Spotlight on Care: Alzheimer's Caregiving
Welcome to Spotlight on Care, the podcast where we share stories, experiences, tips and advice on caring for loved ones affected by Alzheimer’s and other dementias. Spotlight on Care is produced by the University of California, Irvine Institute for Memory Impairments and Neurological Disorders, UCI MIND. Please subscribe to the Spotlight on Care podcast wherever you listen. For more information, visit mind.uci.edu. What would like to hear about next? Email us at mwitbrac@uci.edu.
Spotlight on Care: Alzheimer's Caregiving
The Value of a Geriatrician with Valerie George, PA and Sonia Sehgal, MD
Steve and Virginia explore the vital role that geriatricians play in diagnosing and managing dementia and other cognitive symptoms in older adults. The co-hosts are joined by Valerie George, a certified physician assistant with UCI Health, and Sonia Sehgal, MD, a board-certified geriatrician and internist with UCI Health, who discuss how geriatric care should take a whole-person approach—addressing cognitive impairment, chronic conditions, and social factors while actively involving caregivers. Valerie and Dr. Sehgal explain the difference between geriatricians and gerontologists, share their experiences supporting families, and highlight the benefits of seeking an early diagnosis and team-based care. Together, they emphasize the importance of compassionate, proactive support for both patients and caregivers throughout the aging journey.
From the University of California, Irvine. This is UCI MIND's Spotlight on Care, the podcast where we share stories, experiences, tips, and advice on caring for loved ones affected by Alzheimer's and other dementias. Welcome everyone to another edition of Spotlight on Care. We're really excited about this, as we always are about the new topic that we're going to be talking about today, and we have two wonderful ladies here with a terrific medical background, which I'll introduce in a second. So let me just remind you to please subscribe to this service, and when you do, you'll be notified of new content that comes online, and occasionally, we might ask for your opinion about what you'd like to hear about. Virginia, do you want to comment at all about any of this, before we get started?
Virginia:Well, thanks, Steve. I'm really happy that we're doing this. Looking back, I sure would have loved information about this when mom was first coming down with her MCI and then Alzheimer's. I didn't know how to search out a particular doctor what I should be looking for and to tell you the truth, I never found real good ones. So I'm going to be very interested in your answers to our questions.
Steve:So the topic today is this whole concept of geriatricians and the significant value they represent in terms of diagnostic abilities within the caregiving environment. We're going to talk a little bit about that as an alternative, in some cases, to neurologists and the value of what they do and what they provide in terms of caring for patients over a period of time. So let me introduce our two ladies. On my left, which you can't see, of course, is Valerie George. And Valerie has 14 years of experience as a certified physician assistant, and she works for UCI Senior Health Care Center. She's kind of instrumental in the evaluation and the development of this whole process about geriatricians and their value. Her area of expertise is healthy aging, fall prevention, which is an interesting topic, and kind of the geriatric and chronic disease and the various forms of dementia. So she's kind of a pro in this space, and we're excited to have her. I forgot to mention that she's also a Fantasy Land attraction hostess in her early years. Imagine how she learned about caregiving there. In addition to that, we have Sonia Sehgal . And Sonia is an MD. She's a board certified geriatrician and an internist. Her area of expertise is
similar:healthy aging, hypertension, osteoporosis -my mom suffered from that- and preventive medicine. Elder abuse is another topic. She's also the director of the Geriatric Medical Unit at UCI Health, so we're thrilled to have the two of them here, and we'll get with the questions. Okay, let's start
with:"What is a geriatrician and how is that different from a gerontologist?" We'll start off- Sonia, do you want to answer that one?
Sonya:Sure. Thank you very much for having both of us. It's really our pleasure to be here today.
Valerie:Thanks for inviting us.
Sonya:Great question, and we get this all the time. So a A geriatrician is a physician who specializes in
Steve:So how does that different from a gerontologist gerontologist is someone who studies aging, and in general, care of the older adult. So generally speaking, we are primary care clinicians. So we've done a residency in either then? these are individuals that don't necessarily have a medical family medicine or internal medicine, and then we've chosen to do an additional one or two years of training really focused in on the aging body and wellness and conditions that become more common as we get older. degree, so they're not MDs, they have PhDs and are engaged in research involved in aging. And this research might include social factors, sociology, public health, medicine, but it's the study of aging. Okay, I think that's helpful. If you were worried about your memory and/or if you were someone who was a loved one caring for someone, you would recommend that you would start with a geriatrician.
Sonya:Absolutely.
Steve:Okay. Well, you both have patients, right?
Valerie:Yes.
Steve:Maybe Valerie, you could talk about the kind of patients that you see-that what type of age are they, and what kind of level of maybe memory issues do you see?
Valerie:We see patients, I believe from 65. We had lowered our age limit at one point to 50 because we were taking care of the children of our patients, but we raised it back up to 65 and older. We see patients that have chronic disease, congestive heart failure, atrial fibrillation, diabetes, hypertension, those kinds of things. But we also have a variety of patients that we'll see, who may have some mild cognitive impairment all the way up to severe dementia, and the whole gamut of going through that entire journey with them.
Steve:Well, I have a follow up question here. We hear people that are actually coming in earlier now to get diagnosed, but that there's still a significant number of people that are waiting and waiting and waiting and waiting and thinking it'll get better, and really they should have come in earlier for a diagnosis. Do either of you want to take that question?
Sonya:Sure, you know, I think you're right. We practice out of the UCI Senior Health Center, and that, like Valerie said, we care for patients over 60, and we hope that we start with individuals and provide primary specialty care early, certainly for cognitive issues, symptomatology, even if it's very subtle, we want to know about it, because often we find that things like vitamin deficiencies, mood issues like depression or anxiety, you know, changes in life circumstance can lead people to have poor memory or concerns with short term memory, and it might just be reversible in some situations. So if we can get people into specialists, get some lab work done, get a work up done, maybe we can find something that we can act on early. Sometimes we can't, but if we can't, we can definitely work to get families and patients the support they need early on. We know that if it's an early onset cognitive impairment, like a dementia, there's often an adjustment period. It takes time to accept the diagnosis, come to terms with all of the change, and we want to be there for these folks as they walk that walk.
Steve:Well, you just said something important, and maybe Valerie, you can answer this, be there with them. So I understand that one of the things that you do as a PA or a geriatrician is you're following these patients over time. What's that like?
Valerie:As you were asking those questions, that's exactly what I was thinking about. I've actually been at our clinic for 22 years, and it's interesting that I know patients from when I first started. Took care of them, and I have gone through their medical history or their disease process, and have been with the family. You get to know them very closely, their children, their brothers, sisters, and you can see them aging disease process, and then sometimes they end up passing away. I tend to come close with the family members and all that, and it's hard. I remember when I first started as a PA my friends would say, "Oh my gosh, my patient died." And I'm like,"Oh, but that's part of life, you know?" Because I've just been in geriatrics, and I think that that's kind of an expectation over time, but it has been a great privilege to watch or to go through that with them, and to be there for them in all their different stages if they need help, and getting to know them on that personal level, I'm able to probably be able to talk to specialists and say, "This is important, this isn't important." And so it's been really a great aspect of my job that I get to do that.
Steve:One of the complaints that we hear sometimes about neurological visits with neurologists- and we're not knocking neurologists here, they're busy, but they don't often have much time for the loved one or the ability to answer questions. Is it a different experience in working with a geriatrician?
Sonya:I think so, our focus is whole person care, and we believe that whole person care involves family caregivers, community caregivers, and if we support our caregivers, we know that our patients are going to get better care. They'll have less exposure to elder abuse or other risks, and so we do approach it differently. You know, geriatricians work in teams.
Steve:Oh, what kind of teams?
Sonya:So our teams include physician assistants. They may include nurse practitioners. We certainly engage with social workers, care navigators, neuropsychologists, and we try to support our patients by utilizing our team and the expertise that they bring. So our care does look a little bit different than neurology. We first, of course, involve the caregiver, but we're also taking care of all of the issues that occur alongside the cognitive impairment. So if someone has MCI, if someone has a dementia, their social network needs to be looked at, their home environment needs to be looked at. Is there some training, education that we can provide to the patient's care team? We want to get people hooked into that we want to take care of their blood pressure and their diabetes and their heart disease at the same time.
Virginia:Is a neruologist not part of your so called team?
Sonya:So they are.
Virginia:They are? Okay.
Sonya:They're not involved in the day-to-day team that we have. So at the Senior Health Center, we have a team that's physically there on site with us. And if I need to reach out to my pharmacist, for example, I can do that. If I need to talk to Val or she needs to talk to me, we're there and can collaborate. But neurologists are certainly part of the team. They're an extension, and they follow patients for that one very specific concern, the cognitive impairment.
Steve:I ran into my first PA the other day when I was going to see a neurologist. I had never worked with one before, and it was like working with a doctor, except they had a little different kind of care orientation. How would you describe what it's like being a PA versus being a MD?
Valerie:Well, I'm not a MD.
Steve:Yeah I know, but you work with MDs.
Valerie:We are considered mid level practitioners. Advanced practice practitioners are now the new kind of title: APPs. It includes nurse practitioners and PAs so we're mid level. My schooling in general is less, physician goes through a lot more education, schooling. I do everything the doctor does. There's a supervision portion of my degree, seeing patients. But I do everything that the doctor does. I can't tell you about how other PAs are. I feel like I've heard or I see commentsthat PAs tend to take more time, or they talk a little bit more. I don't know if that's just the training or that's just the person, but whatever the doctors have, they know. They teach me, I know. So it's really always a teaching thing. If I wanted to, say I wanted to go into ortho, my first love was ortho. I was going to be an ortho PA, but I met someone in my schooling who loved geriatrics, and she was a mentor, and she brought me into this geriatric world, but I could always switch my position so I can go work in ortho. They just have to train me, where a doctor is pretty much locked into their specialty unless they go back to school.
Steve:Sonia, you mentioned something that I didn't think to follow up on. You mentioned that you have additional training over just in geriatrics. Why is that? Why wouldn't your initial training be sufficient?
Sonya:That's a great question. So after medical school, so we go to med school for four years, and then if you choose primary care as a discipline, you can choose internal or family medicine, and that's a three year endeavor. During that time, you do learn about caring for older patients, but you're learning about adult patients in general, so you're not really specifically for any meaningful length of time, teasing apart older adults and what their specific needs are. And we know that, that body ages, physiology changes. There are certain conditions that become more common, like MCI, dementia, other cognitive impairments, mood disorders, urinary incontinence, mobility-related issues. And as an internalmedicine or family medicine practitioner, you know about these conditions, but you're really not an expert in managing them.
Steve:So it's focus. You're really putting more and more focus on people who are aging.
Sonya:Absolutely, so the year or two that we spend training is specifically designed to care only for the older adult patient.
Steve:Now you both work with older people. What's it like? Is that difficult?
Valerie:Well, I always say that I love my job. I think that you have to love older people in order to be in geriatrics.
Steve:Thank you. My heart feels good. Especially today, right?
Valerie:You have to love them, because it can be difficult. You
Sonya:But you choose what you love in medicine, right? Whether know, you have someone that has mobility issues. We have our set time for our appointments. It may take them 15-20 minutes to get in the room, and now you're like, I'm 10 minutes in. Can't go over their medications. There might be slow cognitive problems. So you have to have patients. There's a lot of paperwork and Medicare guidelines that have to be followed. So a lot of people say, "I don't want to have those kinds ofpatients because they're too involved, too much going on." But really, in reality, everybody is going to have a geriatric patient, unless you're going to be OBGYN, like someone you're a PA or an MD, you choose the discipline that you love. who's going to deliver a baby, a pediatrician. But in every aspect of medicine, there is going to be someone who's an older adult that's going to cross your path. And for all the challenges that geriatrics brings, there are a whole host of incredible, amazing, joyful moments as well, knowing that you are going to be with somebody during happy times, difficult times you're gonna see transition, and the privilege of being there with them during some of the most challenging moments of their life, that's an honor. So you choose what you love. And I think geriatricians and geriatrics, we are one of the happiest disciplines out there when you look at research.
Steve:So it's like the happiest place, huh?
Sonya:It's the happiest place on earth.
Valerie:Just down the road.
Steve:All right, let's go to talking about caregivers, and the people that you meet, if you're doing an evaluation or diagnostic or a visit, maybe even a follow-up visit. What would you like to see from the caregiver that would help you better manage what's going on? Why don't you both take that one? We'll see you have a little difference of opinion here.
Valerie:I think a good caregiver notices things that are going on within the family and within the patient. What can happen is, what's happening in the last visit? Is there any behavior changes? Any changes in medications? They know the medicines, things that can be helpful. If they have high blood pressure, diabetes, they have those records ready for us to review and really to have, perhaps a top one-to-two-to three diagnosis or problem that they want to talk about. Coming in with geriatrics, it can be a big slew of problems. You having a conversation? Oh, I remember that, I remember that. But really, we have limited time, so you want to direct exactly what you want to talk about.
Sonya:You know, for me, I would encourage caregivers to be empowered, to realize that they are the key element in a patient'scare team. So a patient is going to see me for, you know, 20 minutes, 30 minutes, I'm a segment of their day, but the caregiver is going to be with that person for the entire day or the entire week, or even more. And I want them to know that that is incredibly powerful, and their observations, their knowledge of the patient, is invaluable, and they should bring it up to us. I want them to feel empowered to interact with the care team, to share their observations, and if they're seeing a clinician who's not engaging with them, I would hope that they feel empowered enough to ask for the engagement, because that's really what we want. They are the part of the care team that makes it happen. They shouldfeel empowered.
Steve:Virginia, why don't you tell your experience on that? You know, where you felt like you weren't heard when you went in for these visits?
Virginia:Well, yes, we would go into -I'm sure he was a geriatrician- and Mom and I would sit there in the room, and he would look at her and say,"Helen, how are you?" And she said, "I'm fine. How are you?" He didn't, I wanted him to look at me. I got the hang of writing notes before I would go in there, and I'd say to the nurse, have him read this before we sit down. But it was frustrating to me, because I thought we're not in here to chit chat and say we're fine. We're here for issues, and I didn't find- boy, I wish I had found a situation like you both.
Sonya:Yeah you know, it's something that we've recognized in healthcare, that clinicians are often not comfortable engaging with caregivers. In our training, we're trained to focus on the patient and look at the patient and engage with the patient, but I think in geriatrics, or at least my hope, in geriatrics, is that we're looking at the patient, but we also have one eye on the caregiver.
Virginia:Thank you.
Sonya:And when the caregivers in the back saying, hey, you know, look at me, I'm giving you the look like, this isn't true or no, there's something different happening, that the geriatrician is looking at that, recognizing it, and then will engage with you afterwards. At UCI, we are in partnership with UC San Francisco, and we're designing some curriculum that will be launched nationally that focuses in on training primary care clinicians on how to engage caregivers.
Virginia:Oh good.
Sonya:And giving them some tools on how to do this, because we recognize that it is an issue.
Steve:This is going to be a tough question. Now I'm caring
Virginia:Excellent. for Patty, and I know she's got memory issues. I think it's neurological right, or at least that's what I've heard. And you start to do some reading, and would you recommend that Igo and see a geriatrician before I see a neurologist?
Valerie:Think that that's a great option. We are trained to recognize if people are having memory loss. We can do screening and testing at our office, we have two neuropsychologists, so we have some changes that we're not quite picking up, butmaybe the family is talking about or maybe the family is saying, you know, this is happening, but when we do a screen, it's pretty normal, then we have opportunity to have our neuropsychologist to do a much longer battery and can pull out things that we wouldn't be able to do.
Virginia:Is a neuropsychologist, part of your so-called team?
Valerie:We have it available to us. We only have two, so there is some limited space, but we are able to refer to them and to do a neuropsych testing.
Virginia:Okay.
Valerie:Kind of similar to, iMind here. They do a neuropsych testing.
Sonya:I agree. I think geriatrics, or geriatric clinic is a great place to start. I mean, our neurology colleagues are amazing, but they're also very busy, and it is often a very long wait time.
Steve:Let me tell you, not busy. It's almost impossible to get an appointment.
Sonya:It is.
Virginia:A friend of mine was told six months.
Sonya:Oh my goodness. Yeah. So we feel like if patients do have cognitive concerns, if they come to us, we can rule out metabolic issues. We can draw labs. We can do a pretty detailed physical exam. We can even administer basic cognitive tests in the clinic. If we feel like someone needs to see a neuropsychologist, we can get that going. We do have two in our office, and for patients who have, you know, in medicine, we call atypical features or early onset. Maybe they have some movement complaints. If we can't come up with a diagnosis, we absolutely refer to our neurology colleagues and work in partnership with them. And we can often get patients in within the week or two weeks in our office for an evaluation.
Virginia:That's great.
Steve:Let's talk about the evaluation for a second, because I think a lot of people don't understand that there are various levels of evaluation. There's, I love, the five question test that Patty got, and the doc asked her five questions that anybody could have answered and diagnosed her as fine. And then there's the MoCA test. And I know there's other tests. So what do you think is what you should expect initial evaluation, and should you be asking for even if you're seeing a GP, maybe they can't do one, but you should at least ask about it.
Sonya:So we would encourage primary care to initiate screening on an annual basis. Could be very quick. It could be three questions. You know, do you have memory concerns? Let's draw a clock and maybe ask you a few other questions, and we advocate for a brief screen within something called the annual wellness visit. And so that's a type of medical visit that Medicare beneficiaries can have yearly. And will we di advocate for screening.
Steve:What do you mean by screening? Maybe I'm too knowledgeable here that there's various levels of screening, some of which really don't determine a lot.
Sonya:Yeah, so that screening would be for someone who doesn't have a memory concern, they don't have a cognitive complaint.
Virginia:I just had my annual physical with a PA, by the way, and she said, Can you draw a clock and make it 11:45, my God, I haven't seen a clock in a long time, everything's so digital. But she said, "Do you have memory concerns?" I said, "Well, not yet." That's the first time I've ever been asked questions like that.
Sonya:So you've got a great PA.
Virginia:Yeah.
Sonya:Excellent job there. We advocate for that kind of very basic screening in people who are doing well and don't have any real concerns. But if you come to the office and you do have a concern for a complaint, or family members bringing someone in, and they have concerns for a loved one, we start with a very detailed history. We want to know the granular level of detail when the cognitive complaint started, what the context is of these complaints, we get into detailed medication review, looking for some medication side effects people might not be aware of. We want to assess mood so individuals go through grief and loss and life change that can be impacting cognition. We might administer a MoCA in the office, which is a detailed cognitive assessment. We certainly want to look for reversible causes of cognitive complaints. Sometimes people have vitamin deficiencies, like vitamin B12 or thyroid disorders that are causing cognitive issue. And we want to be very complete in our assessment.
Steve:I think that's an important point about early diagnosis too. I mean, if you're not finding out how you're doing as you're aging, you could be in a position where there is something wrong, but you've decided to not deal with it and put it away. We hear these stories about people like,"Well, I don't want to find out it'll go away." And reality is, they're much better off by getting tested sooner and earlier.
Valerie:Absolutely, besides memory loss, I think that's with a lot of other things that people say, "Oh, I have this lump here. I don't really want to know about it, so I'm not going to go in and get it an exam." And then it gets bigger, and then now you have cancer, instead of taking care of it early on, because there's this, like, there's a fear, right? Finding out the diagnosis.
Steve:Okay, a couple of final questions here, and then the proverbial thing you told me on the phone, which just absolutely blew me away. So would you ask for a referral from a geriatrician, from your primary physician? Would you think if I had a loved one that was 65 or older, and I said, "Hey, I think we've got memory issues." Should you ask for a referral?
Valerie:I think you can. Our clinic is set up as a primary care clinic, and we see all patients who are older adults, but there are some people who want to stay with their primary care and they want to have a consult, or they want to have a geriatrician that they want to meet with once a year, maybe twice a year, and then that becomes a consultative type of visit.
Steve:Does your information go back to the primary physician?
Valerie:Yes.
Steve:Okay, great. All right, if you had one piece of advice that you would give a family experiencing memory issues. What would it be?
Valerie:I agree with you of trying to be proactive, trying to figure out, as Dr. Sehgal has talked about, there's all kinds of things that you may feel, is it normal for getting or is it not? And then to be proactive to get testing. And it might be that you just need testing once a year or screening once a year, and it may be nothing. You have to look at the person as a whole make sure that everything else is intact. Dr. Sehgal?
Sonya:Sure, you know when I think about it, more and more, heart disease is very common, right? And we don't hesitate to see a cardiologist. There's no emotion around seeing a cardiologist. We go in, we get our blood pressure checked, we get our cardiac test. There might be some fear and anxiety around it, but there isn't necessarily the hesitation that people associate with cognitive disorder.
Virginia:It's the stigma.
Sonya:The stigma, the fear. And I want people to know that if they seek out a geriatrician or a geriatric office like ours, we do everything we can to mitigate the stigma, right? And so if someone is concerned about cognitive issues in themselves or others, I want them to know that there are spaces that are safe where they can come and have an evaluation and receive compassionate care and diagnosis if there is one that is to be had. But even if there isn't, we're there to provide the best whole person care that we can, and that is preventive, right? That is looking forward, really emphasizing healthy aging, even in an individual who is experiencing cognitive impairment, because they and their caregiver deserve to have that.
Steve:That's an interesting point. Healthy aging is finding out what's going on with your body as you age, rather than waiting for it to become a problem.
Sonya:Absolutely.
Steve:Okay, so Valerie, when we talked, you had this great phrase, and you said- I said"Well, it's hard to get in. It's hard to go see these..." And you said- what did you say?
Valerie:I said, "Welcome. Bring it home. Bring it to us."
Steve:Yeah, you said, "We're ready."
Valerie:We're ready.
Steve:We're ready. So anyway, let's end with the fact we have two absolutely incredible people in the medical field talking about the fact that they love older people and that they care about older people and that they're looking to try and help them as early as possible. So we'll put it in the notes, but if you're looking for help, call your local geriatrician, and especially the ones at UCI. Thank you ladies.
Virginia:Thank you so much.
Sonya:Thank you.
Steve:Spotlight on Care is produced by the University of California Irvine Institute on Memory Impairments and Neurological Disorders, UCI MIND. Interviews focus on personal caregiving journeys and may not represent the views of UCI MINDindividuals concerned about cognitive disorders, prevention or treatment should seek expert diagnosis and care. Please subscribe to the Spotlight on Care podcast wherever you listen for more information, visit mind.uci.edu.
