's. Because it's a fairly common statement that people will say, oh, I was really glad to hear that my mom doesn't have Alzheimer's. She just has dementia. What's the difference? So that's actually, it's really a common misunderstanding. Dementia is just a very general term of which Alzheimer's is the most common type. So it's just like saying, there's all kinds of airplanes, and the most common kind of airplane is a jet. I mean, I don't know if that's a very good analogy. But the most common kind of dementia is Alzheimer's disease. And there are some that are not Alzheimer's disease. You can't really say that Alzheimer's disease is better or worse than other kinds of dementias. Because Alzheimer's disease is, there's a lot of variation in Alzheimer's disease. There's also a lot of variation in other kinds of dementias. Let me just talk about Alzheimer's disease because that's what people are most interested in general. It's basically very commonly when I would do a consult, people would say, I don't really, you know, my mom's memory is really great. She can remember things that happened 10 or 15 years ago that I can't remember. And I have to point out that that's actually not the first finding in Alzheimer's disease. Alzheimer's disease, the most common way it presents, is forgetfulness about things that happened very recently. So the things that happened far in the past are much more deeply embedded in the brain, the things that happened very recently. Basically, don't get past the RAM drive and don't make it into a deeper memory. So they may not remember what they did yesterday or they may not remember what they had for breakfast or whether they actually had breakfast and things like that. But a certain amount of that is just natural with aging, isn't it? I mean, where's the line? Where do I see, say, in a relative, a loss of memory, a failure to record it to the hard drive where I'm so concerned I come and see a physician about it? And I say, I think my relative actually has Alzheimer's. Where's the line? Yeah, I don't think the line is at crisp, actually. There is some general cognitive decline with getting older. And let's just say a very normal older person who's 90 years old. And the computer analogy is actually very, very important. Let's say you're 90 years old and somebody asks you, where did you put your keys or something like that? The cognitively normal person may not respond as fast. As a younger person might respond. And that's still quite normal. And the analogy with the computer is, let's just say your hard drive is totally full with 90 years of memories. That's a lot different to pick something out from that hard drive and have it produced verbally. It takes a lot more time out of a computer that's got a lot of stuff in it than a person that basically a hard drive that has no information and just can throw it out. I mean, we all have that experience of computers brand new. Boom, it works right away. And then as we jam it up with stuff, it gets slower and slower and slower. I mean, that's normal. It takes a certain amount of expertise to know when it goes from normal to this is really not normal. And the line is not that definitive. I would even say that even among experts, some people would say, no, I think this person has got Alzheimer's disease. Some other people would say, no, not quite. The reality is the person who says person's got Alzheimer's disease is more likely to be right. Because the more the years go on, the more people get all of it, it's going to be right. But I don't think there's a real sharp line. I think that I've seen where some old family members will bring a parent in and say, this person, I think they've got Alzheimer's disease. And we do very detailed testing, maybe an hour or so of testing, says, it's probably still within normal limits. And the children are convinced that it's not within normal limits. And I think there's two points. Number one, it might be that this was not exactly the way the person would have responded 10 or 20 years ago. Or the other possibility is that the family might actually be right, because this person had a very high baseline, very, very bright to start with. And they can clearly see a cognitive decline, but it's still within normal limits. So you want to match it against how he was before. But what about the classical trends, say, with uncharacterized dementia? In other words, you don't know exactly what it is. You don't think it's Alzheimer's. And Alzheimer's itself. Does Alzheimer's move faster? Is the decline greater than against the ordinary curve of dementia? Yeah, so I'll say a couple things about Alzheimer's disease. Generally, the younger the onset, the more concerned we have. It's basically, we feel that the patient is either more vulnerable to the Alzheimer's disease or has a more aggressive version of the Alzheimer's disease. That is pretty clear that, especially with very young onset Alzheimer's disease, the prognosis is a lot worse. We see some people with Alzheimer's, very late onset, late 80s, early 90s, who have a very slow rate of progression. So the rate of progression of Alzheimer's disease is extremely variable from person to person. We do know some things about averages that generally a person with Alzheimer's disease, their life prognosis is definitely shorter. Overall, there's maybe about a three to five year from time of diagnosis. Is that right? That's pretty quick. Considering it's only mental, or is it more than mental? Well, let's put it this way. So it's three to five years, but how long do you expect a person to live once they reach 80 or 85 years old? You know, even without dementia, a person who's 85 years old, their life expectancy is what we call remaining life expectancy. It's not that long, whether it's from dementia or anything else. But I think that dementia does affect it a little bit. But we were talking about bell-shaped curves before, and there's a dramatic bell-shaped curve with Alzheimer's disease. We see some people who are just diagnosed one day and a year later, have just dramatically worse. Then we see some people who will just year after year just get a little bit of decline, a little bit of decline. It's a huge amount of variation. I would say this non-Alzheimer's dementia has that same degree of variability. So it doesn't make that much difference? In terms of the long-term prognosis, it doesn't make that much difference. I think in terms of the features of the dementia, sometimes there's some variation between Alzheimer's disease and other kinds of dementias. I know there's a lot of research on Alzheimer's because it's really so tragic and profound in a given family and for the individual, of course. But what's the state of that? If I can stay alive for another X years, am I gonna find a cure, a reversal of the process with the plaque in the brain and all that? Is this something that medical science is actually gonna solve? What do you think? Well, I think that I'm not holding my breath. Even 10 or 15 years ago, we thought we had some major breakthroughs with the vaccine and then we found out how many problems we had with it and it never came to market. But there's always new hope that comes and new understandings and there were some recent findings, again, related to rats, but humans are not rats, right? About some of the features of Alzheimer's disease. At this point, there's not a major breakthrough. I think that most of the drugs that are out there are, there's people who take them, I mean, some seem to get better and it obviously has some effectiveness. I mean, they're FDA approved, but for most patients, the effect is not gonna be dramatic. Yeah, we're almost out of time, Lauren. Can I ask you to look at camera one and see through camera one the public, okay? And what would you tell, say, a member of a family who believes that one of his relatives, his father, mother, some relative in his family is declining because of old age dementia and because of Alzheimer's. What's your advice to him, how to conduct himself? How the caregiver should conduct themselves? Well, I think that you'd like to make a diagnosis, but I always like the concept of are you doing something to a patient, for a patient or with a patient? And those are three different concepts. I mean, when you're doing something to a patient, you may think it's, you're actually in a way punishing the patient. For the patient is you're doing it because you think it's important for the patient, but the patient may not agree. And sometimes we see families push too hard in that direction. I think that a lot of times what a patient has a good relationship established with their primary care doctor and just to bring it up with the primary care doctor, primary care doctors are much better at recognizing dementia than they used to be. They are not very sophisticated at diagnosis, but at least to help have the physician involved in trying to figure out the next steps and obviously getting a consultation is optimal. But be very careful about pushing a patient too hard for a diagnosis. The other hand, family is very important. You have to have an advocate. And if you're alone, maybe you're a widower and there's nobody around, your family is gone or far away. You need to have an advocate. And that presents some difficult problems for an individual who may believe that he's losing it, but he doesn't have anybody to bounce that off. And I guess he should see his primary care physician and try to get connected. But it sounds like it could be very sloppy. I mean, we've seen patients who basically have not seen their doctor for a long period of time. Nowadays, the healthcare system tends to monitor patients a little bit more closely. We tend to be a little bit more proactive in following patients, but there are patients who haven't seen their doctors for years and are a mess. And every situation, I just can't provide you with a kind of a formula, do this, this and this. Every situation is a little bit different and it needs to be tailored to that specific circumstance. Thank you, Warren Wong. Dr. Warren Wong, geriatric physician. It's been great to talk to you. Thank you for coming on. Thanks, Jay. Aloha.