Americans are getting older. According to the nonprofit Population Reference Bureau, larger percentages of the U.S. population have been shifting steadily into older age cohorts for many years, due largely to the aging of the Baby Boom generation and slowing rates of childbirth and immigration generally. Given that this trend will have an enormous impact on the American healthcare system over the next several decades, the UND School of Medicine & Health Sciences has made the study of aging – and the production of health providers focused on the senior population – an important component of its mission. To that end, the School will host a Continuing Medical Education (CME) symposium entitled “Disrupting Aging” as part of its annual UND Homecoming 2021 festivities on Friday, Oct. 22. To get a better handle on the issues facing providers, researchers, and anyone expecting to get older in the next decade, North Dakota Medicine gathered the symposium’s presenters to chat aging and the so-called geriatric “4M’s” of healthcare provision: medication, mobility, mentation, and what matters.
The speakers below include Don Jurivich, M.D., chair of the SMHS Department of Geriatrics; Chester Fritz Distinguished Professor in the Department of Biomedical Sciences Holly Brown-Borg, Ph.D.; Department of Physical Therapy Associate Professor Meridee Danks, D.P.T.; Department of Occupational Therapy Associate Professor Cindy Janssen, Ph.D., OTR/L; Rick Van Eck, Ph.D., associate dean for Teaching and Learning in the SMHS Office of Education & Faculty Affairs; and Rebecca Brynjulson, Pharm.D., director of Introductory Pharmacy Practice Experiences and assistant professor of practice in the NDSU School of Pharmacy.
Thank you all for your time. There’s obviously a lot happening in the lab, classroom, and clinic related to aging. What are some exciting developments in your respective disciplines?
Don Jurivich: The excitement for me is that research is showing that we can stabilize and potentially reverse some of these aging processes. There’s preliminary evidence that have come out of human trials with specific diseases such as pulmonary fibrosis, which is an aging disease, that interventions have basically stabilized the disease rather than allowed it to progress. The second interesting point is the concept that we age at different rates, so our chronologic age may not match our biologic age. This raises the whole question of how we can lower the population that is “older” than its stated age into a more youthful category. The third, somewhat controversial, thing we’re asking is whether life extension is possible. People have speculated that 120 years is the maximum human lifespan. But some researchers think it’s unlimited and that we just need to find the key to unlocking immortality. With that comes not only the biological but philosophical-spiritual questions.
Holly Brown-Borg: There are ways to slow aging, you know, diet, exercise, of course. But there are also pharmaceutical tools. I think the most exciting pharmaceutical aspect of that is something called senolytics or senotherapeutics. These are drugs that are already FDA approved for the most part, or they’re natural compounds, like polyflavonols, that have been found to increase longevity and increase healthy aging, at least in animal models. These senolytic compounds can kill off “senescent” cells—those that stop dividing but do not die. Researchers think this accumulation of senescent cells within tissues is what’s driving inflammation and inflammation is what’s driving a lot of decline in physiology.
Which is for people who may already qualify as “older,” right? But that’s secondary to keeping people “younger” or healthier longer in the first place.
HBB: Yes. Dietary restriction and exercise—that’s been the gold standard in the field for a long time. Those things can slow aging. Genetics is another method, but it’s not straightforward any longer. Although things like CRISPR have been in the news in terms of abilities to manipulate genes, that’s a ways off for the number of age related diseases as a whole.
DJ: And genetics really has very little to do with it. The problem is that researchers have studied centenarians and there are virtually no genes that can be identified as being associated with living to 100 years old. Random events, environmental events, send us down this other rabbit hole in terms of things we can do to prevent those [physiological] changes in aging—diet, exercise, and maybe some of these antiaging interventions. As we progress in time, these so-called senescent cells will continually accumulate, so we need to keep addressing those year to year to try to remove these cells. That’s the concept. In terms of senolytics, then, one theory is that the accumulation of senescent cells starts driving disability as we get older. But by selectively knocking these cells out—killing them—as we get older, we can perhaps stop that process, maybe can get a reset or rejuvenation.
And this sort of thing is starting to make its way into the education of health providers, yes, the 4M’s?
Meridee Danks: Cindy and I both teach geriatrics, and so a lot of our students come in thinking [geriatrics] is not the route they’re going to go. They often think, “I’m just going to treat people with a sports injury.” I say to them, “You are going to treat older people. This is what’s coming at you, so you need to prepare for this.” After students take our geriatrics classes, they realize the complexity that occurs when you’re treating somebody who is older. And they realize: this is real. The complex patients require a team of providers. It’s getting that interprofessional connection which I think is really important. I mean, PT and OT, nursing, the doctor, the social worker, the dietician all have to work together because of all the different things going on. I’m focused on mobility, but I think it’s interesting that with the 4M’s, you’re never dealing with one at a time. Medication affects mobility. And if you have dementia [mentation], that’s going to affect your mobility.
Rebecca Brynjulson: At North Dakota State University, we teach PharmD students to consider many factors, including aging, to determine appropriate medication use for patients. Prescription medication, non-prescription medication, and herbal product and dietary supplement use should be evaluated routinely as patients age to assess for both benefit and/or risk with use. Helping students learn to optimize medication use and recognize when it is appropriate to recommend deprescribing medications can be impactful in geriatric patient care.
Cindy Janssen: My topic is What Matters to older adults. I tell students, if they’re going to be working in a rehabilitation center, for example, 80% of the people they see are going to be geriatric, and that opens their eyes. Occupational therapy has historically been seen as rehabilitation after an illness or injury, with only 3% of OTs indicating they were working in community settings in the 2015 workforce survey. We’re changing that now, through community-based wellness, and OT has a program called Lifespan Redesign, a wellness program where Clark et al. (2011) found in a randomized controlled study that there was actually a cost savings by having community-dwelling older adults participate in wellness programs. OT is changing to include community care and health promotion, addressing both physical and mental functions for overall health and quality of life, through participation in meaningful activities.
Rick Van Eck: And there’s a fifth “M” now too—medical or multiple complexity, which reflects that fact the majority of people over age 65 have more than one health condition and multiple treatment regimens that interact and must be accounted for in providing care. In the past, society assumed that aging and complex medical conditions was a fact of life and meant you had to consider long-term care. But people over-65 represent a huge proportion of the population and they don’t see it that way. Aging in place is what they expect and they have the attitude, money, and clout to lobby their representatives to make changes. Those things that you’re talking about, Cindy, have to be covered. People are going to want to stay in their home as long as they can, and they have the clout to make that happen, and that’s going to require changes in billing and in practice too.
And you’re part of a team, Rick, that has developed an aging game for students and providers, yes?
RVE: That’s right. We (Don’s team) quickly realized the need for both in-depth training around the day-to-day geriatric care challenges providers face. But part of the challenge is that many providers do not know about the 4M’s and/or see them as an “add-on” that will increase time and cost and reduce care. The benefits of the 4M’s are visible only over time and at the population level; it can be hard to see their impact on a patient-by-patient, annual basis. The video game allows providers to apply the 4M framework over time at the population level. In the first level, they apply the 4Ms to a panel of 100,000 patients for hypertension beginning with patients 65-74 and continuing treatment at 75-84 and 85-100. By doing so, they can see that fewer healthy people develop hypertension, mortality goes down as fewer with hypertension die, and cost goes down as disease prevalence goes down. Putting this into a game format is not about making it fun; it’s about allowing them to see the longitudinal impacts of the 4M’s through time compression and the scale of impact at the population level. As a result, more providers will be interested in digging into the 4M’s more deeply, hopefully through a comprehensive geriatric certification program, which is also part of the grant.
And with more people needing to think about this sort of thing, the culture changes more broadly.
DJ: People in general don’t reflect on their mortality. They often overestimate their lifespan, particularly in the face of multiple chronic conditions. There’s a wide range of attitudes and understandings of lifespan. So, people on one extreme, who suffer and have disabilities, see a closer relationship to their mortality whereas people who are healthier don’t reflect on that as much.
HBB: Along those lines, I’m in a course right now through the Gerontological Society of America that they call “reframing aging.” And because ageism is a big issue, they’re trying to change the way people think about aging. Instead of an “illness”—decline, decline, decline, then death, you know, everything’s devastating and detrimental—we should try to turn that around and convey that aging is an opportunity. It’s a collective benefit. We used to just talk about wisdom, but it goes way beyond that. It starts at conception. That is, it doesn’t just start at age 60. There are things we can do for all communities, if they have access and if it starts earlier, that can be incorporated into healthcare education and into our discussions with medical students and OT and PT. But it has to occur earlier, and we have to think in a more positive way, instead of “oh, it’s awful when you get older.” That’s something we should try to incorporate, and it goes beyond what we’re doing today.
MD: We’re trying [in physical therapy] to get away from using the term elderly—it’s older adults, or just “adults.” I think just the mindset and trying to change things and to be honest about changes. There are changes for a toddler, going into adolescence and puberty. These are just additional changes in the body that occur that happen to be related to time.
CJ: Our textbook on aging [Functional Performance in Older Adults by Bonder, et al.] intentionally rewrote the cognitive changes chapter, and they don’t use the term “cognitive slowing” anymore. They intentionally and transparently reframed their wording—and they were very open about this—telling the reader that they’re no longer describing the negative changes of cognition, but just the “changes” that occur.
MD: Cindy and I do a fall prevention program called Stepping On. We do a seven week program, with some exercise, and there has been a national study that showed such programs decrease falls by 30%. And it’s not just meeting with the person, but it’s meeting with the person and doing lifestyle changes over a period of time. You meet once a week for two hours for seven weeks, and they kind of buy into it. And the people love it. When I first started doing it, I thought “This is so basic; people are going to be bored.” But the older participants told us, “That’s what I needed to know what I can do to keep myself more mobile; what I can do to keep my balance better.” These are basic exercises, but they just needed somebody to guide them.
CJ: From an OT standpoint, we’re tying it into function. For example, standing on one foot when brushing your teeth. It’s an evidence-based exercise, but you can enhance it here by tying it into normal activities and environments. I think it’s interesting that with the 4M’s, you’re never dealing with one at a time.
RVE: Yeah, and building right off of that, the thing that I think is most interesting is this shift away from reactive to proactive healthcare. Shifting to a population health framework and the interprofessional teams is all part of that idea, but the challenge has always been the right funding and the insurance model. The social determinants of health. We know that this is the direction that we have to go: to be more proactive and to provide healthcare, continually, where people are when they need it. And I think the convergence of this change with the pandemic has forced us to consider radical changes like telecare and telehealth. Because now that we want telehealth, now that people realize the convenience of being able to take a cell phone image of their kid’s mouth, send it to their pediatrician, and ask “Do I need to bring him in or not?” all without travel, time off work, etc., there is no putting the genie back in the bottle. And I think that’s the most exciting thing.
Interviews conducted and edited for space by Brian James Schill