Introduction & What is Aging Well?

Dr. Mia: Hello, and welcome to the podcast: Ask Dr. Mia: conversations on aging well. I am Dr. Mia. Thank you all for joining this introduction episode. I wanted to tell you a little bit more about who I am and why I am hosting this podcast.

[00:00:25] My name is Mia Yang. I am a geriatrician. For those of you who do not know what a geriatrician is, it is a physician who is specializing in the care of older adults. When I started my fellowship in geriatrics, a fellowship is one where someone who has finished training in residency, in internal medicine or family medicine, then get specialized training in a field such as geriatrics. When I was doing my fellowship at Johns Hopkins, The orientation showed a video of people going out to the harbor around Baltimore, asking passerbys what they thought a geriatrician did. This video was recorded around 2008, but most people had no idea what a geriatrician does. A lot of people played around with the term "geri", "jury". "Trician" made a lot of people think of nutritionist. But very few actually made the connection that a geriatrician, much like a pediatrician, is a specialist focusing on older adults. The field of aging is called geriatrics or gerontology. A minor side point, a gerontologist is someone who studies aging. This is usually someone who is a non-clinician, so a PhD or some sort of graduate school training versus a geriatrician, usually indicate someone who is a clinician and has gone through medical school. Some advanced practice practice practitioners, such as nurse practitioners or physician assistants may also specialize in the field of geriatrics.

[00:02:27] So now that we have talked about. What a geriatrician is, who am I? And why am I hosting and starting this podcast?

[00:02:38] In general geriatricians are very nice and humble folks who do not brag about our expertise. However, I think that as geriatricians, we have a lot to offer and a lot to say about our aging population. This is my own passion project to directly talk to the public geriatric principles that could be applicable to the people in your own life. Whether that's you, you who is listening as an older adult, or that you have an older adult in your life, such as your parents, your spouse, your grandparents, or even your great grandparents. Those are the people that I have dedicated my career to assist in aging well. We're going to talk a lot about what it means to age well in this introductory episode, because we need to know the direction where we're going. Where people want to go in their aging journey really differs depending on who you are.

[00:03:50] I'm going to share my own story of how I became interested in the field of geriatrics. And it really has to do with my own grandparents. I was lucky to grow up with all four of my grandparents. I was born and raised in China, which is where I lived until I was 12. My own upbringing and childhood experiences are a separate episode perhaps in the future, but I was lucky enough to spend the first 12 years of my life, almost exclusively with my four grandparents. My paternal grandparents really raised me while my parents came to the United States. My early childhood experiences were really shaped by these four people. unfortunately, both of my grandfathers have passed away, but I want to talk about all four of them and both of my grandmothers are still alive.

[00:04:54] The first person I wanted to talk about is my paternal grandfather or as I call him YieYie in Mandarin. YieYie was a very accomplished leader in his life. He led in his professional life and also led in our family life. He was definitely the patriarch of our family and was a very prolific reader.

[00:05:26] In his later years, he even wrote his own autobiography and self-published it. However, YieYie was not the healthiest . He was a pretty heavy smoker. He smoked for most of his life and he has tried to quit many times, but always kinda came back to smoking. He was unfortunately never really able to quit smoking for more than a couple months at the most. It was just really how people socialized and a lot of business and conversations and Entrepreneurial type of investment were done over meals where people also smoked. YieYie really was a home body after he retired. He really enjoyed just sitting at home. He said that he, loved to keep our home safe. And he liked to stay within the confines of his home and enjoy reading while the rest of us went out and play. YieYie really started the whole process of us immigrating to the United States. I think that really profoundly changed the trajectory of my parents and of course myself.

[00:06:48] The next person I'm going to talk about is my maternal grandfather GongGong. So GongGong was a professor in a university, but I really did not know him when he was still teaching. All four, my grandparents had already retired by the time I was born and GongGong was very much the opposite of my YieYie. In the sense that he was very quiet and subdued he had a very calm. Personality. He didn't seem to have a lot of opinions or at least in verbalized them in the way that my YieYie loved to do.

[00:07:28] He was always someone who handled the housework on my mother's side of the family. He cooked, he cleaned, he took care of groceries, also a home body in the same way as paternal grandfather, but in very different styles.

[00:07:45] The third person I'm going to talk about is my maternal grandmother or PouPou. Interesting fun fact was that my PouPou and my YieYie went to elementary school together, they were in the same class. And that is actually the story of how my parents met each other. My paternal grandfather and my maternal grandmother went to an elementary school reunion, which I have no idea how people will keep up with their elementary classmates, but that's what they did.

[00:08:25] They went to an elementary school reunion where they said, oh, Hey, I have a child. Marital age. And would they be interested in meeting each other? And that is how my parents were introduced. Sort of an arranged marriage, but not quite. My PouPou is very talented, very creative. She was also a professor in college after she retired. She had a lot of hobbies. She even went back to a senior college and learned how to do lots of artistic stuff. She learned to paint with Chinese water color and made these elaborate beautiful paintings of intricate detail. We actually brought them to America and hung them in my parents' house where they still are hanging today. If you look at them, you would think that a professional artist painted them. That was how great she was. She spoke her mind very much like my paternal grandfather . PouPou pretty much ruled the roost at my mother's side of the family, she was the matriarch of the family.

[00:09:47] Last but not least is my NaiNai, who is my paternal grandmother. She is the youngest of all four of my grandparents. She is going to be 90 this year. NaiNai has never had the typical Asian woman physique. She has always been the biggest person with a lot of abdominal padding that made her so lovely to hug. But she actually had a lot of difficulty finding clothes that would fit her in China. When she came to visit us in the US, she actually found a lot more clothes to fit. My NaiNai, my maternal grandmother was a pediatrician before she retired. The reason why I wanted to mention all four of my grandparents to you is to really talk about their aging process and how each of them differed.

[00:10:49] My YieYie, my paternal grandfather lived until he was 85. He really was very functional up until the very end. I didn't hear until after he passed that the last couple of years he was becoming more homebound. And that was really limited by incontinence. He's a very proud person who was a leader in most of his professional life. He really did not want to go out when there was the possibility of embarrassing himself. There were some declines in his daily function, but his scope of his world was pretty small. He really enjoyed exploring the world through reading.

[00:11:33] He had good eyesight and good hearing to be able to enjoy that up until the very end. how he passed was actually rather sudden. He like many older adults that I see unfortunately had a fall near the bathroom. I think he slipped and hit his head on the concrete floor. Most homes in China are made of concrete and he lived in an apartment. There was no carpet whatsoever and also not in the bathroom area. Unfortunately he hit his head that he ended up having a subdural hematoma or intracranial hemorrhage. For those of you who don't know what a subdural hematoma means, it means that the small blood vessel that goes inside the skull was injured from the fall. It started to bleed inside the head. But because the skull is so hard, there really isn't any room for that blood to go. Instead it creates a pressure on the brain and people die when the pressure in the brain becomes so much that the brain herniates and the person passes away,

[00:12:54] when this happened, I was already in residency. I remember very clearly because it was my first year of residency, which I was an intern. They not only called my father, who has been living in the United States for a long time, but he also called me as to whether to have surgery to relieve his intracranial hemorrhage. The consensus at that time was made very quickly, and I participated in that decision. I just knew from knowing my grandfather that he would not want a prolonged end to his life, he would not want to be a burden to his family. He would not want his wife, my NaiNai to take care of him. So we decided to not have surgery, even though it was offered. And he passed away very quickly.

[00:14:00] At his funeral, a lot of people actually commented on what a blessing it was to go quickly. I had never really heard about that as a blessing before, but there was a moment on the phone where I thought: am I making the right decision? Is this too rushed? Could there be a chance of recovery back to his prior level of functioning? But unfortunately I think the surgeon also said that was unlikely and all of us came to the decision and we felt good about the decision. So would you consider that aging well? I would say that is because my YieYie had what we call in geriatrics, the rectangularization of aging, meaning that instead of a slow decline over time, like the side of a triangle going downward, you are horizontally maintaining your same level of function until the very end when you sharply go down.

[00:15:18] Obviously, I don't know if YieYie would have agreed with our decision because he was not able to speak at that point, but I like to think that he was conscious enough to perhaps hear our conversation and understand it. They said that he had a tear in his eyes running down his cheek at the very end and I'd like to think that he agreed with the decision we made. With that said, even as a medical professional, even with the consensus among my family, it was still a tough decision. I can definitely see how decisions like this could be a lot more complicated and contentious in other families. But I think that my YieYie had the outcome that he would've wanted .

[00:16:17] My GongGong, on the other hand, was the opposite of my YieYie. GongGong lived until he was 96, but unfortunately the last five or so of his life was a very prolonged and slow decline. He had dementia toward the end of his life and was both cognitively and physically limited. The benefit of living in China, is that labor costs being much cheaper than here . My uncles and aunts, my parents contributed to a full-time caregiver who took care of my GongGong for several years. My husband and I actually got to meet my GongGong about a year or so before he passed. Even at the time that we saw him, we thought he was going to die imminently just because of how frail he looked. He really could not converse with us. He did seem to recognize me and smile but it's unclear how much he understood of our presence. We thought that he would definitely have been hospice- eligible if he were here. He proved us wrong and lived for another year or more. I think this is what great caregiving can do for you when you have the financial and the physical support to be able to take care of someone, to have that slow decline over time, which may be what some people would have wanted as well. In GongGong's case he lived for much longer than all of us would have predicted. He got to spend that time surrounded by his family. He was cared for at home, got to see his grandkids grow up. So that's another way to age well.

[00:18:38] The third person to talk about is my PouPou, my maternal grandmother. PouPou is still alive and PouPou is this creative, spunky woman who in the past couple of years have had a number of strokes. Interestingly, similar to my paternal grandfather, PouPou's medical decisions also involved me to some extent .My aunt who is my mother's sister-in-law is a nurse in China. She actually rose in the hospital leadership to be a high- up hospital administrator. She really coordinated a lot of the care for my maternal grandparents. Without her, I am sure they will not have had the level of care that they both have received.

[00:19:39] After PouPou had her first stroke, part of the stroke workup determined that she actually had carotid stenosis. Our carotids are the major arteries that go up around our neck, and supplies to blood to the brain. When there are blockages in our carotid arteries, if it's more than 50% blocked on either side, oftentimes a vascular surgeon would do a procedure calledcarotid endarectomy to to remove the blockage. I distinctly remember my mom asking for my opinion as to whether or not PouPou should have carotid endarterectomy. At that time, while she has had a stroke, she really was recovering quite well from the stroke. I really thought that the risk of surgery is worth the alternative of having decline from multiple strokes. I don't think I fully explained myself to the extent that I would have had in my role as a physician. I think many of you know, that even if you are very accomplished in your professional lives, when you're in your family, oftentimes we revert back to our childhood roles. In this case, I very much felt like I was grandchild, certainly not the same level of contribution as my aunt, who really handled the ins and outs of their care. So PouPou and our family decided not to have carotid endarterectomy. I think my aunt contributed very much to the decision and thought that the risk of a surgically related stroke or death during that procedure was too high of a risk. Unfortunately, PouPou has had a number of other strokes since that original one and she is much more homebound now.

[00:22:03] She also has really severe hearing loss, which really limits her communication with people. Hearing aids or the accessibility of hearing aids are really not well- established where they live in China. Speaking to her, even on the phone is very challenging. Basically her caregiver has to yell into her ears for her to hear anything. I think there are also some cognitive comprehension involved in speech that's not just due to hearing. PouPou has actually expressed explicitly to my mother that sometimes she feels jealous that my YieYie went so quickly without so much suffering. Despite the challenges that my PouPou has, she can operate an app that's very popular in China where family members can send her messages and pictures of the grandkids or great grandkids. She loves to look at pictures and she'll send messages back with little emojis of thumbs up. Even in the limited function that she has, I still think she's doing remarkably well.

[00:23:24] Last, but not least, is my NaiNai. She has been really overweight for my entire life that I know her. NaiNai had some metabolic illnesses like hypertension, diabetes, that sporadically are more well-controlled than others, but she is still highly functional. She loves to travel. She has a great mental attitude her entire life. My grandfather used to joke that she's truly blessed because she really worried about nothing. My grandfather did all the worrying for her. Even people who have wronged her in her life, she easily forgives them. NaiNai is able to use the same app to FaceTime with us. She loves to hold her phone really close, so I can really only see her forehead. Sometimes I can see her whole face. And of course, hearing her voice is wonderful. Whenever NaiNai sees my husband or my children, she just giggles and laughs and loves to see them.

[00:24:41] I hope you enjoy the stories of my four grandparents. I think they all aged well or are aging well, in their own separate ways. A lot of how we age is really outside of our control, but I think some of the examples that I have to shared elucidate some common things that we try to do in geriatrics. When is enough in terms of procedure or medical intervention? When is it not enough? I hope we can explore a lot of those in the following episodes. I hope that you'll also talk to your loved ones about what it means for you to age well. If you have enjoyed this episode, I encourage you to write a review on the podcast app of your choice and share this episode and this podcast with people in your life, who you think might enjoy listening. Thank you so much. See you next time.