 Our next topic is chronic illness and seniors, successfully managing depression and anxiety while growing older. And I'm pleased to present to you Dr. Adam Rosenblatt, who is right here to my right. He's the director of geriatric psychiatry at the University of Maryland Upper Chesapeake Health in Hartford County. He was previously a professor of psychiatry and neurology at Johns Hopkins University, and most recently the director of geriatric psychiatry at Virginia Commonwealth University. He's widely published in the fields of neuropsychiatric conditions, dementia, assisted living, and Huntington's disease. Dr. Rosenblatt, welcome. Thank you very much. Can everybody hear me alright? Is this working okay? Yes. I might move around a little bit. So that's a tough act to follow. I'm going to try not to be too dry because I thought that was just wonderful and I don't mind being a little bit late. It's great to be back in Maryland. I've only been back in Maryland for a few months. I came from New York originally, went to Johns Hopkins, married a Towson girl psychiatric nurse. We've worked together at the same institution, you know, everywhere we've gone now for 26 years. And recently I did a seven-year hitch at Virginia Commonwealth University and I'm back in the great state of Maryland again and it just feels terrific. And I really appreciated the previous discussion. You know, I'm very grateful to all of the people that let me learn psychiatry by working on them when I was learning stuff. I think I know a thing or two now, but I didn't always. And I'm very grateful when anybody is willing to share their story for other people. It's a very difficult thing to do, but it's just tremendously helpful and it makes me feel good because I think that these are often people that were helped by psychiatric treatment and they want to share that with other people and encourage other people to seek out help too. Brought back some memories. John Freeman was one of my mentors in child neurology at Hopkins and he was the sort of modern-day father of the ketogenic diet. And I had cornbread for breakfast this morning, so that made me think of a lot of things here. So I'm going to talk to you about chronic illness and seniors managing depression and anxiety while growing older, but I'm going to talk about a lot of other things that are also related to seniors and psychiatry and topics like that. You can't talk about geriatric psychiatry without talking about dementia, which is the elephant in the room. And so I don't see a lot of people in the audience that are in the typical age of risk for dementia, although nobody is completely not at risk for it. But just about all of us probably have parents unless there's something about medicine I don't understand. And so you may be familiar with some of these topics as well. So I want to talk about ways that seniors are different from younger people. And I think there's three basic ways. There are some conditions that we really pretty much just find in seniors, like dementia. I mean, there are conditions that can cause a young person to develop dementia, but mostly it's a disease of elderly people. Then there are some conditions that you can find in everybody, but they look different enough in seniors that it can fool people or there can be a lot of tricks about taking care of people with those conditions. Although depression can look very different in an old person than it can look in a young person. And then the third category is that there are some problems in treating seniors that are just related to age. So age complicates the treatment. Side effects are different. They're more severe. They can cause all kinds of problems. And so you need to know about the sort of patient you're treating. You can't just slap the name geriatric over a unit, put a bunch of old people in it, and you've got a geriatric unit. You have to have people that know what they're doing to take care of old people. I like this. This came with PowerPoint. I just put in and suggested it. But let's talk about conditions found mostly in the elderly. So dementia is an acquired global decline in cognitive function. So if you're born with an imperfect brain, I mean everybody's brain is imperfect, but if you're born with a brain that's not as good as most people's, that's not dementia because it's not acquired. We would call that developmental delay or something like that. And it has to be global in the sense that if you only have one problem, if you have a stroke and you can't talk anymore, but otherwise you're cognitively normal, we would say you have aphasia. We wouldn't say that you have dementia. Dementia literally means losing your mind in Latin. And so you have to have a problem with memory. That's the required category. And then you've got to have a problem in at least one other area, such as speech or recognizing things or people, physical tasks or executive function. And you're going to hear a lot about executive function. So think about what an executive does or what a chief executive does, makes decisions, solves problems, thinks about the future. So executive function is the part of the brain that has to do with decision-making, judgment, problem-solving. It's mostly handled by the frontal part of the brain. And so people that have executive function problems can look very normal until they come up against one of those deficits. And so those are some of the trickiest kinds of cognitive symptoms that you could deal with. And then to be a disorder in the rule book, it's got to be bad enough to interfere with day-to-day function in some way. So if the problem is noticeable but doesn't interfere with day-to-day function, we wouldn't call it a disorder. We'd call it something to watch. Suddenly, we've noticed, but you wouldn't fall over the threshold for having a diagnosis. Dementia is not a normal part of aging. I mean, it's statistically normal. It's normal in the sense that it's common, but it's still a disease. Myopia is not normal, but it's common. I have an eye disease. I have myopia. And I wear eyeglasses so that I can see. It's a really common disease if we look out in the audience. I also have presbyopia. That's when I wouldn't admit I needed bifocals. And then finally, I admitted it. And now I think I have bionic glasses, because I can see near and far in a miracle. So it's different from age-related cognitive changes. As people age, they slow down a little bit. You hope that loss of speed is replaced by wisdom, but they slow down a little bit, but they're still functional. If somebody can't find their bedroom or can't operate the stove, that's slipped over the line into being a disorder. It's a very common disorder, but it's still a disease process. It's sort of like a child falling off their growth curve. So just as children have a growth curve, how tall you expect somebody to be based on how tall they started out and their parents and that kind of thing. If they fall off it, you call that growth retardation. If they have short parents and they start out short and stay the same percentile their whole life, you just call that being short. That's not a disease. It's just a human variation. So if an adult falls off their growth curve and you're no longer functioning at the level of a college-educated person that you are or you're not functioning the way that other people your age are, then we start to notice that something is wrong. Dementia is incurable, but so are a lot of things. Hypertension is incurable. I suffer from several incurable diseases. I have hypertension and gout. Nobody's been cured of either one. Emphysema, diabetes, all incurable diseases that cause suffering and limit people's life expectancies. So dementia is a perfectly good company. I'm not all broken up about it not being curable anymore than a lung specialist is broken up about emphysema not being curable. What I do is I treat it and try to make people's lives better and suffer from dementia. So there are medications that are somewhat effective, definitely a lot better than nothing. There are precautions you can take so that people with dementia don't get hurt or come to harm. And then there are a lot of environmental changes that you can do to try to make life better for somebody. Dementia is very common in older people. Maybe about 5.7 million Americans suffer from Alzheimer's disease right now. About 1 in 10 Americans over 65 suffers from dementia. And it gets higher and higher with age. So when you get up to 75, it's more like a quarter. Get up to 85, it's more like a third. It tops out around 50%. And then there's just not enough people alive at that age group to know what would happen. But it could be the human brain just not designed to last 100 years. The human prostate is not designed to last 100 years. Every prostate goes bad. 90-year-old men all have prostate cancer if you look at their prostates at autopsy, but it just never got bad enough to be a problem because most people don't live to be 90. So maybe we would all have Alzheimer's disease if everyone lived to be 150, I don't know. But the risk factor goes up substantially as people get older. But there are about 200,000 Americans that have younger onset types of dementia, meaning before age 65 or 70. Other risk factors for dementia include a history of head injuries, smoking, alcohol abuse, are risk factors for dementia or at least an earlier onset of dementia. And low education, probably not because it makes your brain deteriorate, probably because you don't have reserve capacity. So if you have a big, giant, highly educated brain, you can lose a fair amount of it and compensate so well that you won't receive a clinical diagnosis. And so I think that that may be a lot of the basis for that as a risk factor. And then about two thirds of people with Alzheimer's disease are women, mostly because there's a lot more women alive at the age of risk for Alzheimer's disease than there are men, not necessarily because they're more likely to catch it. And older African Americans have a much higher prevalence of Alzheimer's disease than older white Americans. Probably a large part of it is that they have more of these other associated risk factors like hypertension and diabetes that cause little injuries to the brain and deprive you of reserve capacity and probably make you more likely to develop Alzheimer's disease. Some of it could be other kind of genetic things that we don't fully understand. So here's a picture of Dr. Alzheimer. Then he looked smart and he was a psychiatrist. Freud was a neurologist, Alzheimer was a psychiatrist, as my old chairman liked to point out. Psychiatry and neurology are not entirely differentiated even today. The only two fields of medicine that I could think of or even more closely entwined would be obstetrics and gynecology. But we have one board and I've kind of lived my whole career a little bit in that gray area between the fields. Now on the right there is the first person to be diagnosed with Alzheimer's disease. Her name was August Dieter and she was a woman in her late 40s I think when Dr. Alzheimer met her and she was at a hospital for the mentally ill and epileptics, right? So that was the name of the place in Germany, anyway, in Frankfurt, Germany because psychiatry and neurology hadn't differentiated and epilepsy was considered some kind of mental illness which we don't think of it that way today. And what he observed was that she had this general deterioration that other people maybe became psychotic or became depressed but she seemed to be losing all of her mental faculties at the same time. Now what was so unusual about this? In Dr. Alzheimer's today they didn't realize that instead of it being a rare disease of middle-aged people it was an incredibly common disease of old people. There weren't as many old people in Dr. Alzheimer's today walking around having Alzheimer's disease and they hadn't made the distinction cognitively in their own minds between age-related cognitive changes and the disease of Alzheimer's disease. So he said, oh, I've got this wild case. There's this person in her 40s who's having general mental deterioration. It was the exact same phenomena that maybe his mother was having at home. I don't know if his mother was alive but so he observed her over years and he left that facility he would write back and say how is August doing and eventually she became totally infirm. She died of an infected bed sore and he said, would you mind setting me her brain? They didn't have IRVs and consent forms in those days. So they said, no problem, we'll send you her brain. He examined it under the microscope and it might have looked something like the brain on the right. This isn't her brain. This is just a comparison but this is the brain of a person who was cognitively normal at death and the brain of a person who had Alzheimer's disease and I just want you to notice the spaces here. These are the gyri. This is a gyrus and this is a sulcus. The spacing between them and the sulci are enlarged and if you were to look inside the brain the ventricles, the fluid spaces inside the brain would be enlarged too because all of the brain tissue is shrinking and under the microscope he saw amyloid plaques which are made out of amyloid which is this protein and neurofibrillary tangles which are made out of tau protein which is this other protein and there have been various experiments trying to break these things down and preventive performing. Every single one has been a dismal failure worse than the one before it. It's not that we won't maybe succeed one day but the experiments having treatments based on this have been so unsuccessful that people are wondering if we've got the right explanation for what causes Alzheimer's disease. I don't say that it make people feel bad but I'm very much a here and now guy. What can I do right now to help people that are suffering from this right now? It doesn't do me any good to tell you about some fascinating thing in a lab that everybody with Alzheimer's disease will be long dead before it ever makes it to market. So I'm a right now guy. You want the future guy to give you a talk about his laboratory research but I'm not a lab researcher. Alzheimer's disease can be recognized by the shape of the course. It has an insidious onset. I ask a family, I don't want to ask you what the first symptom was and I don't want to ask you how many years ago it started. I want to ask you this. Is it easy to say when this problem began or is it hard to say when this problem began? And they will almost always say it's hard to say when the problem began if we're talking about Alzheimer's disease. It sneaks up on you and they'll say, well, I thought something was wrong. It wasn't until we went to that family reunion he saw a bunch of relatives that he hadn't seen in years and they said he's really not himself that we realized something was really happening or it wasn't until he forgot to pay the water bill or drove the car into the lake or something like that. Sometimes artificially it seems like a sudden onset because there's been some life event like the loss of a spouse. So, dad dies and all of a sudden mom doesn't seem to be able to pay the bills or operate the stove and then you go back and you ask about it and you realize he'd been taking over those functions for years and covering for them which is what spouses do is not wrong just makes my job a little harder to make the diagnosis. So, sometimes something like that will hide the onset. People lose co-energic neurons. So, neurons exchange chemicals to communicate with each other and neurons that exchange acetylcholine are the ones that preferentially seem to be lost at Alzheimer's disease and that's relevant because there's treatments that rev up the acetylcholine system and how most of the Alzheimer's medicines work. Now, there's a lot of things people are gonna tell you about it that we mislead families. So, a diagnosis of exclusion means, you know, don't diagnose it until you've eliminated some other things that you might be more certain about. So, somebody who looks like they have Alzheimer's disease usually gets some tests done, some blood tests that look for things like vitamin deficiencies and old syphilis infection and things like that. We still do them, they're important but they almost never come up as an alternate explanation and then, you know, after you've excluded these things, you have your diagnosis. To be 100% certain, you have to take the brain out, look under a microscope and see if you see these plaques and tangles. Now, very few people are gonna volunteer for that while they're still alive. So, you've gotta make the diagnosis while the brain is still in the person's head. So, sometimes doctors who are squeamish about it will say, well, does my mom have Alzheimer's disease? Oh, it's impossible to be sure, you know, you could never tell until autopsy. So, let's just do nothing about it. I won't give you a diagnosis and don't contact the Alzheimer's Association, don't read books about it. You know, we're just all gonna pretend like this isn't happening. I can't possibly be expected to make this diagnosis. But you'd be 90% accurate, you know, once you've done some basic tests and taken a very good history and done a good exam. So, don't believe somebody that tells you it's impossible to diagnose. It's not that hard to diagnose. You know, somebody asked about how are we gonna get more doctors. There is never going to be enough psychiatrists. There's never gonna be enough geriatrics psychiatrists on top of that. So, we have to create a system where other people are able to help us with this and doctors can kind of function in a more supervisory role because the day is not gonna come where a person of ordinary means can pick up the phone and that afternoon you'll be sitting in my office and have a nice three hour interview. It's just, it's not enough of me to go around. So, we have to educate primary doctors, nurses, nurse practitioners, physicians, assistants, community workers, therapists to be better at spotting these things and channeling people the right way. Whatever the solution is, it's community-based. And I did a big assisted living study and I got a call from a reporter and she said, what do you mean the government doesn't pay for assisted living? And I said, oh no, they don't. It's a private pay thing. And she said, well, were you gonna fix that? And I said, would you rather have roads or would you rather have the government pay for assisted living? Because that's probably similar budget if everybody had to go to assisted living for free. So, whatever the American solution is for dementia and we're about to be up to our neck and people with dementia because our population is aging, it is community-based. I don't know what the answer is, but I know it's community-based. I know it isn't institutional because there's not enough money in the world. But doctors don't know how to talk about it. And I try to educate them so they do. The average Alzheimer's patient is diagnosed three years into their condition and stigma contributes a lot to it. Nobody wants to call it what it is. Nobody wants to acknowledge the problem. We feel that it would kill the patient, it would crush their family, that sort of thing. I call it dropping the A-bomb the first time you use the word Alzheimer's disease with somebody. But I have discovered that if something is said with love, you can tell people just about anything that they need to hear. But you have to say, I'm here to help you. I'm not telling you anything you didn't already know. You're sitting in a neuropsychiatrist's office. It's pretty clear there's a problem. So, I've given it a name, but I'm gonna start you on a treatment. I'm gonna give your family some advice. You're gonna come back and keep seeing me. I'm gonna send you to some good people I know. We're all here to help. This is not a death sentence. It doesn't mean your life is over. You can be a happy person. And just because you have Alzheimer's disease doesn't mean that the whole ball game is over. So, that's the message that I have to impart to people. They're not given a prognosis. Unfortunately, it's a progressive condition. I can do some things to improve people's cognitive function and I could certainly change their environment to play to their strengths and avoid their weaknesses. But it can't change the fact that the condition is going to progress. So, you have to plan for the challenges ahead. And you can't assume that things are not gonna happen for a million years. So, you have to say, all right, well, you're still able to drive, but the time's gonna come for anybody who lives to be old enough when they probably shouldn't drive anymore. How are we gonna deal with that when it happens? What happens if you can't go up those stairs? What happens if you shouldn't be living alone? How are we gonna plan for those things in the future? So, think about transportation. How's the person gonna get medicines? Home safety. There are some other types of dementia that are not as common, but they're still very relevant. One is so-called vascular dementia, which you get from having multiple strokes or other sort of phenomena like that. I don't know, who invented the term mini-strokes? I've never heard any doctor use it. But when you hear it, it usually means what we would call a lacunar infarct. Something that you would discover on imaging, but the person wasn't walking down the street and had a stroke clinically, so you find them afterwards. But people with a lot of these may go on to develop vascular dementia. It has a less gradual onset and the progression may be kind of step-wise. Do okay for a while, then go down a step. Do okay, go down a step. And we might diagnose that because your cognitive deficits are not so global. They're sort of patchy. Maybe we do a CAT scan or an MRI and we see a lot of little bits of brain damage in there. Maybe your exam, you've got a paralyzed arm or if you can't see out of part of your field of vision, something like that. Dementia with Lewy bodies is an interesting one. These people develop fluctuating symptoms so they can have very good moments in the day and very bad moments in the day. They tend to develop Parkinsonism so some of the symptoms of Parkinson's disease, a slow walk, a tremor, muscle stiffness, they tend to have visual hallucinations. And then front of temporal dementia, even rarer, even more unusual, they often present with personality changes or speech problems. I had a guy who drove past Connecticut. He was on his way to Connecticut for a business meeting and he drove through the whole state and then noticed he had driven past Connecticut. He turned around, drove past it again. At this point he was six hours late for his meeting so he went home and the next day they fired him. He didn't get a diagnosis of front of temporal dementia until two years after that. They tend to have a younger onset and a more rapid progression. Parkinson's disease is also a very common condition in elderly people. My father had it. I watched him go through some of these changes and they have a lot of interesting psychiatric manifestations and I've spent some of my time working with movement disorders neurologists so I've seen a lot of Parkinson's patients. The motor features are a tremor that is sometimes described as pill rolling. It makes the person look as if they're rolling a little pill in their hands like that. They tend to have other kinds of tremor. They tend to have a slow walk. They have trouble initiating movements. They tend to be stiff. They suffer from a lot of depression. They also suffer from the symptom apathy. Apathetic people aren't sad. They just have no motivation. They don't wanna do anything. If you put them in front of the TV they'll watch it all day long. If you turn the TV off they'll watch the empty screen all day long. They spend a lot of time in bed but not necessarily asleep. Very common in people with brain injuries and various kinds of dementia and it's not the same as depression and people will think the person's depressed but they don't answer yes to any of the depression questions. They're not terrible. They're not sad. They're not self critical. It can coexist with depression but it's different. Emotionalism. You're gonna hear words like this all the time. There are a million words for the same condition but people that are losing their inhibitions. Their emotions are kind of out of control. They may become irritable. They may become tearful. They may laugh for no reason. They may do impulsive things. This has to do with this frontal issue, this executive function issue. Anxiety. Very common in Parkinson's disease and psychosis by which I mean delusions and hallucinations. So I already talked about the clinical features. Their cognitive deficits are what we would call a subcortical pattern. So Alzheimer's disease is your typical cortical dementia. The cortex is the outer part of the brain. A nice wrinkly part of the brain. And when you have a cortical dementia, you have diseases that affect the cortex mostly. You have forgetfulness. Short-term memory is much worse than long-term memory. You have trouble remembering to complete tasks and things like that. Disorientation. But those people tend to retain their personality and lie their social skills. Talk to somebody with a cortical dementia and you don't realize there's anything wrong with them until they begin to repeat themselves or you ask them what year it is and they say it's 1952. Subcortical dementia, there's a lot more personality change, a lot more executive function problems, a lot more mood problems. You see subcortical dementia in diseases that affect the inner parts of the brain, under the cortex, the subcortex, like Parkinson's disease, Huntington's disease, certain kinds of strokes. Depression is very common in Parkinson's disease. Maybe about 40% of patients who suffer from it at some point can be moderate to severe in intensity and frequently also associated with anxiety symptoms. So then the question always is if somebody's got a bad disease and they're depressed, what do I make of this? Is it a reaction to having a bad disease? Some of these diseases are fatal. Who wouldn't feel depressed? When I would talk to people about Huntington's disease, they'd say, oh, you're a psychiatrist. What kind of problems do Huntington's patients have? And I'd say, well, they have a lot of depression. And they'd say, well, what is Huntington's disease? And I'd say it's a fatal progressive hereditary condition. They'd say, oh, yes, who wouldn't be depressed? Well, the answer is they're depressed in complete out of proportion to other diseases that don't affect the brain. So if you look at people, for example, with kidney failure who have three years to live, there are nowhere near as depressed as people with brain diseases who have three years to live. So there's always the question, is this person upset about their prognosis and their suffering or has the disease affected their brain in such a way as to cause depression? And the answer is, in individual cases, it can be hard to tell. We know there's some contribution of both. Depression sometimes shows up in people before they develop the Parkinson's symptoms and they never had depression before and it could actually be an early sign of the condition. That certainly sounds like a brain problem. Other times, it's the other way around. If you improve someone's motor function with Parkinson's disease, they don't tend to become less depressed, has a life of its own. If you treat their depression, their motor problems tend to improve. So there's a lot we haven't disentangled about these things, but I would not assume that they're upset about having Parkinson's disease. Why wouldn't I assume that? Because I can't change the fact that they have Parkinson's disease. So if I assume that their depression can't get better, I'm not gonna do anything to try to improve it. So I think it's safer to assume that it will respond to treatment. They're an anxious bunch. People with Parkinson's disease have a lot to be anxious about. They fall a lot. Their body sometimes doesn't respond to instructions to get up and move. They can sometimes freeze solid. They worry about their future. So I think that definitely contributes, but probably something also has to do with sort of the brain disease aspect of it. Sometimes you find it together when depression sometimes different. But it's distinct from understandable worry. The problem in psychiatry is everybody has an opinion. Nobody says, here's my opinion about the liver. But in psychiatry, they're like, oh yeah, who wouldn't be worried? That's perfectly understandable. But that doesn't mean it is the explanation. That's just something we made up. So to find out whether it is the explanation, you have to say, is there a way to design a scientific experiment that would answer this? What if we compare this group of people to that group? What if we look at their brain? What if we try this treatment or that treatment? It's probably some combination of biological and psychological factors. I had a guy with Parkinson's disease and if you distracted him, he did okay. So his wife was ready to pack it in because he would follow around the house all day long. If she went to the bathroom, he'd be standing at the door. When are you coming out? So she enrolled him in an adult day program and he would do well for about three quarters of the day there as long as it was a really good program, as long as he was kept distracted and busy, do okay. And then the last quarter, constant obsessing about whether she would pick him up on time, had she fed the dog what was gonna happen. So he was just as anxious the last part of it. But I think as far as anyone could tell, his quality of life was a lot better, the first three quarters of every day and his wife's quality of life was a million times better. And she was the person keeping him out of the nursing home, out of the hospital, out of the grave. So you have to take care of these family members because that's my most important tool. And if they can't do it anymore, then what's to become of my patient? Apathy is common in Parkinson's disease. Like I said, it's a state of diminished motivation. About 12% of Parkinson's patients have an apathy syndrome and don't have depression. And you wanna tell the difference. Emotionalism, this word I used before, inappropriate, unmotivated sentimentality, about 40% of Parkinson's patients report increased tearfulness. But you'll see this in every kind of dementia. And it doesn't imply that they are depressed because the tearfulness might only last a few minutes. Sometimes it's, the slightest thing can set it off. Like what college did your mother go to again? Oh, my mother was a beautiful person, that sort of thing. And then is gone a few minutes later. Let's talk about stroke a little bit. So I know Dr. Reginald talks about post-stroke depression. There are also post-stroke anxiety disorders. I had a guy, he got hit by a falling air conditioner unit and he had a severe head injury and he came out of it with an anxiety disorder. If somebody asked him for the time, he would throw up. He finally got better after years with a combination of cognitive behavioral therapy and medication. And he got so well, he was able to go back to the old country and visit his mother and that sort of thing. So he recovered over time. And maybe some of it was his brain kind of forging new pathways and repairing the injury. Other conditions you can get are, so pathological affect, this is the same thing as emotionalism. Whichever doctor you talk to, whatever specialty they're in, whatever disease they work on, they have their own name for the same condition. But affect refers to expressed emotion and pathological affect, they cry for no reason, they laugh for no reason. You can even have a post-stroke psychosis where people can have delusions or things like that in severe cases. Catastrophic reaction I wanna draw your attention to. This is when a person with some kind of a cognitive deficit can't cope with something, they can't understand something or they can't carry out some task and they freak out basically. They react as if it were catastrophe even though it's minor. So in a milder case, there was a lady that I took care of and her daughter would leave her alone during the day while she was at work. And most of the time, she's perfectly fine. One day she calls her daughter on the work phone and she's crying and screaming out of control. Her daughter thinks the house must be on fire. She says, I gotta go, drops everything, races home. Turns out it was a bad rainstorm the patient, my patient, the woman's mother, couldn't figure out how to close the windows and water was getting in the house and she couldn't operate the window latches. And she meant to just call and say, how do I operate these windows? And was tearful and distraught. In a more severe case of dementia, a guy's supposed to get on the bus to go to the senior center and he can't any more kind of figure out how to coordinate his movement. So he's got one foot on and he's standing there. So someone very helpfully comes up behind him without telling him what they're about to do and start shoving him. So what do you think happens? Flailing, yelling, fighting back, lying on the ground, catastrophic reaction. So remember this line from the book The House of God in an emergency, first take your own pulse. So if a catastrophic reaction is going on, everybody takes a big step back, you don't try to force the issue, you allow the person to calm down normally, wait, you'll forget about it, try again a little bit later. Post-stroke depression maybe about 35%. At one point we were very solidly that it mattered exactly where the stroke was, what side it was on. The evidence for that is not as strong as we thought perhaps. Diagnosis can be difficult if the stroke is real bad, the person may not be able to communicate very well. We expect people that have had a big stroke to be sleepy or withdrawn or have a poor appetite. So it can be hard to tell, am I looking at the stroke itself or a complication like post-stroke depression? But they can last for years, the average one lasts about nine months and they do respond to medications in controlled trials. So again, you don't wanna say who wouldn't be depressed if they had a stroke, you wanna say this is a really significant depression and probably the risks of treating it are lower than the risks of allowing it to go on like this because this person is not eating properly, not taking his heart medicine, not getting out of bed. And post-stroke anxiety disorders I've mentioned again, they're associated with a poor recovery of function. ADL stands for activities of daily living. Benzodiazepines are generally speaking always the wrong answer in geriatrics psychiatry, especially in somebody who's had a stroke, they fall down, they hurt themselves. The most important personality characteristic you have to have to practice geriatrics psychiatry is the heart of stone because all day long, you're telling people no, you can't take Xanax, no, you can't take opiates, no, you can't have something to help you sleep at night, you need to get up and move around, that kind of thing. Again, it's said with love, but there's a lot of no in this field. Seizures in the elderly are usually caused by a number of fairly common conditions like strokes that leave scars in the brain that are irritable, alcohol withdrawal, Alzheimer's disease causes seizures in some people, cerebral vascular disease and electrolyte disturbances, which they might be more likely to get because they have kidney problems or liver problems, that sort of thing. So the treatment is to resolve the underlying cause. But then the question is should I give an elderly person an anti-seizure medicine? Well now the calculus is different in an old person. These medicines run around in your brain 24 hours a day. So if you have somebody that has one seizure, maybe we're not even sure it was a seizure, they think they saw something, the person goes to an ER, what happens they get slapped on a seizure medicine, send back to their primary doctor, maybe they have one neurology follow, nobody ever goes to check on it again. Three years later they're still carrying around this medicine. And I'd say he had one maybe seizure, he doesn't drive a car, he doesn't climb ladders, he doesn't take baths by himself. If he had another seizure, it's probably not going to kill him. Did you consider the costs of being weighed down by this anti-seizure medicine that he's carrying around 24 seven? So the calculation is different with an elderly person because they're more sensitive to the side effects of the medicine. Everybody know this guy and recognize this ad, right? So this is Danny Glover in the, what is it, New Dexter I think is the drug. And he's talking about pseudo-bulbar affect. Oh, God help us. That's what happens when you let the neurologist name the condition. I'm not even good, it would take me half an hour to explain what pseudo-bulbar affect is, but it's the same thing as I've been describing all this time. It's the same thing as disinhibition, emotional incontinence, emotionalism, hyperfrontality, whatever name you want to call it, it's this loss of inhibitions. And there's sort of a positive and a negative side to it. There is the positive side, irritability, impulsive behaviors, poor judgment, and the negative side, apathy, withdrawal, lack of speech and activity. And it's associated with a lot of conditions. Head trauma, frontal lobe tumors, strokes, Tourette syndrome, various neurodegenerative disorders like Huntington's disease, Parkinson's, front of table dementia, Alzheimer's disease, intoxication can all cause this. Some of these are reversible like intoxication, some of them are permanent. This guy, this is a man named Phineas Gage. Who is he? Why is he holding that pole? How come he's only got one eye? Oh my God, that's why he's only got one eye and why he's holding that pole. So he was a railroad worker. He's like the index frontal patient, right? He was a railroad guy building the railroad. He was a foreman, so he was a person of authority. And they were using dynamite or gunpowder explosives, whatever they used in those days. And he had this tamping iron that they used to tamp down the charge and it went off, which was an occupational hazard. And it went right through his head and shot out the top of his skull and landed several feet behind him. He survived it miraculously. And actually, he made money at some point by exhibiting himself going around like this and posing for pictures. I don't know if that was really the tamping rod or if he just got another one for the picture because he couldn't work at his previous job anymore. But the most important thing were the personality changes that he had. And he was described by the doctor that treated him as he was now fitful, irreverent, and grossly profane, showing little deference for his fellows. He was also impatient and obstinate, yet capricious and vacillating, unable to settle on any of the plans he devised for future action. His friend said he was no longer gage. Now, he wasn't the same man. He was hypofrontal. He had a dis-executive syndrome. He had that same condition. But in this case, people realized what part of the brain could cause it because they knew what part of the brain that huge iron rod had gone through and took out the poor man's frontal lobes. For many years, we didn't know what the frontal lobes did. People tried removing him from dogs. They seemed the same. There were people with injuries. They couldn't figure out exactly what was wrong because what they do is so subtle and yet so important that you weren't paralyzed after a frontal lobe injury. You just had a different personality. Let's talk about conditions that are complicated in the elderly. Elderly people have more depression than young people, maybe about three times as much. You need to consider depression in an elderly person when there's a change in their behavior or a decline in their function that's not explained by something else. And then there's always the same balancing act. Should I regard this person's low mood as being understandable or should I regard it as being pathological? And what's the right way to try to help them to feel better? So elderly people have accumulated a lot more losses. They lose spouses. They have physical problems. They have financial difficulties, things like that. So are their feelings normal? Will their mood respond to treatment? If so, what kind of treatment? Do they need counseling? Do they need medication? Do they need a change of scene, more support? Those are the puzzles you have to deal with. You can confuse depression with other conditions that are common in elderly people. So depression and dementia can look like each other, right? Demented people can be withdrawn, not talk much. They can be tearful. Bereavement, right? That's a normal phenomenon and expected to last a long time. The most stressful thing that can have a new person is the loss of a longtime spouse. It's even worse psychologically than the loss of a child. If you've been married to somebody for 50 years and they die, you are not likely to survive another year. So I deal with a lot of people that are dealing with that and it's six months later and people think it's supposed to be over and it's not and there's nothing wrong with somebody who's still grieving after six months after losing a long term spouse. That's actually normal. Chronic pain, very common in elderly people. And they may have somewhat different symptoms. So elderly people in general, they have a lot more aches and pains. They may be more focused on bodily issues. So the person may keep coming to the doctor with abdominal pain or some kind of discomfort. You can't find any explanation. You might think, well, does this person perhaps have depression? And also depressed elderly people complain of memory difficulty that they don't in fact have. So if you test them, their memory is normal, but they're convinced that they're losing their memory because of depression. There's also this condition pseudo dementia, false dementia. It's not really a false dementia. What it is is a reversible dementia. I prefer the term the dementia of depression. And so this is when a person is so severely depressed that they look like they have Alzheimer's disease. They can't answer any question. They won't get out of bed. They're slow to respond. But they may not be tearful or obviously depressed in those other ways. And it's possible to have both conditions. You can have depression and dementia and each one can make the other one look worse. And it's more common in people that have a history of mood disorders in people with dementia. That is, if you have dementia and you have a family history of mood disorders, you're more likely to become depressed in the course of that. Catastrophic reactions I talked to you about already. If somebody is having anxiety issues, an elderly person that seemed to exist on their own, there are some important questions who ask about it to figure out what approach to take, right? Because we know we don't want to medicate these people with tranquilizers. So instead of reaching for that, you say, well, let's do some more analysis of the situation in the first place. So are they anxious all the time or do the anxiety episodes come in discrete intervals? Is there anything that seems to cause them or make them get better? Are there environmental stressors going on that weren't there before the anxiety episode started like a new caregiver or having to move to a different house or a new medical problem? So you start with environmental and behavioral management. See if we can avoid the thing that's setting off the anxiety. See if we can do the things that seem to make it better. The role for medications is limited. Tranquilizers are almost always a terrible idea. So some antidepressant medicines, as some of our speakers have said, will help people with anxiety over a greater length of time. There are medicines like Busebarone or Busebar that can help people with anxiety over some length of time. Maybe not as powerful as benzodiazepines, but definitely works in my opinion. I think Busebar is actually pretty good medicine. A lot of doctors turn their noses up at it. They think that people are like man-eating tigers. You know, once they've tasted human blood, there's never going back. They'll say, oh, you can't give Busebar to somebody who's had Xanax. If they've had Xanax, they'll never take Busebar. I don't think that's true. So I think that's a medicine I'll put a little pitch in for. I kind of like it. And then let's talk about treatment issues related to age. So medication issues in older people are a very great concern. There are age-related changes in metabolism and what we call clearance, which is how your kidneys and liver get rid of drugs and their breakdown products. There are a large number of other medications that elderly people take. So when I get somebody admitted to the hospital, and maybe I'm afraid they're delirious, or I want to add a new medicine, and I want to leave room in their brain for my medicine, I look down and I say, well, how many of these things are absolutely necessary? You know, do we understand what each of these is for? Did anybody go back to see if it was working? Could they live without it? Oftentimes I can get rid of half the medicines on the list. They're like a Roche motel. Medicines check in, but they never check out again. They see a lot of different doctors. They're all prescribing medications. It's very important for elderly people to have one primary doctor that knows their whole medical case. You won't always be able to have that person be a geriatrician, although it would be nice, but there's not a lot of them either. But somebody's got to know the whole case. And you also have to think about drug-drug interactions, not just how many drugs, but how do they interact with each other? And you have to think about, can they afford all these medicines? So sometimes you give an elderly person on a fixed income an expensive medicine. You didn't do your homework to think about how much it costs. You don't know how much their other medicines cost. They don't take it. Or they stop taking one of the other ones. Or they take a medicine every other day that doesn't work if it's taken every other day because they're trying to save the money. So you have to, are you able to afford these things? And there often are inexpensive choices that you can make. Sometimes they're not ideal, sometimes they are ideal. So the latest and greatest, most expensive medicine isn't always the best one for somebody. And elderly patients are very easily made delirious. And that can look like anything. And so delirious people are brought in thought to be psychotic, thought to be demented all the time. The way you recognize delirium is there's a relatively acute onset and they fluctuate typically. So they'll say, well, how can you say he's delirious? He was sharp as a tack this morning. And you're like, well, that's kind of the definition of delirium is that sometimes he's looking good and sometimes he's looking bad. This fluctuation is part of how I can say that he's delirious. There are a lot of medical conditions you can't diagnose looking at the person once. You have to see them a few times. They have disorganized thinking. There's some alteration in their level of consciousness. They can't pay attention to anything. And they tend not to remember anything that happens or is said to them because they're not forming new memories because they're not taking in the information in the first place. So there could be inappropriate behavior. They can be fearful, combative, even violent. They're disoriented. They can see things, hear things. Visual hallucinations are really not common in most sort of garden variety psychiatric conditions. Patients that come into ERs and say they see things are often putting on a show. People that really see things usually have either eye disease or delirium or a small number of unusual forms of dementia. So if you have a loved one that's seeing things, that's pretty serious and you wanna try to figure out what it is that's going on. And there's two flavors of delirium. There's the hyper-vigilant type that you commonly see in drug intoxication and you see it in alcohol withdrawal. The DTs, delirium tremens means I'm delirious and tremulous at the same time. You know, this is the person who's delirious like in the movies. He's delirious, Jim. The other kind of delirium where people are just lethargic and you can't keep them awake and they fall asleep in the middle of a conversation. That can be very dangerous and it's often not diagnosed. Everybody at hospital is sleepy and in and out. So they never put delirium on the list of conditions when they go to see the guy, but that's what he's got. Delirium is very expensive. So it's an extremely common condition in hospitalized elderly patients and maybe somewhere around half of them are undiagnosed as I just said. It's associated with a mortality rate anywhere between 10 and 65% because whatever's making you delirious is probably a pretty serious medical problem and there's an enormous financial impact. So 7% of people over 65 become delirious annually and way back in 1998, the cost of delirium was estimated at $8 billion. My father became delirious all the time. My stepmother would call me up and say, you know, he's seeing flying French toast and he thinks his doctor's trying to kill him and oh my God, is he ever gonna be well again? I'm like, this is delirium. Tell him to dial back his pain medicine, put the light on in his room, have somebody sit next to him to remind him what's going on, this'll clear. Three days later, he's clear again but he's very easily made delirious because he was an elderly person with Parkinson's disease taking a bunch of other medicines and he had an infection at the time. And I told you about their impairment. This is Dr. Beers and some of you might have heard of the Beers list or the Beers criteria. So Dr. Beers was a geriatrician who I think did part of his training at Tufts and then I think maybe Harvard and then he worked at UCLA and he discovered that a lot of the elderly patients he was taking care of were being hurt by the medications that they were being given and so he did a big project where he and his associates studied 650 people that lived in nursing homes and they looked at their medications and the outcomes from it and he said, there are certain classes of medication that it's really just not very safe to give to elderly people because they can't metabolize them properly and they don't handle them well and among these were benzodiazepines, certain old fashioned antidepressants, opiates, some medicines, the medicine Ditcher pen that you don't see much anymore that was used for urinary incontinence was not a safe medicine to give to elderly people. Well, who develops urinary incontinence mostly elderly people? So here they were being given the very thing that they weren't supposed to be taking and in some cases it wasn't even working. So in my assisted living study I would interview a person who smelled of urine, I look at their med list, Ditcher pen is on the list, it's like it's demonstrably not working and it's on the beers list. Dr. Bier suffered from juvenile diabetes. So he only lived to be about 50 years old or 54 years old. He lost both of his legs and he became an advocate for amputees and helped people like that and God bless him, he worked very hard in the service of his patients right up until the end but he may have been more sensitive to the things that could go wrong because he had such a significant medical problem himself and his name remains enshrined in the beers list. So today it has 53 potentially inappropriate medications and classes, those things that should be avoided in the elderly. Now never say never, I've given all of these at some point if there was a really important reason to but I was aware I was taking a risk but there are some that should be avoided in the elderly, some should be avoided in the elderly people with certain conditions like poor kidney function and some should be used with caution in the elderly and it's periodically updated and it's based on the review of the scientific literature and outcome studies and this list is kept running. So I mean if you wanna be a pain, if you've got your dad at the doctor and the doctor says I'm gonna do this and that and change all these medicines, you'd say well now did you check the beers list or any of these on the beers list? Sure that you went to this lecture. So some beer drugs, antihistamines, old tricyclic antidepressants like Allerville, right? A good antidepressant works great but difficult to tolerate not a great idea in elderly people and there's a lot of old-timey docs giving that out for sleep and that kind of thing. They're safer choices. All of the anti-psychotics carry a warning that says if you give them to demented people for their behavior they have a higher mortality rate. What do we do about that information? Well we don't stop doing it, we don't have a whole lot of better alternatives, we're not gonna give them tranquilizers which are even worse. We just know that. They're powerful drugs that affect not just the brain but other parts of the body and so probably a lot of powerful drugs we give to elderly people might be associated with higher mortality but if the issue is if you don't do something about it this person is gonna hurt someone or they're gonna get thrown out of their assisted living or they're nursing home, we need to try something but have a reason for everything you do, use the drugs in modest doses, go back frequently to look and see if they are working and if the person's doing well go back and say maybe he doesn't need it anymore and let's think about a trial discontinuation. That's what I've done with that information. Benzodiazepines, chronic use of sleeping pills, Zolpidem is, what's the trade name of Zolpidem? Real popular sleeping pill now, Ambium, right, right. All of these say not intended to be used for the rest of somebody's life but we don't really follow that. Did Japan, and finally I just wanna end with a note of hope and then I hope we might have time for a few questions. Incurable does not mean untreatable. Like I said, the world is full of incurable diseases. Untreatable conditions may have treatable consequences so even if I don't have a treatment, say, for Parkinson's disease it will reduce its effects, I can improve the tremor, I can improve the depression, the anxiety, those kinds of things. And patients and families benefit from education, prognosis, support, and regular follow-up. So if you had told me I would have gone into this branch of medicine 20 years ago or I guess now it would be like 25 years ago, I would have laughed, are you crazy? Those, you know, a lot of those patients can't even talk, they're all dying, they've got these depressing conditions, why would I wanna go into a field like that? I love my field, you know, I can triple somebody's function on a good day. I get a lot of my enjoyment from talking with my patients but also talking with their families and their caregivers. What you need is an upbeat attitude, a good sense of humor, you take your victories where you see them, I am not a saint. The saints burn out in a few years and they're like, you can't help these people, right? They don't have enough professional detachment to be able to do this. I didn't go into child neurology because I didn't think I could take a steady diet of watching children suffer for the rest of my professional life. I knew I didn't have maybe what it took for that field. I had what it took for this field. So if you have the right mindset, you can do it forever and there are lots of victories and people get better all the time. People recover from these conditions, don't listen to people that tell you, oh, these are permanent, you'll never get better, you know, you'll never recover from this. Recovery happens all the time in every branch of psychiatry, depending on how you define it. And even if I didn't have any effective treatments, people have been coming to doctors for thousands of years. So clearly they've been getting something else all of that time. If you went to see Hippocrates, there was almost nothing he could do for you. I mean, by modern standards, he could pull an arrow out of you if you've been shot with an arrow and he'd probably give you an infection while he was doing it. But what did he do? He told you what your condition was. He told you what to expect, probably fairly accurately what to expect. He taught you ways to cope with it and make it better and you could keep coming back and seeing him and he would continue to give you this message of hope. We all have to die, all right? So all I can really do for anybody is try to make their life better in the time that remains to them. And when a patient of mine dies, which happens a lot, a family member, I've done a good job, will call me and they'll say, Dr. Rosenblatt, I wanted to tell you that dad died. And I'll say, oh, I'm so sorry to hear that. And they'll say, we want to thank you for everything that you did. And I usually think to myself, and sometimes I'll say out loud, I wish it could have been more, I'm sorry, you know, I did the best I could. And they'll say, well, we think it was enough. You know, you definitely made his life better. You told us what was the matter with him. You helped him cope with it. You were always there to answer questions. You know, you saw it right through to the end. You never stepped away from the case. You never seemed squeamish about it. You know, you talked straight to us, you were supportive. You know, and that's a good day for me. You know, it might not be for everybody, but I think geriatrics and neuropsychiatry is a great field. And you can always give people what Hippocrates could give them, even if I don't have the latest or greatest. So I don't mean to make fun of people that do laboratory research. They make the stuff that I give people today, but they mostly made it 20 years ago. So if somebody's working on it now, it's probably not coming out tomorrow. So that's the bulk of it. And if we've got some time, I'd be happy to take some questions from the audience. If possible, isn't it better to keep an elderly person or relative at home rather than unisoning them to the nursing home? Well, sure, I think that's almost always true, if possible. I mean, barring if the home situation is dangerous or abusive or something like that. But elderly people, particularly elderly people with dementia, they do learn new things, but they learn it slowly. And so a change of scene can be very disruptive, and it may take a long time to get over that. There was a patient I remember, his son brought him up from Florida because he wasn't making it in Florida. He brought him to live with him in Maryland. And he said, I thought I was doing the right thing, but my dad is so confused. He's up in the middle of the night. He peed in the trash can last night instead of the toilet. What do I do? And I said, you know, I examined the patient. He wasn't delirious, you know? And I said, it's the disorientation of the move. You did what you had to do, but it's gonna be a while before he learns his new environment. So I think we're possible, but we also have to be good to ourselves, you know? So if a family member is faced with having to quit their job and take their kids out of college, you know, in order to render 24-hour care to their parent in their own home, at a certain point it's a bridge too far. So I think we're possible. We always try to keep people in the home. I have a good friend Quincy Samus at Hopkins that's been running a project called The Mind at Home, which has to do with learning what can help seniors stay in the home and receive the services they need without having to be institutionalized without having to be in a different setting. So I think it's very important, but I also sometimes have to say to people you gotta give yourself permission, you know, because at a certain point if you're moving heaven and earth, you know, and that's the only criterion is not moving the person, you may be just doing more than is humanly possible. But yes, I definitely do agree that it's almost always better to keep people in a familiar setting, you know, with familiar people, with routines that they're used to and not disrupt that because they may not even live long enough to recover from that disruption. Yes, at the microphone? Hi, I'm a case manager with the Department of Aging and Disabilities in Anne Rundle County. And I have two things that I kind of encounter a lot. One is some of my clients who are similar to in the black community where they say I'm not crazy. And they refuse to go see a psychiatrist because of that or a neurologist. And I also see doctors who think they have tried everything. And I'm not a nurse, I'm not qualified to make medication changes at all or even suggest them. But when I see things like that where they're on a medication that might be affecting them negatively, how would you suggest approaching a doctor, a primary care doctor? That's a tough one, you know. I mean, I think if there's a family advocate that you can insert in there, they typically have more pole. Sometimes the primary care doctor, you know, and again, I rely very heavily on primary care doctors, but sometimes the primary care doctor may be in over his or her head. You might suggest the person have a geriatric consult and say, well, what would you think about having a consultation where the person would go visit a geriatrician and they could look over everything? Sometimes the primary care doctor will say, oh, thank God, that's a great idea. I love that, you know, and so they won't get their backup because it's another doctor, you know, a subspecialist giving them the advice instead of somebody they don't regard as medical, you know, can be a way to do it. Occasionally you're gonna find somebody who's such a bad egg that you would need to say to the family, you know, maybe you should try going to see somebody else for a change and just see if you do better. That's a last resort. You know, I don't like to take people's patients away from them or cast aspersions on somebody. I wanna elevate everybody if I can. But sometimes you may not have a choice. People that won't accept help, I think persistence and getting the same message in a loving way from people that care about them, you know, most people eventually come around. I've said to a lot of families, look, I don't know how we're gonna get from point A to point B, but just about everybody will eventually get there if we're persistent, not too many people, you know, and then sometimes you really have to, you know, there's a lot of issues where if you're the child and you're now, you know, my age and you've got a parent in their 80s and they won't do what you say, that's not the way the relationship has flowed your whole life. So you're like, I can't make my father take his medicine or make him go to a doctor. He makes me do stuff like that. So sometimes you have to strengthen that family member's hand and you have to say, well, now what would you want him to do for you if the situation were reversed? Or what do you think he would have told you to do if it were 20 years ago and he could have looked in a crystal law and seen this scenario? I mean, you know, you can't be responsible for him falling down the stairs and dying because you wouldn't do it. So you may make him angry, but if you get everybody in there, sometimes you've got to say, and I had to kick my dad's butt a bunch of times. I didn't have to resort to legal measures, but he would threaten to sign out of the hospital with something and I'd say, it's a six hour drive to New York. Don't make me come there just to tell you this to your face. Stop acting that way, Dad, you know, come on. This isn't you. He'd be like, I'm sorry. You know, so sometimes trying to, you know, trying to strain them in the family's hand, most people will eventually come around. Sometimes you've got to take decisive action, but that's a last resort. Things like guardianships and I don't like to involve the lawyers unless it's absolutely necessary. I just wanted to mention is a possible alternative is to think about the visit with the PharmD at the pharmacy to review the medications where they can do a medication treatment management, which is covered under Medicare, which they can reconcile some of the issues with the medications, which may, if you're reporting there's a side effect, et cetera, they could make the recommendation and help the family negotiate that as well. That's a very good suggestion. You know, I rely on pharmacists a lot. I've worked with some terrific ones over the years and I'm always calling them up and saying, I'm thinking about doing this and you know, what do we know about that combination or what do you think might happen? And then also if the doctor is getting a reminder from a pharmacist, they have to take it kind of seriously and they'll say, well I noticed you got four meds on the beers list and you have these two that aren't supposed to be combined and you know, what's your advice about this doctor? And when I get one of those, I have to respond. Now sometimes my response is I'm aware of that and I think that it's worth it and you know, here's why, but other times I'm like, oh, I didn't catch that. So pharmacists are playing an increasing clinical role because there are not going to be enough doctors to handle all of these things directly. So we rely on our friends and colleagues in the helping professions, which includes pharmacists to see our way out of these things. That's a good suggestion. Anyone else? Yes, doctor, I have a comment. Yes. Where's it coming from? I just want to look at you. Oh, there. Yeah, I have a comment and a question. Sure. First and foremost, I'd like to thank you for giving us seniors a hope. You're very welcome. Now, I want to let you know that I'm a patient here at University Hospital. I have many doctors and talking about stroke. That's a stroke 18 years ago, so I'm a stroke survivor. I couldn't walk and couldn't talk through the help and the therapy that I got from this hospital and current in. You see me today. And you may have a problem with shutting me off. Here. Okay, I think I said both things at the same time. So thanks for listening. Thank you. You look like a million bucks. Would you happen to be on the staff here at university? What's that? Would you happen to be on the staff here? I am not. So I took a step back from being a fully academic physician and now I'm more of a clinical and administrative physician, but I'm on the staff in the upper Chesapeake system where I run the inpatient service and geriatrics. And we're trying to provide mental health to all of Hartford and probably a good hunk of Cecil County as well. And it's a very exciting project to be involved in and I'm very happy to be back here. But you have terrific physicians here and I know you'll be well taken care of. I'm abundantly blessed because all of my physicians are housed here at your birthday. So they track me. Thank you very much for your comment. That's a great testimonial. We appreciate that. Let me be clear. The upper Chesapeake system is part of the University of Maryland Medical System. So the University of Maryland Medical Center is our academic hub for the 14 hospitals that are part of our system. So he's part of us. Part of this family. If you come up there I'll be happy to. And I'm gonna ask the last question before we talk about lunch. This question comes from U.M. Capital Regional Health down in Chevrolet. And the question is when is hospice the viable or best option? Oh that's a good one. Hospice is very important and I have great respect for people that work in hospice and in palliative care which is really the name of the medical field that concerns people in hospice and things like it. Generally speaking most hospice is at home. So a place like Gilcrest or something like that where somebody might go and die in hospice is usually the last few days maybe the last week or two of somebody's life. So when we speak of hospice most people that are on hospice are on home hospice or they may live in a nursing home or assisted living and be on hospice there. And the concept is that palliative means making things better but we're not trying to extend the person's life anymore. We're trying to do things that will enable them to have the highest quality of life in the time that remains to them as they see it and to do the things that they wanna do in the time that remains them and to be as free of pain and suffering as they can. But you have to balance it because a person might take so much pain medicine that they then can't socialize with their family so they might wanna be more alert and how you balance those kinds of things. So it's a very important field of medicine and it involves lots of treatment it just doesn't involve trying to prolong the person's life anymore. And it's a whole medical specialty. Generally speaking to enter hospice, some doctor or group of doctors has to think that you have about six months to live or less. That's not hard and fast. Some people enter hospice and then change your mind and leave it. Some people enter hospice and live a lot longer than anybody thought they were gonna live. Those kinds of things. So it's a very personal decision. I do think that to enter hospice you should be dying of something, right? I'll come right out. I am not somebody that approves of things like physician assisted suicide especially like they have in some countries where the people are not dying where somebody will say, oh I have depression and nobody can treat my depression and so I wanna die. You know, I'm like, well that's kind of what happens if people are severely depressed. That's what I treat. Send it with me, I'll take a crack at it. So it's not that anybody can just say, oh I think I'd like to have hospice. You have to have a life limiting condition. So I think it's when somebody feels that they're ready to stop trying to prolong their life or maybe there are no more things to stop trying to prolong their life and they're ready to move into a different phase which is all about quality of life and the experiences that they wanna have for themselves and with their loved ones and with their family in the time that remains. And they might die a bit sooner as an unintended consequence of the pain, medication or the other treatments they're getting but that's okay because time is not the most important factor anymore at that point. And so I've often consulted on hospice patients and dealt with some of those kinds of issues. But, and there are cases where it's very tricky where physicians may not agree on how long the person has to live or may not agree on whether it's worth trying one more treatment or not. You know what the chances are that it might turn things around or not. And so there's been situations where I've said to a patient and to their family, gosh I don't really know. You know people are suggesting something for you and it's not inconceivable that it might work but the chances aren't fantastic. It certainly wouldn't be crazy for a person to say I don't want one more round of treatment. I just want to be made comfortable and have good times with my family. I don't want to spend that time in a hospital. I'd rather spend that time at home. It also wouldn't be crazy to say you think this treatment might buy me a few more years, I'm gonna roll the dice. Sometimes it just comes down to a very personal decision and I suggest the person gather their loved ones around and try to talk about it openly and I try to model for them being able to talk about topics like the end of life and suffering and that sort of thing in a way where I don't go all the pieces and that helps them not go all the pieces so that they can have the conversation that they need to have. I hope that sort of addressed it. I'm sure it did. Thank you. Would you all welcome? Thank Dr. Rosenblatt for his presentation. Thank you very much everyone.