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Welcome to Season 4 of Minding Memory, where we are welcoming a new co-host, Lauren Gerlach to the Minding Memory team. Lauren is a Geriatric Psychiatrist at the University of Michigan and a member of the CAPRA leadership team. In this episode, Lauren shares a little background on her research interests, what it’s like to be a geriatric psychiatrist, and some lessons learned about using “uncool” emoticons or emojis when texting.  

Transcript

Matt Davis:

It is hard to believe, but we're beginning the fourth season of the Minding Memory Podcast and we want to thank all of you who have listened in. Over the last few years, we've discussed some really interesting science and got to meet some really great people. As we embark on a new season, we do have an announcement. Today we're passing the mic to a new co-host. Donovan is now off working on a major NIH-supported project that we discussed at the end of last season. We're going to miss him, and for those of you who listen to the episode where he took a cognitive test, we'll likely not find another person who can name as many birds as he can. But in all seriousness, we're incredibly grateful for his contributions and we'll have to find an excuse to have him back as a guest.

I'm joined today by Dr. Lauren Gerlach. Dr. Gerlach is an assistant professor in the Department of Psychiatry at the University of Michigan Medical School and, drum roll please, the new co-host of the Minding Memory Podcast. She's a geriatric psychiatrist whose research focuses on the dementia population and understanding psychotropic medication use, including evaluating how medications are used at the end of life. I'm sure we'll get into some of this today. Lauren, pull up a mic and settle in. Welcome to the podcast.

Lauren Gerlach:

Thanks, Matt. Happy to be here.

Matt Davis:

First question, right out of the gate here, did you ever think you'd find yourself agreeing to host a podcast?

Lauren Gerlach:

No way. I am an avid podcast listener, but never thought I would be the host. But I'm looking forward to this. I've enjoyed listening to your episode so far and I think this is going to be a lot of fun.

Matt Davis:

I never thought I would be hosting a podcast either. Interestingly, I don't listen to that many podcasts myself for whatever reason. I tend to listen more to books on tape. But I think that's one of the fun things about what we do. We're both faculty members and one thing that I've always liked about my job is that it never stops challenging me. It's like we start off and usually we start off with research. You're like, "How do I conduct a research study?" Then it goes to "How do I write a manuscript and publish it," and "How do I write a grant?" Then all of a sudden you find yourself teaching a course and all these things. I feel like podcasts and things like this that I think are becoming more common is just one of those things that sometimes lands on your plate and you figure it out as you go. That's what we've been doing so far.

Lauren Gerlach:

Absolutely. I think a big thing about research, too, is thinking about how we disseminate the work. I think anyway that we can get good and interesting research out there for people to be able to understand and digest, I think will be helpful.

Matt Davis:

That echoes a conversation that we had with Brian James, a previous guest on our podcast that he himself runs a pretty successful research-based podcast. I don't think that we as professors as we get promoted and all that, podcasts and things like this aren't necessarily built into the criteria that we use, but maybe they should be, because I think things are changing. The classic mantra and research was we conduct a study, we publish our study, and we put it in the literature for all to see, but that's not necessarily the best way to reach people.

Lauren Gerlach:

I agree. Isn't the joke that your mother and maybe two other people read the article? We can certainly think about this as a way to get more people interested in the work that people are doing and reach a larger audience.

Matt Davis:

All right, so we've known each other for some time, but I want to make sure that you have the opportunity to introduce yourself and to the listeners out there. Could you just tell us a little bit about yourself?

Lauren Gerlach:

Sure. My name's Lauren Gerlach. I'm a geriatric psychiatrist and assistant professor at the University of Michigan. I do health services research, really focused on safe and appropriate prescribing of what we call central nervous system active medications to older adults with mental health and cognitive disorders.

Matt Davis:

Where are you from geographically?

Lauren Gerlach:

Yeah, so I grew up in a suburb in between Cleveland and Akron and then bounced around a little bit, did a little geographic tour of the United States, so was in Philadelphia for a bit, North Carolina, Los Angeles, and then came back to the Midwest and I've been here in Michigan for almost 13 years now.

Matt Davis:

In addition to your winning personality, one of the reasons that we really wanted you to help, this is your clinical background. I'm wondering what got you interested in pursuing a career in healthcare?

Lauren Gerlach:

Yeah, I come by it as a family trait. My grandfather was a hematologist oncologist, my dad was a primary care physician. My sister's a pediatrician, so I come by it honestly through family. When my dad was a young physician, the joke was before the days of baby carriers, he used to put me in a book bag and I would do nursing home rounds with him. Apparently I was a big hit, so I always was surrounded by medicine and healthcare, so always had an idea that it was something that was interested in despite my dad and grandpa's efforts to assure us that there are many other professions out there, both my sister and I ended up going down that road.

Matt Davis:

I guess more specifically, how did you settle on your specialty?

Lauren Gerlach:

Yeah, so geriatric psychiatry is a unique specialty and I'd say it's one of the more medically connected of the psychiatric subspecialties. When I was in medical school, I really found myself interested in internal medicine, neurology and psychiatry. I think geriatric psychiatry is a great field that marries all of those interests. It also, and I think if you talk to most folks who work with older adults will tell you that there was some very important older adults in our life growing up. For me, I was very fortunate to have all four of my grandparents growing up who had a big role in raising my sister and I. Just a really always appreciated the wisdom, the humor, resiliency that comes with aging. It's a population I really appreciate. Then some early mentorship. Before I went to medical school, I had the opportunity to work as a research assistant and then clinical research coordinator for geriatric psychiatrists at the Philadelphia Veterans Affairs Hospital and University of Pennsylvania. It really sparked my interest and got me interested in the field.

Matt Davis:

As a person that doesn't have a background in medicine, is geriatric psychiatry considered a subspecialty?

Lauren Gerlach:

It is. What you'll do is you go to medical school and then you'll do a residency in psychiatry and then you'll do a fellowship. Most people do either a one year or two year combined clinical and research fellowship.

Matt Davis:

I think I heard somewhere and that there's some similarities between pediatrics and geriatrics, just not necessarily to... I don't know. Imply anything for older adults, but those are stages of vulnerability and the human life course. Would you agree with that? Do the types of people that gravitate towards pediatrics and geriatrics have some similar threads?

Lauren Gerlach:

We sometimes joke that there is, and my sister's a pediatrician and we sometimes say there's more similarities than differences in the type of work that we do. First, we'd say that maybe those specialties tend to attract a certain personality type. We like to think of ourselves as, I think to work with children and to work with older adults, we like to think that we're a friendly bunch, but I think it's a lot of family systems work in both fields. You're working a lot with care partners and families and other proxies who are involved at times in the care of whether it be a child or older adults, a lot of working with families and systems and sometimes, exactly, vulnerable life stages really an impact ability to impact trajectory at both of those stages. Then I think both populations say it as it is, which is something that I can really appreciate as well.

Matt Davis:

I never thought of... It's the communication aspect, too, because it's not just the patient always in the room. You have often someone else accompanying them, right?

Lauren Gerlach:

Absolutely. A lot of my clinical work is working with patients who are living with dementia. As I think you've talked about in previous episodes, it's just not the cognitive and memory concerns of dementia. There's also what we call these behavioral and psychological symptoms of dementia. Sometimes learning to communicate and best communicate and figure out what those behaviors represent really relies on picking up nonverbal cues, which can be the same in pediatrics as well, too. Really trying to understand what these behaviors are representing.

Matt Davis:

As you know, this is a dementia podcast. I think for people that don't have clinical backgrounds, at least me anyway, the first physician type that probably comes to mind is you think about dementia is a neurologist. I guess I'm curious as a psychiatrist focused on older adults, I guess, and a researcher as well that we'll get into in just a second here, why dementia? To what degree does dementia play a part of what you do on a daily basis in the clinic?

Lauren Gerlach:

Geriatric psychiatrists really specialize at the intersection of medicine, neurology and psychiatry. I'd say probably about a third of my patients come into clinic with general mental health concerns, whether that be anxiety, depression, these can be folks who have had lifelong psychiatric illness that persists into late life or folks who are experiencing say a first episode of depression after the age of 65. Another third of my patients are probably folks who are coming in for an evaluation of cognitive impairment. They've noticed memory changes over time and they're coming in for an evaluation to receive a dementia diagnosis or help manage some of the symptoms related to dementia. Then the last third, I like to say is a mix of all of the above. There's some underlying psychiatric issues going on, there's memory changes, trying to figure out what's what and help people receive diagnoses and come up with a plan moving forward.

Dementia is really a huge focus of what we do in geriatric psychiatry. Sometimes it's a question of whether folks see a neurologist first, whether they see a geriatrician, or primary care doctor, or a psychiatrist. Sometimes honestly, that depends on whose wait time is the shortest in terms of who they get referred to and who they see. As you know, there's a big difference geographically in terms of where specialists are located. That depends on who has access to seeing specialists. The patients that we see do tend to sometimes have more behavioral symptoms associated with their dementia diagnosis is that really is a specialty of ours-

Matt Davis:

Which is common, right?

Lauren Gerlach:

Yeah, it is. Exactly. It's really ubiquitous, almost now all patients, 97% experience some form of behavioral disturbance during the course of their dementia. Those are the symptoms that we really specialize in treating and managing.

Matt Davis:

There's a ton of questions I can ask you around dementia, that maybe is for another time, but I'm curious, there's a lot of providers that can... Different specialty types and everything that can be involved around the time of a diagnosis. From your perspective, what's the most common? Do you find yourself being the person that diagnoses dementia or are there certain physician types that are the ones that predominantly are the ones that actually make the diagnosis?

Lauren Gerlach:

I diagnose dementia a lot in my practice, and so part of the issue is that sometimes it can be unclear what's going on. Some of the early symptoms of dementia, that prodromal phase that we talk about often include things like depression and apathy. Often patients will be referred to our clinic with concerns that someone's experiencing a major depressive episode or they're just not engaged in activities anymore and family or other providers worry they're depressed. Then we do a cognitive evaluation, cognitive screening, get more history and diagnose dementia. Really, I think it depends on where folks' access is. A lot of times it might be a primary care provider, could be a geriatrician, a neurologist, but certainly we're providing that diagnosis for a lot of patients as well.

Matt Davis:

In addition to taking care of patients, you're a researcher. I'm wondering if you could just, I guess, tell us some broad strokes about what you're currently working on.

Lauren Gerlach:

Sure. My research really focuses on safe and appropriate prescribing of what we consider or call central nervous system active medications to older adults with mental health and cognitive disorders. Those include classes of medications, things like antidepressants, benzodiazepines, antipsychotics, other sedative hypnotics. Something I know you're interested in, Matt, too, is that where you live and where you receive healthcare can really influence the type of care that you receive. A lot of my work looks at variation of care across different regions, different provider types and different healthcare settings. I also have an interest in end-of-life care, especially related to dementia and looking at how well the hospice benefit serves patients for dementia and variations in the type of treatment that people receive.

Matt Davis:

How did you get interested in end-of-life care? Was that through just clinical experience?

Lauren Gerlach:

Yeah, it really was. Early in my fellowship we did a rotation in hospice and palliative care and was really struck how a lot of the medications that we use in psychiatry are used in very different ways in the end-of-life care process. As I started to do research in this area, I realized it was a little bit of a black box and that's both a data access issue as well as there's just not a whole lot of great clinical trials and treatment guidelines to sometimes guide how we use these types of medications in the end-of-life period. It was both clinical and some research and data access issues that really got me interested in that area. Then I think personal experiences, too. I think it's really hard to meet someone who hasn't been touched by dementia in some form of personal way. My grandmother had advanced dementia and Alzheimer's disease and was in out of hospice for years and very much remember her end-of-life course and how difficult that was in managing behavior, so both a personal and a clinical interest as well.

Matt Davis:

That's got to be pretty profound stuff. There aren't... My life, I haven't encountered some of these things. In working with people at the end of life, does it change your perspective on life and how you live and things like that at all? Is there any personal impacts of the type of work that you do when working with this patient population?

Lauren Gerlach:

Oh, sure, absolutely. I think it's hard not to have that put things in perspective. I think a lot of times when I tell people I'm a geriatric psychiatrist or what my research is focused on, the response is, "Oh, isn't that sad or isn't that difficult?" It is at times, but there's a lot of beauty and a lot of quality of life and help that you can provide during that time. I really get a lot of joy and satisfaction working with care partners and families, helping keep people in their preferred location of care for as long as possible and helping support families through that process.

Matt Davis:

Just circling back, you mentioned some of those medications, it's probably important to, I guess, point out to people that don't have clinical backgrounds like myself, which is what I represent on this podcast, that those medications are... They can be dangerous. Is it best? I always think about them as squishy medications that there's some margin, that there's some choice that providers make about when to do them. They're not necessarily something that have to be done for everybody. That's why we like to study some of those things, is because there's a margin of differences in terms of how people use them in different parts of life and to manage things in a complex population like older adults living with dementia.

Lauren Gerlach:

Absolutely. All of these medications can be very helpful in specific clinical situations. None of these medications are bad all in themselves, and can be helpful for some patients. However, not all patients need these medications and part of the challenge is figuring out how to tailor the right treatment for the right patient. Part of the difficulty being a physician and being in healthcare is you really want to help. Dementia is a disease where care partners and patients do experience a lot of distressing symptoms and often the path of least resistance is prescribing a medication to help address that. But unfortunately, these types of medications just don't have a lot of great evidence that they're helpful in treating the symptoms that they're sometimes prescribed for. There is great evidence that things like behavioral interventions, caregiver supportive interventions, addressing reversible causes of behavior really have the best evidence in reducing these types of distressing symptoms.

However, it can be really hard to implement those things in the real world. It takes time to train staff or people on delivering these non-pharmacologic interventions. It takes a trial and error approach and can be very hard to do that. These medications are often over prescribed and they do have some serious side effects. For instance, a class that I study a lot is called antipsychotics. These are old medications that are sometimes called neuroleptics, things like haloperidol or speridone. These medications come with a boxed warning that they increase mortality when prescribed to patients with dementia related psychosis. There are some serious side effects that we have to think about when we're thinking about that risk benefit ratio for an individual patient.

Matt Davis:

Just this brief discussion makes it so obvious how important it's to have you on the podcast because you bring this clinical expertise that I don't have necessarily in this space. It's just something that I think is important to acknowledge. I work with numbers for a living and I've been doing it for a long time, and this is something that I tell my students whenever I start out a term and start teaching stats or whatever. There's nothing inherently exciting or interesting or profound about a bunch of numbers, but I think it's important to realize that the numbers in our data sets, we work with huge data sets and national data and stuff. They represent real people with lived experiences and real things as profound as life and death, and it's easy to forget that when we're crunching numbers and doing analyses and all those types of things.

I think it's super valuable for me and I think will be for our listeners to have a person like you involved in some of our discussions around research, just to not only bring that perspective of having seen this stuff, because frankly I haven't seen dementia in the wild outside of my own life. It's just an important thing to keep in mind from a compassion standpoint and also just a stark reminder that the data sets that we work with, they can be profound. It's a responsibility to do good by them and to use them for good and to try to improve the lives of people living with dementia, and their family and caregivers and all of that. It's not just a bunch of numbers. These represent real human experiences. It's just something that I always feel like I need to remind my PhD students that train with me. I'm constantly reminded about it by hanging out with folks like you, so I really appreciate that perspective of the podcast.

Lauren Gerlach:

Absolutely. I think that's a really important point, and that's what makes the research and the clinical work so fun is that one can influence the other. Often I feel like my best research ideas come from something I see in clinical practice, which is either a frustration or something that I feel that we could do better or something that patients and families are struggling with. I feel when they get a chance to inform each other, that's where the best ideas come.

Matt Davis:

The next question is, I guess, a question for both of us. What are our thoughts about this upcoming season and I guess who we want to reach and what we want to talk about?

Lauren Gerlach:

I'm really excited to talk about cool research that uses innovative methods and data sources in ways that we haven't thought about. So much of what we think about for dementia care is really focused on prevention and thinking about research that can move the needle in terms of helping to prevent this illness, I think is exciting. Really interested to hear people's origin of how they got interested in what they're doing and what led them to study what they do. How about you, Matt?

Matt Davis:

Yeah, absolutely. First of all, I'm realizing that it's just fun to meet people that are really driven and altruistic and interesting people that are doing interesting things. I'm hoping to do a little bit more, get into a little bit of some environmental factors around dementia. One of my favorite podcasts was one that we did way back a few years ago, talking about how noise can impact things like cognitive functioning and things. Just some of those environmental factors I think are of personal interest to me. I had a little bit of background in environmental science early in my career. I'm hoping, too, that we can maybe potentially if we can find someone to chat with us about the guide model and other emerging treatment models coming online. One of the things I enjoy most about this podcast is because we're talking about research that have been just recently published, we're on the front end of seeing the potential impacts of new and emerging science.

One I just want to highlight, in a previous episode, we interviewed Joshua Ehrlich who talked about his study that looked at vision impairment as a risk factor for dementia, and that had just been published and it was an emerging new idea and super cool. I'm super excited to report that that finding has impacted the Lancet report and is now considered one of the listed risk factors broadly disseminated of dementia. How cool is that? We got to chat with him at the forefront of that in this podcast. That was super thrilling to see that work play out down the line and something that I really enjoy as an aspect of doing this podcast. One other important thing that we probably want to address is who are we trying to reach in this podcast? What is our target audience? Which is something we've toyed with over the last couple of years. What are your thoughts about that?

Lauren Gerlach:

I think this could be of interest to many people. First off, I think researchers who are embedded in the data using the data sources that we're talking about, very much thinking about these issues, I think it could be of interest to clinicians who are treating patients living with dementia to understand some of the research that's going on. I don't know. How about for you, Matt? Who else do you think we're reaching?

Matt Davis:

I think that's a pretty good description. This podcast, as we've mentioned in the past, it is associated with an NIA supported center devoted to Alzheimer's and other dementia research. The target audience definitely is emerging scholars, people onboarding on to studying dementia, whether it's earlier, mid-career or whatever. That's probably where most of these are geared. However, we're going to try to do these interviews in a way that don't necessarily exclude people from the general public that might have some interest in knowing and learning what's coming in terms of research in the dementia space. As a tribute to our very first episode when we were just starting and trying to learn how to podcast, we did some icebreaker questions and one of them was, what is your favorite or perhaps most used emoji?

Lauren Gerlach:

Well, it turns out that I'm learning I'm very uncool. It turns out there's been some emojis that now-

Matt Davis:

You're in good company.

Lauren Gerlach:

Now canceled. I've recently learned that the thumbs up emoji is considered passive-aggressive, so I didn't realize that that was one we're not supposed to be using. I was looking on my phone and it looks like my most recent one was the red heart emoji, which I think is also pretty uncool right now. I would say my emoji use is probably not up to date.

Matt Davis:

It's interesting how we change our definitions and meanings as a society and have co-evolved with these emojis. I don't use emojis very often, and I'm probably going to repeat myself to the way I answered this question. I still use the old school colon and have a parentheses as a smile just to make the point that I'm old and I predate emojis. I still text with one finger and not two thumbs. Then my last soapbox thing. This gives me an opportunity to complain about things. One thing that I don't really know, but I've noticed that when I go to do things in PowerPoint that it's easier to find emojis than it is to find mathematical symbols. I don't know what to make of that as a society, but it concerns me a little bit.

Lauren Gerlach:

This is now our communication, but at least my nephews help keep me up to date.

Matt Davis:

There you go. Lauren, thanks so much for hanging out a bit and kicking off the season with me. I'm looking forward to discussing some really cool research this season and working with you.

Lauren Gerlach:

Me too, Matt. This should be a lot of fun.

Matt Davis:

Thanks for listening in. Make sure to check out our next episode that features Leah Richmond-Rakerd. We'll be discussing her recent study that demonstrated a link between experiencing a serious infection and dementia. If you enjoyed our discussion today, please consider subscribing to our podcast. Other episodes can be found on Apple Podcasts, Spotify, and SoundCloud, as well as directly from us at capra.med.umich.edu, where a full transcript of this episode is also available. On our website, you'll also find links to other resources we've created specifically for dementia research. Music and engineering for this podcast was provided by Dan Langa. More information is available at www.danlanga.com. Minding Memory is part of the Michigan Medicine podcast network. Find more shows at michiganmedicine.org/podcasts. Support for this podcast comes from the National Institute on Aging at the National Institutes of Health, as well as the Institute for Healthcare Policy and Innovation at the University of Michigan. The views expressed in this podcast do not necessarily represent the views of the NIH or the University of Michigan. Thanks for joining us, and we'll be back soon.