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Interviewer: Sheltering in place because of COVID-19 can increase anxiety and also the feelings of isolation, which are already a threat to older adults.

Gerontologist Dr. Mark Supiano is the Chief, Division of Geriatrics at U of U Health. And if you have a loved one that's 65 or older, that's at high risk, they've been staying at home, how can you keep engaged with them and make sure that they remain mentally healthy? We think about the physical aspects. We don't always think about the mental aspects. Explain what you mean by that.

Dr. Supiano: So, Scot, we're very concerned about the deleterious effects of sheltering in place, particularly for people that were alone already. So this is only heightening their sense of loneliness. We know that loneliness itself is a risk factor for bad outcomes for health. So if you're not able to feel connected with other people because of the physical restraints or physical restrictions that were now imposed on people, those risks could really further escalate.

So in terms of anxiety levels, so what we can do to try to lower these risks or make people feel more connected, making sure that those connections still happen even without physical connections, whether you can do that virtually through a simple telephone call, through a video chat with some platform, but maintaining your connections with family, with friends. Have a daily call. Make sure that you're connecting with someone on a daily basis, that someone is checking in with you.

Interviewer: Being a grandparent is a joy for many, many people that has been kind of taken away, right? You're not able to interact with the grandkids as much, which would also lead to the things we're talking about. Do you have any tips for how that could take place in a safe way?

Dr. Supiano: So I'm in that same boat actually. So my grandchildren are in various parts of the country, and I have not seen them for months. And unfortunately, it will be several months more before we'll have that opportunity.

So maintaining video or, you know, telephone, video chat, we're living on FaceTime and those connections are very important. For people that have the families closer to them, there are still ways that you can interact with your family members while adhering to the recommendations about maintaining physical distance. So it's time and density and protective equipment. Minimizing the time of that interaction, maximizing the distance, so the density, make sure that there are a few people, that you're keeping at least six feet apart, and wearing a mask and making sure that everyone is masked to minimize those risks.

So those types of interactions can still happen, but you need to be careful that the restrictions that we've talked about are still in place and also that your family members, your children or the grandchildren have not been lax about their protective measures. So if they've been out in a group, if they've been out at a party, or with, you know, a group of their friends and there were 100 people there, they're potentially a carrier, and I'm not sure I would want that person, that family member getting close to me.

Interviewer: Which brings up a great point, right? There's a lot of . . . we're learning more and more that asymptomatic carriers, there's a lot more of those out there. So you might not be experiencing any symptoms at all, but you could be spreading it and that would be . . .

Dr. Supiano: Exactly. So if you've had a potential exposure, you should stay away from your older family member.

Interviewer: Yeah. So part of it comes from me realizing what my situation and being honest about that, and part of it is also implementing these protective things. What could I tell somebody in my life who is an older adult? You gave us some ideas of I could, you know, maybe make a phone call, do a video chat. Are there some other pieces of advice that I could give, like a parent or a grandparent, as to how to stay mentally healthy?

Dr. Supiano: So great question, Scot. I think the first point, and this comes from our mental health experts who have been careful to point out, for all of us to hear, that right now it's okay not to be okay and just recognizing that as a fact that everyone's in this together. We'll get through it together. And if you're not okay right now in terms of heightening anxiety and stress, everyone else is experiencing this too, and right now, it's okay not to be okay.

Interviewer: And especially your loved one, if they express that feeling, I think it's normal for us to say, "Oh, it's not going to be that bad," and dismiss it. Probably not do that right now.

Dr. Supiano: I think it is that bad right now. We need to acknowledge that and kind of give people that ability to be open about those feelings. With that, though, there are some tips that have been promoted to try to minimize the anxiety and stress.

One of them is, although we want people to be informed, minimizing the constant stream of bad news and anxiety-inducing news that you may be seeing on your television, through your social media, and other means. Take some stress breaks. Take care and attend to your wellness, which is another factor. And making sure that you're getting exercise. It's hard to do if you're sheltering in place at home, but getting some regular exercise every day, ideally now that the weather's improved to be outside, you're away from other people, getting sunshine, fresh air, but more importantly getting that exercise is a very important stress reducer and can really go a long way in helping with anxiety.

Make sure you're getting enough sleep. So sleep deprivation related to anxiety is going to feed on this even more. So making sure that you're getting restorative sleep. Relax, doing other activities that you enjoy, maybe not watching TV right before bed as an example, and then maintaining those connections with others are the things that would be recommended.

Interviewer: Yeah. You gave me some great ideas there of some questions next time I talk to people in my life. Just to make sure they're sleeping okay and make sure that they're getting their needs met and make sure that they're getting out and getting some exercise. So that's a great list. I love to ask the experts, you know, at the end of the interview. You're the expert, so like what's the one thing you would want somebody to take away after listening to us talk today?

Dr. Supiano: So I'll take two.

Interviewer: All right, you can.

Dr. Supiano: Just I'll do them quickly. So first, if you're over age 65, you're at high risk and be extremely vigilant about these precaution measures. Secondly, social distancing is not physical distancing. So maintain your physical distance but don't be socially isolated. And make sure to maintain those connections.

Interviewer: The highest risk factor for becoming hospitalized and suffering the worst effects of COVID-19 is being 65 and older. We're with gerontologist Dr. Mark Supiano, who is the Dhief of the Division of Geriatrics at U of U Health. Let's start out with the question, why is that?

Dr. Supiano: We do know that there are underlying changes in the immune system in an older person that puts them more at risk of getting an infection. They cannot mount the same immune defenses to fight it off. So that's first. Secondly, there are other physiologic changes in the lungs and the heart, in other responses to an infection that put older people at risk for more complications. So they don't have the functional reserves to compensate for the devastating effects of the COVID infection itself.

Interviewer: In addition to the immune system changes, which apparently starts at 65, is that what you're saying or ish?

Dr. Supiano: Yes. It's not a hard and fast number, but the older you are, the more likely those changes will be present.

Interviewer: Got you. So it's a linear kind of a decline.

Dr. Supiano: Yeah.

Interviewer: All right. In addition to that, are there other reasons why individuals over 65 are more likely to get COVID-19 and suffer the worst effects from it?

Dr. Supiano: I think related to that, and particularly as you go up in years above the age of 65, so it's a very heterogeneous group, but for 75 and older, or particularly 85 and older, the likelihood that you have multiple chronic conditions that are also associated with higher risk of COVID, such as high blood pressure, diabetes, obesity, renal disease, those other risk factors can accumulate. And the more risk factors you have the higher your risk would be.

Interviewer: So it sounds like if I have a mother or a grandfather that has some of those conditions and they're over 65, I might want to take additional precautions than perhaps if my parent was healthy?

Dr. Supiano: Exactly.

Interviewer: But still over 65, that in and of itself.

Dr. Supiano: Even without those underlying conditions, the current information suggests that just age 65 and higher, again, the higher, the more risk, but that age alone would be a significant high-risk factor.

Interviewer: How about the symptoms for people that are 65 and older for COVID-19? Are they the typical symptoms that we see in other people?

Dr. Supiano: So they can be. So the most common symptoms would include fever, cough, fatigue, or loss of energy, sometimes diarrhea. Those are the most common symptoms that have been reported. But as is true with many other infections in older populations, there's more often unusual presentations of that infection. So, for example, there may not be a fever. So older people may not mount a fever in response to the infection. So the absence of a fever should not make you think that the COVID is not a possibility.

Another possibility is that someone who presents with confusion or an acute change in their mental status, that in fact could be a presenting symptom of COVID. There's also evidence to suggest that an unusual symptom of losing taste or smell could be the first presenting symptom of COVID. So we need to have a heightened level of awareness for unusual ways that COVID might present in an older adult.

Interviewer: But the trick there to me is how do you differentiate that from just part of the normal aging process? If I understand correctly, loss of taste and smell, kind of common when you start getting older. Confusion can start developing when you get older. How do you determine if it's COVID or not?

Dr. Supiano: So it's really separating out what we would think about as being usual aging from a potential infection, and the general rule of thumb that I use and I teach our trainees is that age alone is almost never the answer, right? If someone's coming with some new concern or complaint, we need to think it's our job to find out what's going on, and in this case, have a very low threshold to think, is this possibly related to COVID?

Interviewer: If somebody in your life who is 65 or older then develops one of these COVID symptoms, whether normal or not quite as normal, what should you do at that point? Should you get to the hospital immediately? I suppose a test probably would be the first thing.

Dr. Supiano: So I think the first . . . exactly, Scot. And fortunately, with our health system now is very well-equipped to evaluate people with potential COVID-related illness in an environment actually outside of the hospital. We really don't want you bringing that patient into our clinic or directly into the emergency room. They should be evaluated at one of the testing centers where there's the outdoor testing facility. You don't have to leave your car, get the tests done. Then if further evaluation needs to be done, certainly going to urgent care or an emergency room that's equipped to appropriately isolate and manage someone as a potential COVID infection and has the appropriate personal protective equipment and so forth to also protect the other staff and other patients.

Interviewer: Of course, if you have severe symptoms, difficulty breathing, any of that sort of stuff, then . . .

Dr. Supiano: Do not pass go.

Interviewer: Yes.

Dr. Supiano: Yes, go straight to the emergency room.

Interviewer: All right. You're the expert. I always love to ask this last question when I've got an expert here behind the microphone. What's the one thing, when we're done talking, that you would want someone to take away from our conversation?

Dr. Supiano: Wash your hands. No, seriously, I think the main point is that people 65 and older are considered high-risk, and high-risk individuals need to be extremely vigilant about maintaining these precautions, hand washing being one of them, but maintaining physical distance, wearing a mask, minimizing your exposure. All of the things that are on that list, we need to not let down our guard and not be complacent. We need to keep up with those protective measures if we're going to get through this.

Interviewer: And as a loved one, also do those same things to protect those that I love.

Dr. Supiano: Exactly.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: The current medical guidelines for systolic blood pressure are between 140 to 150 but new research indicates that reducing that to 120 can drastically reduce the chance of heart disease and death for adults 75 or older even if they are considered frail elderly. Dr. Mark Supiano is a geriatrician and the executive director of the University of Utah Center on Aging. This study, is this a new revelation that lower could be better with systolic blood pressure especially for elderly adults?

Dr. Supiano: Yes, Scott. This is exciting new information that came out of the systolic blood pressure intervention trial otherwise known as SPRINT. The trial ended late in 2015, earlier than anticipated because of these very dramatic benefits.

Interviewer: When it initially ended early, a lot of people speculated that that meant bad news but it actually meant quite the opposite.

Dr. Supiano: Yes and particularly for the 28% of the SPRINT subjects who are over the age of 75 there were some concerns, myself and other geriatricians, that the very intensive systolic blood pressure target of 120 might not be safe for older people. When we first got news of the trial ending early I first thought that it was possible that older people had more side effects or more injurious falls or other complications of the very low blood pressure and that was why the data safety monitoring board might have ended the study early. In fact, the results were just the opposite.

Interviewer: Like a revelation almost it seems like.

Dr. Supiano: It really was a surprise to be honest. Not so much as a surprise that the benefit but the surprise that the benefit was of this magnitude and that this occurred this early on on the trial.

Interviewer: So the current guidelines are between 140-150. This study points out that 120 can drastically reduce the chance of heart disease and death. How drastic are we talking?

Dr. Supiano: I'll focus on the population 75 and older as I said, this is 28% of the SPRINT cohort and in that group there was a 33% reduction in the cardiovascular outcomes. This is primarily a myocardial infarction or heart attack or congestive heart failure and stroke and then in addition overall reduction of 32% in mortality.

Interviewer: That's pretty substantial.

Dr. Supiano: It is. To be honest there are very few treatments I can recommend for people over the age 75 that can have this dramatic impact on those outcomes.

Interviewer: So if you're going to do one thing, according to the study so far, it would be try to get that blood pressure down to 120. Now, does that mean taking medication? Does that mean lifestyle changes?

Dr. Supiano: All of the above. On average, the people in the intensive group who are managed to a blood pressure of 120 or taking one additional anti-hyperintensive medication relative to people on the standard arm.

Interviewer: Of course your eyes looking at the risk benefits and something like this. So the benefits are tremendous. Are there risks?

Dr. Supiano: Absolutely. The good news was, and again focusing on those 75 and older population, our major concern would have been there were higher rates of injurious falls or what's called orthostatic blood pressure - a reduction of blood pressure when the people first stand up and get light headed or dizzy. First, there was no increase in serious adverse events between the intensive and the standard arm. Second, and again very reassuring, there was no high rate injurious falls in the intensive group, nor were there serious rates in the intensive group. The intensive group did have higher rates of low blood pressure, of electrolyte abnormalities, largely low sodium levels which was to be expected because of the medications that were used and some other adverse events. But when we weigh though over the benefit of preventing heart attack, stroke, heart failure and death, most believe that those benefits outweigh those risks.

Interviewer: That number of 120, can you go lower than that and get more benefits or is there a point where no?

Dr. Supiano: That would be another study. And it's important to point out the one on average for 75 and older group achieve of systolic blood pressure of just under 122. That meant that half the people had a systolic blood pressure above 122. So 120 maybe recommended as a target blood pressure. That doesn't mean everyone is going to get there. Nor does it mean that the benefit won't accrue if you don't get exactly to that target. I think the take home message is, it seems to be that the lower, the better.

Interviewer: So is this something that if somebody does fall under this group or somebody has a grandparent or parent that's in this group that you would recommend that they go to their doctor and say, "I would like to try for a blood pressure of 120"? Because this isn't the guideline yet.

Dr. Supiano: So important point, the guidelines are being written down or likely incorporate this new information but those guidelines won't be out until later this summer. Even with that guideline, like everything we do in medicine and particularly in geriatric medicine we have to be patient-centric. So we need to weigh someone's benefits and risk of their elevated blood pressure and incorporate that those at greater risk are likely to have greater benefit. So it needs to be an informed decision with patient who discussed the pros and cons and determine their level of interest in trying to achieve this lower target and recognize those benefits.

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Interviewer: You're not feeling well. Did you ever consider for a second it could be the medication you're taking to try to feel better that could actually be making you feel worse? We'll discuss that next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Mark Supiano is the Executive Director of the University of Utah Center on Aging. Sometimes medications can cause more problems than they can actually fix especially if you have multiple medications, prescription and non-prescription that are interacting badly with each other.

Dr. Supiano, let's talk about multiple medications and some of the things you've seen as far as how that makes you feel worse and what you would recommend.

Dr. Supiano: This is a particular issue in older individuals, because older people tend to have more medical conditions that we now have wonderful evidence basis of the benefits of medications to treat those conditions.

When we start to add up those conditions however, if you start to have three, four, five chronic conditions, and you're on three or five medications for each of those conditions, that multiplier effect increases your risk of having an adverse medical event or a side effect from the interactions between those medications.

So older people that we treat are more likely to be on more medications and are therefore at higher risk for exactly these kinds of problems.

Interviewer: So is it the raw numbers that's causing the problem or is it the actual what's in the medication doesn't like what's in another medication or both?

Dr. Supiano: The literature suggests that it's simply the number of medications that you're on. The magic number is if say you're on more than 12 medications, and as you mentioned earlier that is a combination of both prescription medications as well as any over the counter medications that you may be taking, if that number is above 12, there's almost 100% chance that there will be a drug-drug interaction.

Interviewer: Wow. So we're talking over the counter being any sort of pain killers you might take, cough medicine, what about like herbal?

Dr. Supiano: Sedatives or hypnotics or sleep aids that you might be taking over the counter, all of those.

Scott: What about herbal supplements and things like that?

Dr. Supiano: Absolutely and Utah is a hot bed of herbal supplements. So we are very aware of that and really need to be careful about the potential interactions between some of those supplements and prescription and other medications.

Interviewer: So if you are taking a whole bunch of pills, it might be good idea to have somebody professionally reevaluate. I would think that my pharmacist would know or my doctor would already know. Is that not always the case?

Dr. Supiano: If you're going to a single pharmacy, if they have an accurate record of all your prescription medications, there are systems now to screen for the most offensive drug-drug interactions. Most physicians are likewise aware of that but there are other subtleties that individuals trained in geriatrics are more likely to pick up.

Another component is the geriatrics is a team sport and as part of our medical home for example we have a geriatric Pharm.D who has additional expertise to be able to identify the appropriate medications for older people.

The other reason that your pharmacist or physician, if they lack that geriatrics expertise may not be sensitive to this, is that there are changes in aging in how the body gets rid of medications that can increase your risk of having the side effects. So if you're not adjusting the dose of the medication appropriately for that person's age or their kidney function that there may be toxic levels of the medication that accumulate and cause these side effects.

Interviewer: So you really can't set it and forget it? You've got a kind of reevaluate quite often it sounds like?

Dr. Supiano: So I tell patients if they have been on the same drug for many years and it can't be causing problems, well, if you're 20 years older now your body is metabolizing that medication differently and the levels are going to be higher than they were 20 years ago, so it now maybe causing problems.

Interviewer: What might be an indication to somebody that they are actually having some sort of adverse reactions through medication interaction?

Dr. Supiano: Great question and this is really a challenge and particularly since many of these side effects, someone might think, "Well, I'm just getting older, so of course I feel run down the next day or I'm having this particular symptom," say constipation. They may think this is just part of getting older and may not ascribe it to the medication.

So we're taught to teach our trainees that anytime someone has a new symptom, we need to first ask, "Is this potentially caused by an existing medication?" What we really want to avoid is treating that new symptom with yet another medication, because that adds further to this list of medications.

It becomes a vicious cycle and you just keep adding on more and more medications and you get more and more side effects, and the patient isn't getting any better.

Interviewer: So how big of a difference can it make if you identify that there's some sort of a medication-medication problem?

Dr. Supiano: If we can identify someone with side effects from a different medication and the term for this is Polypharmacy, if we identify what that side effect is and either reducing those medications or eliminate it, stop that medication and the patient gets better, that's a victory.

And I can tell you, Scott that in my career of some decades now I am confident that I've made more people better by stopping the medication that is causing one of the side effects, than I perhaps ever will by starting a medication to treat a chronic condition.

Interviewer: That's a powerful statement and a statement to probably keep in mind that more is not necessarily better.

Dr. Supiano: Particularly if it's causing one of these side effects, it's a very grateful patient if you can identify that offending medication and eliminate it from their medication list and their symptoms improve.

Interviewer: If I feel like I'm having this type of reaction, what will be my next steps?

Dr. Supiano: So a comprehensive evaluation to review those medications by someone trained to identify these problems would be the first step.

Interviewer: So my primary care physician not that person?

Dr. Supiano: It could be. I think the main principles, although we do this routinely, what needs to be is a medication chest biopsy. So this is a geriatric procedure. You need to go in and biopsy the medications and the way we do that is not with the needle but we ask people when they've come in for their initial evaluation to get a grocery bag and fill it up with all the prescription bottles, and it's called the brown bag technique.

And if one grocery bag isn't big enough, you load up two or, three, or four and bring them all in and our Pharm.D will sit down and look at each one of those prescriptions and review them and make sure that they're appropriate by with indication, by way of dose and review for these potential side effects.

Interviewer: As we've talked another podcasts, geriatricians, even if you're younger and you have a lot of multiple medications could help you. You don't have to just be an older person.

Dr. Supiano: Correct, so this syndrome of Polypharmacy is not unique to age and our team including geriatrician providers and our geriatric Pharm.D are skilled to evaluate patients for that potential problem.

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