Old codgers and living your best life: conversation with geriatric psychiatrist Dr. Matt Kern

 [00:00:00] Dr. Mia: Welcome to ask Dr. Mia podcast. This is Dr. Mia, and today I have a special guest for you. I am talking all things about mental health, specifically geriatric psychiatry with Dr. Matt Kern, and I'm gonna let Matt introduce him. 
[00:00:20] Dr. Matt Kern: Hey Mia. Appreciate the opportunity to be here and talk a little bit about geriatric psychiatry.
[00:00:26] I know that we've worked together a little bit, but this is actually my first podcast that I've ever done. So, Really excited about that and appreciate you inviting me onto your show. 
[00:00:34] Dr. Mia: Absolutely. I like to say that geriatric psychiatrists are like the unicorn amongst unicorns because there are so few geriatricians in a country, there are even fewer geriatric psychiatrists.
[00:00:51] So one of the first questions that for you is I wanted to hear about how you got interested in this field and just a little bit about your story. 
[00:01:01] Dr. Matt Kern: Yeah, absolutely. There aren't a lot of geriatricians or geriatric psychiatrists and I think that's unfortunately because. A lot of people aren't exposed to older folks in their formative years.
[00:01:13] For me, that was something that I fortunately had a lot of experience with. I had my grandma re, my Granny Zions and Grandma Kern Grandma Kern, my dad's mom actually. Lived with us the last few years of her life. And so I grew up around a lot of older folks in addition to aunts and uncles, great aunts, great uncles, those sorts of folks.
[00:01:33] And. I saw people living into older age even with their various vices and ailments and really understanding that a good attitude and social connection were really important. And these folks had a lot of things to teach me growing up, and I realized later on that was a connection that I really value.
[00:01:52] Equally importantly I saw the value that I could give to older folks as well. They seem to enjoy speaking with me, which wasn't always the case when you're a kid. But as you get older, as you get a little bit more experience and expertise people are interested in talking with you and if you can make them feel like a person, you know, have that human connection, it's really rewarding from both sides.
[00:02:15] Dr. Mia: Absolutely. I think I share a very similar childhood too of growing up around all four my grandparents and I actually talked about this in my very first episode about, you know, what is aging well? Because there are so many different ways to age, and in my opinion, there's really no wrong way to age in the sense that there is so much that's outside of our control and even people who did quote unquote unhealthy things like smoking their whole lives. My paternal grandfather did that until the very end. I also came to the understanding that, having good attitude and important social connections were very important, especially as people retired and their lives kind of took on a different chapter. 
[00:03:09] Dr. Matt Kern: Yeah, that's so interesting, isn't it? You know, we think about being healthcare providers, our job is to help people be healthy, to live well. And I feel like in my role as a geriatric psychiatrist I've really embraced some of the philosophy of, living well. And I feel like a lot of our colleagues in medicine, focus on the living part, but not necessarily the living well. Of course, you want people to be healthy. You want them to avoid things that are gonna be harmful to their health. But yeah, being around these old codgers as I affectionately call them, these uncles in their seventies and eighties, drinking and smoking on the weekends, growing up that was normal for me. Now, as a geriatric psychiatrist, I look back and think, Man, if other healthcare providers saw that environment, they would say, "Oh my gosh, these guys are so unhealthy."
[00:03:55] But there's, there is something to living your truth. And I think when we talk about motivational interviewing and what's important to people that's part of the conversation. And yet the older folks that I grew up with, they have a much different concept of what living well means apart from the medical structure that we use.
[00:04:17] Dr. Mia: And your family's from rural Arkansas, is that's right?
[00:04:21] Dr. Matt Kern: Yeah. I I grew up in Fort Smith, so if anybody knows where that's at, it's on the Arkansas, Oklahoma line, about a hundred thousand folks, but about an hour outside of town. There was a farm, which is really just bunch of land that my dad bought when he was young and was, has been fixing up the work of a lifetime.
[00:04:38] We've had a number of folks live out in that area. Aunts, uncle. Grandparents. And so I, I've had the privilege of going out there with him on weekends growing up and being around some of those folks, but probably the most formative person was my grandma who lived with us for a number of years.
[00:04:53] I remember I would sometimes play hooky from school in grade school and say, I don't feel good. I need to stay at home today. And then once my parents went off to work, me and my grandma would play skip bow or dominoes and watch the prizes. Right. And those were some of my favorite memories.
[00:05:09] One of the things that got me into healthcare: one night my parents and my siblings had all gone out somewhere and for some reason I stayed home, didn't wanna go out and do whatever they were doing. So it was just me and grandma and I was playing a computer game when I heard her dinner plate clattered to the floor.
[00:05:24] I remember she was watching Wheel of Fortune and we had a great relationship. So I said, Grandma, you getting wild in there? And she didn't answer. and I knew then that, that something was wrong. So I went in and checked on her and she was struggling to move. She wasn't speaking, and she had this look of fear in her eyes.
[00:05:47] I immediately got fearful and I went to her and I said, Grandma, are you okay? She had nitroglycerin, pills and a little capsule around her neck. And even though she had to have had a, a terrible. I could see her clutching at those nitroglycerin pills with her fingers. And so I got one out and I gave one.
[00:06:06] I put one in her mouth and I said, Grandma, I'm gonna go call 9 1 1. I'll be right back. So I went and called 9 1 1. I called an aunt who lived across the street, and then I came back and I sat with her and I held her hand. I said, Grandma, everything's gonna be okay. You know, helps on the way. and I remember seeing the fear in her eyes, but also the strength and the love that she had for me in that moment.
[00:06:25] Even though she didn't have any words that she could use to comfort me, I could tell just from the look in her eyes how strong she was and how fiercely that she loved me to be able to have that moment and to sit with someone who's going through a terrible, terrible health incident that eventually took her life a few days later.
[00:06:43] To be able to sit with someone in that moment and share that space with is so powerful. And that's to me, one of the most important things about geriatrics dying is a part of living. And I think if we can reconcile ourselves to that fact, it's not just about how do you wanna live, but how do you want your last days to be, your last moments?
[00:07:04] What does dying well look like? And I think reconciling ourselves to that helps us understand what living well means. 
[00:07:13] Dr. Mia: Absolutely. That's really beautiful and profound kind of what you just said about that very special moment you shared with your grandmother and. I think so few people actually have had that experience with their grandparents. Because I think our family units oftentimes are much more separated compared to an intergenerational household. And that, just being that presence is so important and that presence alone, is almost like, a spiritual connection in that respect. And I try to also remind myself for some of my patients where, cure is definitely not possible, and care sometimes is touch and go and trial and error, but I like to remind myself that the presence of being with them during whichever part of their journey is in itself a healing practice, a healing presence. So thank you for that, for sharing that with us.
[00:08:24] Dr. Matt Kern: Absolutely. And one thing that I think that growing up with older folks around, especially the irreverent folks, the codgers, as I've affectionately called them before. It helped me understand we all go through hard things and seeing how they responded to adversity, health problems, death, other folks that they've lost.
[00:08:42] It's helped me. Connect with older folks. I don't necessarily have the same health problems or struggles or issues that they do, but one thing that I don't do is spend much time at all feeling sorry for them. Feeling sorry for people doesn't help, and I think sometimes as providers we get caught up in this, "Oh my gosh, your life sounds so hard. You're dealing with such terrible weight of burden, medications , other problems." But okay, yeah, that's all true. But what do you want your life to look like? Knowing the context, knowing everything that you gotta carry, how can we make your life good today? And honestly, that's the coolest part about geriatric psychiatry is, you know, it's their life. They're living it. They know that they've got a lot of issues and struggle. To a degree, we all do. They don't want to be patronized or pitied by their healthcare provider. They want their healthcare provider to help them live their best life, whatever that looks like. 
[00:09:30] Dr. Mia: Absolutely. And for the audience who may not know can you tell us a little bit about the training process to become a geriatric psychiatrist?
[00:09:39] Dr. Matt Kern: Yeah, I think it was something like 27th grade that I graduated. I joked to my nieces and nephews about that. So four years of medical school, I did four years of residency at Wake Forest, Atrium Health, Wake Forest Baptist now. And then I went back to Arkansas for a year to do a one year fellowship in geriatric psychiatry.
[00:09:58] Dr. Mia: Gotcha. And who are the, patients that would say, I need to go see a geriatric psychiatrist like you, versus going to a regular psychiatrist with understanding that because there are so few of us, I think that ends up being an access issue more than anything.
[00:10:19] Dr. Matt Kern: Yeah I hate that there's access issues and I wish that there were more folks that were interested in doing this work because it's so rewarding. And I think there are folks that are interested that may not realize they're interested yet. So I'll say, if somebody's, from the patient perspective, if you're struggling with something, talk to your doctor talk to Dr. Mia. Right? And Dr.. Mia or your primary care doctor is struggling to manage this stuff. Know that there's always an option and that's the hope that I give all the patients that I talk to as well. Say, here's what I'm thinking. Let's start you on this, or let's do this intervention. And down the line, here's a few more things that we can do. So I think as a provider where whatever discipline you're in, If you're running out of real estate for what you think maybe is the next step, don't wait to try to reach out and get a geriatric psychiatry consultation for your patient.
[00:11:08] Sometimes it's a one time, we're working on doing setting up a new e-consult, where you can just send a message and I can review the chart and let folks know what's going on or what I think best next steps are. Sometimes that's all you need. Or if that's not sufficient, happily see those folks and provide them with a roadmap that I think will help them towards success. There's always a shot at success. 
[00:11:29] Dr. Mia: Absolutely. And I think there's still a lot of stigma about mental health compared to physical health and the type of psychiatric illnesses that perhaps people are not able to visibly see. Like if you broke your leg and you can't walk, you know, that's a very obvious, hopefully non-judgmental illness. Then say if you have bipolar. There is still very much a stigma with mental illness compared to a physical illness and that there are some internalized thoughts that, " this is not a problem because it's just the situation that I'm in right now." or perhaps "I don't want to take a medicine to change who I am" or, " I'm not crazy." Just curious as to what your advice would be. If you have patients who think like this or have folks who are trying to convince their loved ones to, to seek some psychiatric help. 
[00:12:32] Dr. Matt Kern: Absolutely. And it's a big question, right? There are multiple approaches. It depends in part, on your own personality. It also depends on your role. As a caregiver, that's something different than a provider as a family member. So I'll say my general strategy is let's not, call it mental illness, first of all, I think using their language especially for older folks or folks who come from different cultures. But, clinical words can often be off putting for older folks or folks from different cultures, they may not say I'm anxious or I'm depressed. I have one patient who calls it his" shaky". More than a few don't feel like they're depressed, they're just worn out or they're tired of caregiving. And so what the way that I talk with them is I say, " the medicine I'm suggesting can help you feel, help you with your shaky feeling, or can help you with feeling worn out."
[00:13:20] I think we need to maybe pivot away from talking about mental illness and let's talk about mental wellness. you feel like you're living your best life right now? I feel like very few of us can say, Yeah, I'm living my best life right now. And if you are, that's fantastic. I don't think you need to come see me at all. If you don't think that you're living your best life, ask yourself, what can you do today, in the next week, in the next month to set yourself up for success? Maybe not becoming the best version of yourself, but at least getting closer, incrementally closer all the time. If you can't answer how to get closer to living your best life or to living more well, then ask your friends, ask your family. Hey I don't think I'm living my best life right now. Maybe they've got suggestions. A lot of times they don't. Okay. Maybe then it's time to talk to your doctor. If your doctor's got a couple of suggestions, great, fantastic. If you make it all the way to me, you're probably aware that maybe you're not living your best life.
[00:14:12] So I don't really care what we call it. That's one of the virtues of psychiatry is. Have a broad diagnostic range. It's more art than science of psychiatry. You can't test a blood level and say, Yes, that's depression. Yes, this is anxiety. But we, what we can do is talk about what's bothering you.
[00:14:29] What's, if you have anxiety, if you have shaky, what is that stopping you from doing that you'd like to do? Okay. I don't wanna focus on the symptoms, I wanna focus on your goals. What's important to you and how can I get you there? You mentioned, I think in episode two about the five M's.
[00:14:45] I use a very similar model, the four M's. So mobility, medication, mentation or thinking, and then what matters. And when I'm teaching in clinic and talking to residents and medical students, PA students I tell them, the what matters is the most important question that you can ask somebody in geriatric psychiatry. Because without understanding what matters to them, you're not gonna reach them. You're not gonna collaborate, you're not going to do what they want you to do. And ultimately what they came to your office to accomplish. 
[00:15:16] Dr. Mia: I feel like there's a lot of similarities between geriatricians, geriatric psychiatrists, behavioral neurologists, all of us who kind of deal with the same patient population, but coming from a slightly different discipline. And I know Matt and I have shared some patients who have both mood issues as well as memory issues. And sometimes it's very challenging to get to the bottom of which ones the chicken and which ones to egg. I think going back to what matters to most to people is really important and sometimes depression and mood changes almost makes a person not really know what matters. 
[00:15:59] Dr. Matt Kern: Mm-hmm. . And I think that's actually a clue that like, if you have trouble thinking about what you want, like how to live your best life, there may be a component of depression in there too. If I could a minute to speak about depression and the loss of perspective, Cause as you mentioned with your mom, sometimes it's difficult to engage somebody in a conversation about their mental health. So first and foremost, it's gotta be their choice to, to seek help. But the way that you can frame that is, "Hey, mom, Hey dad, here's what I've noticed. Have you noticed these things? Do you feel like you're living your best life?"
[00:16:34] And they may say, "No, I'm not living my best life, but here's why." Okay. Okay, we'll let it drop for now, but revisit the conversation in a week, two weeks, three weeks, four weeks, and ultimately say, you know, Mom, what's the hurt in maybe going to talk to somebody about it and say, "I don't wanna do that. I'm not crazy."
[00:16:49] I'm not saying you're crazy. I'm just saying if it has, 1%, 2% chance of helping, why don't we give it a shot and just see what you think. So a lot of times you can engage older folks that way of saying, Yeah, but what else are you doing on Tuesday? You don't got a job to go to. And that's more my style of just that down to earth, prodding people towards their wellness. Ultimately if they don't got plans, why don't we go give it a try? 
[00:17:12] One metaphor that I use in talking to people about the loss of perspective is, being depressed or dealing with mental illnesses like living in a shoebox. It feels very dark. It feels like your world is very small, and it feels like there's just not a lot of light or energy, and that's true. It's literally true because you're living in a shoebox. You're gonna feel cramped. You're gonna feel worthless, like you can't do anything. My job is to help you see that it might be possible that there's a world outside of that shoebox.
[00:17:42] It may not feel true, but if we could let a little bit of light in, if we can let that crease in, maybe you get one ray of sunshine for just a little bit, maybe it goes away too. But if we can provide that brief perspective of a world outside of your depression, a world outside of your anxiety, maybe that's valuable. And maybe we can use that to work towards wellness. 
[00:18:04] Dr. Mia: Absolutely. And I think it's not a discussion of either or, It's not just taking medicine without doing other life enriching activities. It's sometimes people need a little bit of medical assistance to be able to then access other life rejuvenating, mood helpful things like, seeking social connection. I think depression and anxiety to many extents are so common and social isolation and loneliness are so common, especially as people age. I think that's very easy to fall into the thought that, this is just what happens when I hit 75 or 80 and all my friends have passed away. So there is very little meaning left in my life, and I think that's a thought. That may not be actually true but because of whether it's ageism or just our culture, I think it's easy for people to fall into that kind of thinking.
[00:19:10] Dr. Matt Kern: Absolutely we use the biopsychosocial model in psychiatry and therapy. And that basically, the way I explain it to patients is about 33% of your mental health is gonna come from your biology, your genetic inheritance from your parents. Also, the medications that you take, not just psychiatric medications, but some of the other things like blood pressure medications can affect your energy level. And then about 33% is gonna come from your psychology or how you feel or how you think about your mental health. And then another third is gonna come from your situation that you're in, your social situation. What kinda activities do you do? Who do you engage with? What does your support system look like?
[00:19:45] And you mentioned medication is not the only answer. And I emphasize that I, as a psychiatrist, I'm not trying to sell you on medication at all. I'm trying to tell you, this is just a piece of the puzzle. Where are your deficiencies here? Maybe you're taking too many medicines, which is often the case in our geriatrics folks.
[00:20:01] Maybe we need to focus on the social interventions or, I'm hearing some all or nothing thinking. I'm hearing some dark, pessimistic, way of viewing your life. Maybe we really need to focus on the psychology because each of those contributes just about equally to how well you're gonna do and how well we can optimize your mental health.
[00:20:20] Dr. Mia: Yeah. The all or nothing thinking, I think, gets a lot of people in trouble and I see myself falling into some of those thought patterns sometimes too. So just to normalize that, not everything is an illness. Last question for, Dr. Kern is, are there any other tips or things you wanna tell folks who may not know much about geriatric psychiatry? 
[00:20:46] Dr. Matt Kern: So first of all, geriatric psychiatry isn't just about treating the patient. Oftentimes it's about helping families understand the illness that the their loved one is going through. Whether it's talking about a new normal or what we can expect from the progression of an illness like dementia caregiver fatigue and burnout are often the triggering events for when a person needs to transition to a higher level of care like an assisted living or nursing home. And I think you talked about some of that stuff in episode three. But so oftentimes I can help with that caregiver fatigue, caregiver burnout. It's not just about talking to a patient. So you may think, Oh, mom or dad is too far gone, like a psychiatrist isn't gonna help. I can still, we can still talk about planning and how to approach these situations, how to keep them calm. Maybe medication is a part of that. But maybe we're just having a conversation as caregiver and provider for what we can do to manage these things at home. Keep these folks at home as long as possible, because often that is the goal.
[00:21:40] Another thing that I like to do is like I said, use a no nonsense down to earth approach. Talk about if I were you or if I were in your shoes, I find that speaking non clinically can be disarming and avoid a battle, right? So I'm not recommending this as a doctor. I'm recommending this as a person who lives this life most days. And so may have a perspective that's a little bit more informed than, the fearful or depressed perspective that you're coming from. You're struggling. You came here to obtain my expertise and I'm gonna give that to you in a no nonsense sort of way.
[00:22:14] So using this as, if you were my loved. It can help soften the blow of recommending a medication. I've joked before to some of my folks, if I were your loved one, I would come down and I would strap that CPAP to your face every night, because I know that will help with your mental health and your physical health. And in joking a little bit like that can help set people at ease while still emphasizing the importance of what I'm recommending. I often joke for my quote unquote non-compliant folks, I said, Okay, you ready for me to wag my finger at you? And then they say, Okay. And I wag my finger at 'em and I say, Okay, now we got that out of the way.
[00:22:50] Let's talk about why this has been hard for you. And that can, they there's shame and guilt for not following doctor's advice. Or sometimes, you don't wanna tell your doctor that you haven't been taking the medication. Let's talk about it. Let's get that other crap out of the way cuz this is your life.
[00:23:02] One other strategy that I wanted to mention that I found useful, especially in the context of people who might be a little bit skeptical about medication, skeptical about psychiatry in general. I like to literally weigh my options. Imagine you're holding both hands up in the air, and you're weighing things in both hands. And I say, you have a choice. I'm not gonna make this decision for you, but what I can help you do is understand the pros and cons, the risks and benefits of what you're going through. You came here for a reason, here's an intervention.
[00:23:31] We can try or you can continue like you've been without anything changing. That seems harder to me. So maybe we can try something new. Knowing we can always go back to how things are now. And the whole time I'm giving them the spiel, I'm weighing my hands in the air to show them, this is your choice. But gosh, it sure seems like one of these options might be a worthy trial. 
[00:23:56] Dr. Mia: Absolutely. And I think patients wanna know that. That it is a trial, that there are a lot of fear and nervousness about trying medications. But I think I always tell my patients the same thing, that if this medicine doesn't work for you, let's talk about it and let's come up with a different plan, and certainly I am not a pill pusher for you at all. In fact, oftentimes we work on ways to take away some of the other medicines that you might be on that perhaps you don't need to be on. But thank you so much for joining us today, Matt. I really appreciate this conversation and for those who are listening, if you are enjoying this conversation, please leave me a review on Apple Podcast or the podcast platform of your choice and share this episode with those that you think my enjoy listening as well. Thank you so much. 
[00:24:58] Dr. Matt Kern: Thanks Mia.