Talk with the elder about their wishes while the elder can make decisions. They should be able to make their own choices without coercion; either regarding other’s opinions (finally coming out as gay and wanting a new relationship), or to not spend the money on the elder’s care that is the elder’s to use.
With all that’s going on in our country, our economy, the world, and on social media, it feels like so many of us are under a great deal of stress. Caring for elderly or aging parents can be particularly stress-inducing. We know chronic stress can be as unhealthy as smoking a quarter of a pack a day. What are stress management strategies that people use to become “Stress-Proof? What are some great tweaks, hacks, and tips that help reduce or even eliminate stress when caring for our aging parents? In this interview series, we are talking to authors, and mental health experts, who can share their strategies for reducing or eliminating stress. As a part of this series, I had the distinct pleasure of interviewing Dr. Elizabeth Landsverk.
Dr. Elizabeth Landsverk, MD, brings over two decades of expertise in geriatric healthcare, boasting board certifications in Internal Medicine, Geriatric Medicine, and Palliative Care. As the founder of ElderConsult Geriatric Medicine, she has been a trailblazer in addressing complex medical and behavioral challenges for older patients. With roles at prestigious institutions like the University of California, San Francisco, and Stanford University, Dr. Landsverk’s commitment to geriatric medicine is evident. Currently serving as the Medical Director for Silverado and Kensington Dementia Care Communities, she is also a valued member of the Scientific Panel for the Alzheimer’s Association. Dr. Landsverk’s extensive experience and academic journey, including graduation from Stanford University, position her as a key figure in the ongoing dialogue surrounding elder care.”
Thank you so much for joining us in this interview series! Before we dive in, our readers would love to know how you got from “there to here.” Inspire us with your backstory!
After several years in Internal Medicine practice…after I had my 2nd son in 2 years, I went back for a Geriatric fellowship at Mt. Sinai Medical School ( 4 hours a day commuting, little sleep at night… all worth it.)
I found that particularly geriatric psychiatrists had incredible new treatments for dementia and agitation (many times getting rid of meds causing agitation, such as Benadryl and Ativan, or treating pain would do the trick). I learned how to calm agitation, relieve pain, minimize medications and organize the care team to allow the person with dementia to regain quality of life, not just sedate them to stop agitation.
I have had several who were bedbound, not really speaking, or walking over the course of months with medication adjustments, regain function to the point that they went home to more independent lives; including serving as a deacon in church.
After teaching for 5 years as an assistant professor of Medicine at UC, San Francisco, and consulting for the SF Elder Abuse Forensics Center, I started my house calls practice, ElderConsult Geriatric Medicine in the SF Bay Area. We have been busy ever since. We were called for patients who spent 2 months, 5 months in the hospital, in academic hospitals, or patients who returned to the ER 3–4 times a month for 20 years… until we worked with them to address undiagnosed dementia, get the needed care team in place and adjust their medications to improve quality of life.. not just sedate for agitation.
I found my niche. Elders with dementia were my Sudoku. It was/is such a joy to give elders their lives back. It was such an emotional and financial relief to the families as well.
What lessons would you share with yourself if you had the opportunity to meet your younger self?
First, I would be more kind to myself for not being mother who could always be at home. Being a single working mom is tough. I made sure I took care of my patients at work (important to be diligent with frail elders), and then was there for my sons.
Second, Scrutinize the leadership at any workplace. If they have policies that put profits greatly ahead of patient care or decent working environment or allow a lack of accountability for other team members… leave. There are better organizations that can use your talents- I’m talking to you primary care and geriatricians.
None of us are able to experience success without support along the way. Is there a particular person for whom you are grateful because of the support they gave you to grow you from “there to here?” Can you share that story and why you are grateful for them?
Rosanne Leipzig MD, the director of the Geriatric Medicine Dept at Mt Sinai Medical School, when I completed my fellowship in Geriatrics was/is inspirational. She built a dynamic program to develop geriatricians for leadership and research. I advise her new book, “Honest Aging” for solid evidence based medicine to stay strong as we age (spoiler… it is not from expensive supplements).
My research project was to audiotape elder’s initial visit with the faculty, then analyze it in 10 second intervals ( for a 40–90 minute visit) to categorize items that Medicare pays for… the evidence showed that Medicare does not cover 30% of what a geriatrician does from the get go. There are only 3500 full time practicing geriatricians in the US (pop 330M). There are not enough primary care doctors now as well. I am distressed for our nation’s health.
Are you working on any exciting new projects now? How do you think it might help people?
I developed ElderConsult Geriatric Medicine, a booming house calls practice in the SF bay area over 19 years. Loved the work, hated driving. My partner’s dream was to sail around the world. I am now writing you from a catamaran in the Caribbean.
My practice, now Dr Liz Geriatrics, pivoted to an online TeleMedicine practice, that to my delight works even better than house calls. I can be available to evaluate the same day for medical concerns and quickly come up with a plan of action; occasionally, that means going to the ER, but more often we will have a visiting RN see the patient and address the medical needs at home, instead of the ER, or waiting 3 weeks to see a doctor in the office.
We also have DLG Consulting, with seasoned nurses and care managers, with dementia care expertise available for online one-to-one consulting.
I have a book, “Living in the Moment: Overcoming Challenges and Finding Moments of Joy in Alzheimer’s and other Dementias” A “What to Expect…” for Dementia; that addresses the messy parts of the disease. From strange behavior to getting a diagnosis, to protecting from financial abuse, identifying problematic medications, and relieving agitation (particularly when behavioral interventions are not effective)- spoiler Ativan/Xanax often make behaviors worse long term.
Most important is our online DLG Community- to provide access to discussion forums for families or eldercare professionals to address challenging medical, social or possible financial abuse situations for elders… and for anyone over 50. We will provide support groups, a training module and an “Ask Me Anything with Dr Liz (me)” to share expert experience and studies to guide care in a poorly understood area of medicine… and life. I can help a few hundred families now, but want to get information out particularly to underserved areas from the Carib, to the Texas border to upstate Minnesota.
Ok, thank you for sharing your inspired life. Let’s now talk about stress. How would you define stress?
Stress is when the demands on a person exceed what they can provide and have time for themselves, exercise, sleep or taking care of their own medical needs.
In the Western world, humans typically have their shelter, food,and survival needs met. So what has led to this chronic stress? Why are so many of us always stressed out?
That is a big question. As a geriatrician? Or as a baby boomer who has seen the world change over the last 40 years? I’ll take Boomers for 80.
I see the world my 20-something sons are starting careers in. Everything is 10 fold more expensive, from housing to college, to oh, the cars and Tostitos coming in smaller bags for twice as much (suspiciously corporate profits are up, making up 53% of inflation for 22–23).
Tech entry jobs have vanished and retail jobs have erratic schedules that come out only days before planning a life (let alone a family) very difficult. Although wages are up most significantly since the 1960s and unemployment is at ~ 3% Those who make the least have improved the most in the last few years.. along with the billionaires who have doubled their wealth.
What are some of the physical manifestations of being under a lot of stress? How does the human body react to stress?
Emotional stress increases cortisol. Cortisol increases blood sugar, blood pressure, anxiety, decreases sleep… and by cascade increases risk factors for heart attack, stroke. Most dramatically from serious stress- such as Debbie Reynolds dying 1 day after her daughter Carrie Fisher ( it is a thing- it’s where voodoo death comes from, being scared to death…) can cause stroke and heart attack.
As humans we often try to make ourselves feel better, sweets, alcohol, tobacco, Ativan/Xanax and other substances to try to dull our pain. It’s another talk to discuss the problems of each of these substances on health. Basically, they all cause problems. Best to have a plant-based diet and exercise — actually, walking is my stress reaction (and chocolate)… that I do before anything else on bad days.
Is stress necessarily a bad thing? Can stress ever be good for us?
Managed stress is where great achievements come from. Having had a ring side seat on Apple product launch, they do it well, but there are many moving pieces, a lot of stress. And of course, there are the moon shots… talk about stressful, but amazing.
Personally, there is a sense of satisfaction in achievement.
It is important to have (some) control over one’s situation and not be left as the only person working endlessly, no pay, no time off… as some family members find in helping parents and then having the rest of the family want them to give up their lives for years for free with no help. Really.
Let’s now focus more on the stress of caring for elderly or aging parents. This feels intuitive, but it is helpful to spell it out in order to address it. Can you help articulate a few reasons why caring for our aging parents can be so stressful?
- It is NOT the natural order. Your parents raised their children. They often see the adult as their child, and may not want to take any direction from that person. The elder may have brain changes to make them more paranoid, which often focuses on the person caring for them. “You are trying to control me, taking my car (in unsafe driving concern) or my money, (when the elder cannot manage their finances)”.
- Elders may have undiagnosed early dementia which makes reasoning… impossible. They may be acting very irrational, but sound socially OK and have the doctors, and other act as if they should care for their own affairs… which they cannot do. For example, an alcoholic formerly successful 75 yo businessman who’s second wife is divorcing him. Get gets angry and yells in court, he is refusing help at home, cannot get anything done, including cooking for himself and keeping the home functioning, then yells at caregivers. He is better when treated with the appropriate meds (low dose Depakote) and his alcohol is slowly weaned off. The judge is deciding the division of assets and I am told this man will not have enough money to pay for 24 hour care… which he needs, since the assets (his wealth) will be divided. Our society does not see many cases of early dementia. The money should be there for his care and any left-over then divided.
(Off the record Rudy Guiliani should be evaluated, the US Attorney that brought down the mob, has had serious decline that led to him arranging a presidential press conference at the Four Seasons Landscaping parking lot; before he has to face court). - There may not be enough money to hire care or pay for assisted living. Families may decide that only 1 person has to give up their life as long as it takes to care for the elder (should never happen).
- Sometimes others are taking financial advantage or emotionally abusing the elder. Adult Protective Services is supposed to protect frail elders, but it is more difficult if not physical abuse or obvious theft or harm from the abuser. A new second wife was reporting a 72 yo man (again he had the wealth) had seizures, which no one else saw, then that he was agitated, in pain and ended up having the man sedated, bedbound, not eating in about 4 months and called for hospice… which took over care and then they waited for him to die. His son came to visit, saw him with a dramatic decline over 4 months and took him to the hospital. Many of the meds were stopped (no seizures seen by anyone) and he regained consciousness, started to eat and his son took him home and nursed him back to health. A very dramatic story, but variations are common. Protecting an elder from abuse can be difficult, if it is not obvious abuse.
- The idea the one caregiver “should” do it all alone. That person needs caregiver support groups. The elder’s assets are there for the care of the elder. Everyone needs help.
- “Medicaid Trusts” for high net worth elders… to save the millions for the heirs is so sad. First, it is financial abuse perpetrated by family members. Second, if mom has $5 million in assets, do you think she really wants to spend her last days in an industrial nursing home meant for helping the poor (which can be terrific for some needy elders).
Can you share with our readers your “5 Things You Can Do To Reduce Stress When Caring For Your Elderly Or Aging Parents”?
- Talk with the elder about their wishes while the elder can make decisions. They should be able to make their own choices without coercion; either regarding other’s opinions (finally coming out as gay and wanting a new relationship), or to not spend the money on the elder’s care that is the elder’s to use.
- Have a family meeting with extended family, so everyone understands the elder’s wishes. To know what to do when they decline. If an elder with early dementia wants to go to a ball game, take him to a B league which is easier to get in and out of… or get box seats to allow him to have space and not have to sit with a crowd. If that does not work well, it’s time for the big screen TV for the ball park feel. Sadly, because he had become paranoid about his son, this man had a conservator and the conservator refused to allow the elder to have any baseball experience besides the usual TV at home.
- Do not try to care for an elder alone. Their assets are for their care. Hire help. Get family to pitch in. Caregivers need to take time to relax, exercise, take care of their health.
- Keep the elder engaged in groups that were important, whether that was church or Rotary, as much as they can participate. When services are too long, arrange for the priest/minister to visit the elder. Keep them engaged socially, and music provides special joy… for everyone. I saw two men getting into an argument in a day program and the leader expertly started up a rousing chorus of “Take me out to the Ballgame” and the tiff was over. Masterful.
- Look into day programs, assisted living when care at home is not working or is not possible, or is too expensive. See our book “Living in the Moment:” for more discussion. The elder is likely to be resistant to change, but a day program where the men can play dominos, there is dancing, corn hole, or an assisted living community with engagement and care supervision can be life affirming…or a parking lot for elders who are parked in front of a TV without enough staff to care for the elders’ needs. Do your research. Do not be fooled by fancy building that look like a Hyatt- it is the people that make the place a home.
- As a geriatrician, I have seen many times when the ER doctor says there is no medical problem (and they have not done a work up) or the elder will die- just recently a man had COVID, stable vital signs, but was quiet, not eating much. The ER MD did not tell the family the pt had COVID or offer any treatment. He said the patient had respiratory failure and should be on comfort care. He was not following the patient’s wishes and had already decided this live was not worth attempting to even treat. I was told of the ER transfer and found that the elder was not eating, but otherwise fairly stable. And that the pt could be treated for COVID. I took that information to the family who then understood that treatment was possible and was in line with the patient’s wishes (with a no intubation directive). Yes, sadly, it is not a rare occurrence. The ER MD said the man would require weeks in the nursing home… so he decided the patient should not be treated. I knew this elder was chairbound and the care home would take him back as soon as he was treated and stable. And he did go back a week later. Get an advocate, care manager, better yet the primary doctor to intercede when an elder is admitted to the hospital. Agism, cost cutting and a seeming lack of concern for elder’s best outcome are distressing changes in our health care system.
- Avoid Medicare Advantage; needed care is often denied, doctors are harassed by insurance refusing medications unless burdensome “prior authorizations” (PAs) are done. What had taken me 20 minutes a few years ago to get approval for a needed medication in past years took over 5 hours and 7 calls to Carelon to work to get a needed medication that was critical for an elder’s treatment. It was still denied. Shocking.
Do you have any favorite books, podcasts, or resources that have inspired you to live with more joy in life?
Well, I find literature to be a source of joy. My favorite book is “Infinite Jest”, by David Foster Wallace which starts out very schizoid, unconnected and evolves with a crazy, convoluted story into (spoiler alert… it’s 800 pages, many won’t go there) into life affirming “old alligators” of AA (Alcoholics Anonymous) words to live by. Each page is a dense truffle of dialog and reading 1 page a day can be a pleasure.
I really enjoyed “Grant” by Ron Chernow (Strange how Ulysses looks like Robin Williams). He was really a loser until his late 30s, failed at farming, business. In the military, at the start of the Civil War, he was very sharp in planning, and he would never retreat… he would move to the side but not retreat and really pulled out Union from the jaws of defeat. Also great writing.
Currently, I am reading a collection of lectures Vladimir Nabokov wrote for courses on Russian Literature at Cornell University. I’ve started Gogol’s “Dead Souls” on VN’s say so. He does not like Dostoevsky, too mundane, but loves Tolstoy’s” Anna Karenina” — that goes on my list.
Podcasts:
I come from a long line of poor sleepers. I cannot have caffeine ( or more than a cup of decaf in the morning) or alcohol if I want to sleep. Melatonin and other sleeping pills gave me a hangover (I feel asleep at a stop light driving!). I listen to history podcasts. I have listened to all that Michael Duncan produced- The history of Rome, Revolutions. I have listened to Byzantium, Italy, England and now the History of Russian Rulers- very engaging… but also a suave voice to go to sleep by.
And of course Heather Cox Richardson, writer of books on the Civil War, the Republican party, defender of democracy, historian and chronicler extraordinaire compiling the daily events of our country and putting them into a historical context, with citations for historians in the future.
You are a person of great influence. If you could start a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
Cool. Queen for a day. I like it. Well, besides defending democracy- I have told my sons their inheritance is going for such causes, getting out the vote, particularly in areas of voter suppression, SURG.org is already doing great work as a volunteer voter advocacy organization.
Me. I see medical care being taken over by private equity, and even with the ACA (Obamacare) providing more access to millions of citizens, including those in my family; Americans still pay twice as much and don’t live as long as European countries with national health plans.
I am really living my dream (no, not living on a boat in the Caribbean, and going to Europe for the summer). I am working to develop an online community where people can get good evidence based medical information on staying healthy, strong and independent for all over 50.
A lot of my work is for elders and those with dementia, but now that I am a woman over 50 and have been rolled and disregarded, I want to have a space for women (and men) over 50 to talk and share.
Such as a 78 yo woman on the plane, told me as I mentioned I was divorced and getting used to the idea of dating again. “Be careful, they (men) will see you as a nurse or a purse”. Wise words.
I went scuba diving a few days ago in West Caicos. There were 4 gray haired women out there… out of 10 divers. No need to stop exploring as you age… just make sure you take care of yourself and stay strong. Or get strong, it’s not too late.
Anyway, back to the greatest good. If I could extend the online community to area that don’t have doctors — the Texas/Mexico border, the Caribbean, communities that don’t have access to top flight medical care- and alert them on what medications to avoid, what to do when someone is acting strange and the doctor says they are just old, where to find help, why Tylenol three times a day is fine, but Tylenol PM anytime is not.
In addition we are working on front line training modules to teach the needed geriatric care concepts to elder care professionals. Complete with CEUs, needed for licensing. How to keep elders strong and mobile, how to decrease falls, when to call the MD, when not to feed elders, what medications can cause problems. The myriad of issues I face daily caring for my elders in assisted living, with home care or in the hospital.
The sway of alternative, nee functional medicine is also concerning. I welcome the emphasis on getting to root cause..really it is simple. A plant-based diet and 30 minutes of exercise daily are the basis of healthy living. I am not the one to help a person working to sort out the parts of their life that are not working. I admire those with the knack to help coach people into heathier habits and getting stronger. MDgurus who take advantage of people’s anxiety to sell expensive supplements and “magical” treatment for profit renounce their oath to “Do no harm”.
Particularly, taking advantage of the trust our society has in doctors.
So no, wheat will not cause dementia (eating too many donuts may increase risk of Diabetes, that increases risk of dementia).
Coconut oil is not healthier than butter (both are saturated fats) and will not cure dementia.
The MD guru with the 36-point plan saying that he cures dementia has no independent randomized controlled trials published in major medical journals- the mark of reliable research is touted online. I have had to care for some of those patients afterwards. There is value in a doctor taking time to remove problematic medications, encourage healthy habits, and being engaged to support a patient. However, the $10,000 cost over 6 months ($5000 for scores of blood tests and $5000 for expensive doctor visits and 30 supplement pills a day) did not produce any cure for elders I then cared for. One elder was aggressive and spent weeks in the hospital. We changed his medications, and he could be brought home and cared for there for the rest of his life.
The guru that says he was visited by the spirit at the age of 4 and given powers of diagnosis and treatment greater than doctors… and he cures all with celery juice… is more creative.
I am a much better doctor than I am an online producer. But I am working on it. Remember, there are only 3500 full time practicing geriatricians in a country of 330M. Many medical organizations are replacing doctors with nurse practitioners and physician assistants. I have trained dozens of nurse practitioners, and many are terrific, dedicated and empathetic. However, they do not have the training of an MD. Having complex elders cared for only by those with less training can be dangerous.
I want to leave something for those who don’t have access to the needed medical and health information beyond the few hundred families that I can work with at a time.
What is the best way for our readers to continue to follow your work online?
Our book “Living in the Moment: Overcoming Challenges and Finding Moments of Joy in Alzheimer’s and Other Dementias” (I am not one to give into blurb-friendly short titles) is on Amazon- a great step-by-step guide to the messy parts of dementia care- getting a diagnosis, understanding the effects of medications, relieving pain, calming agitation without sedation….
Working on a second book- addressing financial elder abuse. I don’t see a user-friendly book out there so….
DrLizGeriatrics.com sign up for our newsletter, join the community, take the modules, give us feedback, tell us what you need. It’s kind of a Fitzcarraldo thing that I want to do before I finish my career. The content is the easy part. Working online to develop all the tools is much harder… I am definitely a non-native boomer.
Facebook: @DrLizGeriatrics
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This was very inspiring. Thank you so much for the time you spent on this. We wish you only continued success.