SPEAKER_00 0:00

Welcome to Retirement Navigator, the podcast for adults 55 and above who are ready to make their next chapter the best one. I am Kwame Kwade, your host, co-founder of Next Chapter Media and Agent Professor of Finance at Johns Hopkins University Kerry Business School. As we get older, the healthcare system becomes a bigger and bigger part of our lives. But how do we make sure that system is actually designed for older adults? And what does it take to make aging not just longer but healthier and more fulfilling? Joining us today is Dr. Terry Fulmer, a nationally recognized leader in aging and healthcare, and president emeritus of the John A. Hartford Foundation, which she led for 10 years. She was a driving force behind the age-friendly health systems movement, and today more than 7,000 healthcare organizations have been recognized as age-friendly, and that work has reached more than 9 million older adults. She is an elected member of the National Academy of Medicine, a living legend of the American Academy of Nursing, and she now teaches medicine at the Geisel School of Medicine at Dartmouth College.

unknown 1:23

Dr.

SPEAKER_00 1:24

Fulmer, welcome to the Retirement Navigator Show. Dr. Fulmer, welcome to the Retirement Navigator Podcast. I am really excited to have you here today. Thank you so much. So I want to start. You've had a very storied career, and you're still um an adjunct um faculty at Dartmouth School of Medicine. But I want to focus on your your career started as a nurse and and and then you worked uh for 10 years at the Hartford Foundation. And I want to understand from your perspective as a nurse, what do you what did you see that people who were writing checks in organizations like the Hartford Foundation or other similar organizations did not really appreciate?

SPEAKER_01 2:19

Well, thank you again for having me. I think getting the word out to your audience is so important about all the ways we can improve care for older adults and you know do what we do our part to assist in quality of life. Um I uh went to Skidmore College and got my degree, uh my bachelor's degree, and then got my license as a registered nurse. So I think that sometimes there's confusion in the public about what does RN mean? Well, RN is your license, and then you have your degrees, so I have a bachelor's, a master's, and a PhD. And so uh what transcends my career is the fact that I am a nurse and have brought to bear all of my skills and strategies that I have learned to improve care for older adults. So, having said that, I think that uh the trajectory of my career has been one of incredible opportunity. You noted my work in Boston, where I began my career and had extraordinary leadership under Joyce Clifford, who was a renowned, internationally famous nurse leader at the Beth Israel, and then uh got my master's at Boston College, my PhD at Boston College, began my academic career where I worked at Harvard Yale, Columbia, Northeastern, uh Salem State College, uh, along with um uh my work at uh Dartmouth today. So my opportunities have been to generate new knowledge as a scientist and bring that science to bear on the care of older adults.

SPEAKER_00 4:01

Yeah. And so, you know, I think that we are in an era where, you know, I the issue of how care is delivered, um, I don't think it's being talked about enough. And some of the statistics that we have um shows that majority of people, whether they like it or not, would have to age in place or age at home. Because even if you know people even want to go somewhere to an assisted living facility or whatever, we don't have enough of them. And so I am excited that you know the the the work that Dartmouth is doing now is focused on delivering care at home. Can you talk a little bit about the importance of that and why that shift and why that emphasis?

SPEAKER_01 4:52

Sure. Well, the data are clear. Older people want to stay at home, they want to get their care at home. And if we are supporting older people in their goals of care, then we need to create wonderful hospital-at-home programs, health at home, as as um uh Dr. Nathan Gold Nate Goldstein says, health at home. And so Darth has just gotten some extraordinary philanthropic gifts to ensure that they can uh create, based on the science we already know, a world-class health at home program. So that if an older adult has, for example, suppose one had, you know, an acute case of an pneumonia, generally speaking, in the past you would have gone to the emergency room, you would have been admitted. We now know that we can provide that care at home very successfully. Uh and and that way you're you're not only addressing what the older person wants, which is to stay at home, but you're providing state-of-the-art care. So kudos to my friends at the Geisel School of Medicine and the Dartmouth community writ large, because there are so many schools at that college that are engaged in this work together. So we're really excited about that and grateful to our donors who have been so significant in their support. I also want to particularly uh comment that Dr. Joanne Conroy, who's the CEO of Hitchcock Medical Center and Hitchcock Health, uh has really role modeled that in that she kept her mother, uh, her mother's care at home through her mother lived to be 100 years old. And we saw Dr. Conroy role model that that extraordinary opportunity to get world-class care at home.

SPEAKER_00 6:43

So, no, that's that's that's that's amazing to hear because I think a lot of people don't see um what that looks like for them, you know, even if they want it. So, can you speak a little bit of some of the components of how, you know, even if it's a future, you know, even if if it's an aspiration, or even if there's models that are working right now, if somebody wants to, you know, live well and live long at home, you know, there are a lot of components of the delivery system that, you know, we are used to thinking that it can only be done in a facility at a hospital. What have you learned that, you know, has surprised you about some of the care that has been successfully delivered at home, in addition to the example you just gave us about pneumonia?

SPEAKER_01 7:31

Yeah. So so you said what surprised me. I'm not surprised because I've watched visiting nurses, I watched the visiting nurse service of this nation do this for hundreds of years. You know, starting in the early 1900s, the VNS system has been in place, providing quality care at home. What's different now is that starting in the, particularly in the night early 1960s, all of a sudden we had the advent of this wonderful science explosion in healthcare, antibiotics, pacemakers, renal dialysis, transplants, all of those things have extended life. And what we are doing is playing catch-up with how to provide care as we extend life. And so, so um traditionally, and and remember that in the 40s and 50s, doctors made house calls. So we're really going back to back to the future, right? Right. Where um uh uh a physician or uh a visiting nurse who knew you, knew your family, knew that certain things might run in your family, for example. If your grandmother had arthritis and your mother had arthritis, you might be getting those symptoms, for example. Uh and so really using that that high um highly thoughtful analysis of the person, this is person-centered care, right, making sure that we are um again personalizing this care and providing it in the home where where people want to get their home. I've never heard a person say, gee, I really like going to the emergency room.

SPEAKER_00 9:10

Right, right, right, right. Yeah. And and let's talk about cost in relation to that. You know, we assume that if it's coming home, it's gonna be expensive. Is that a good assumption?

SPEAKER_01 9:27

So you're there are a couple of things, and we know that there are lower costs. Studies have shown that costs can significantly be less due to fewer routine tests and reduced overhead. So, and there's fewer complications, which means lower costs. And data shows us that you have lower 30-day readmission rates, fewer infections. When you come into a hospital, you're in an environment where there, you know, there's excellent precautions, but still there are in there are germs in a hospital. And so we know that if you stay at home, your infection rate is lower and your overall patient mortality rate can be lower too. And so there are certain things you have to. The American Hospital Association, by the way, has an excellent hospital at home uh information page where everybody tells people if there's wonderful resources and there's an action community that uh has regular conversations about what they're doing and how they're doing it, and and really um everybody can benefit.

SPEAKER_00 10:29

Right, right. So I want to switch gears to the age-friendly health system that you you worked for such a long time on with the Hardware Foundation um and the uh Institute for Healthcare Improvement. Um, and you know, the 4Ms, I want you to talk about that. And then for my audience, is there a part of the 4Ms that, you know, looking at their own care, that they can begin to ask questions about the next time they are in a hospital setting or a healthcare facility?

SPEAKER_01 11:04

Sure. Um, I'm very, very excited about our progress in the eternally health system social movement as we as we think of it, because we are reimagining the way care can be delivered as a set for older adults. And so we launched this in 2016, and in the 10 years, there's been extraordinary progress. We have a research center at UCS UC UCSF led by Dr. Julia Adler Milstein, who is really generating uh the ongoing science community to work on this, and uh we're grateful to the National Institute on Aging because they are having a meeting in October to think about measurement for quality improvement in the forums. Um you asked about older adults and what they can expect. What when when I make presentations about age-friendly health systems, um I I always start by why? Why are we thinking about this? And that's because the care that older adults get can be disorganized, it can create harm, and it can lack evidence. And so with IHI and the American Hospital Association, along with the Catholic Health Association, we combined our forces to say who are the experts in the field who have been working on geriatric care models their whole careers, and where are the CEOs of health systems and their thoughts on this work? So we had a meeting in 2016 at IHI and brought together these expert groups. And after a very arduous day, and let me tell you, people were exhausted by the end. We we knew that of the care models, if you took a look at them, there were about maybe 30 care models in geriatrics, but you could distill it. First, we looked and we had 90 care features. Well, nobody's gonna work on 90 anything. Right after a lot of work in distillation, we got it down to 16 and then down to four. And the experts in the room agreed that there was a lot of redundancy in our models, but all of them featured these four M's. What matters to the older adult?

SPEAKER_02 13:23

Right.

SPEAKER_01 13:23

Your goals and preferences. This is not end-of-life care, it's goals and preferences every time. Right. Your medications. Are you on the right medications? Are you on too many? Have you been de-prescribed? Are you carefully examining uh medications and eliminating those that would fail the Beers criteria? So Mark Beers did his wonderful work that's been ongoing with uh the American Geriatric Society, looking at what meds you should avoid for older adults. Very clear evidence and easy to find on the internet. The next is mobility. For decades we've been working on falls prevention, and I I am a proponent of preventing falls. Having said that, there's more than false prevention. It's mobility enhancement. Every older adult needs to enhance their mobility. If you're in a wheelchair, if you use a cane, every person can improve their mobility where they are. So that we know the science is clear too, that uh enhanced mobility improves your well-being and your overall health functioning. Function is so important. So mobility, mentation, which means your mind, your mood, your memory. So, so what about that? Well, that is, first of all, you know, are you um uh having any concerns about your memory? Maybe you are, maybe you aren't, but there are very simple uh screens that can be done to see whether or not you need any assistance with that. Uh there is an increased prevalence of dementia with aging. That does not mean everybody's gonna get dementia. Right. Two messages there. Increased prevalence, so be on be aware. Yeah, but not everybody will get that. So there are memory cognitive changes that go on with aging. That does not mean you're gonna have dementia. But what else goes into that um mood, memory, mind? Depression.

SPEAKER_02 15:28

Yep.

SPEAKER_01 15:29

Older adults can become socially isolated. We know that that is dangerous. Some people, uh the surgeon general uh uh talked about it as uh dangerous as smoking cigarettes. Well, that's a powerful statement, isn't it?

SPEAKER_00 15:42

Yep.

SPEAKER_01 15:43

Being socially isolated is uh devastating to the health and well-being of older adults. So I've been really impressed by the work going on with like the American Library Association and uh groups uh that are so dedicated to enhancing the way that older people can be with us and intentionally and interact and get that uh source that they need. So it matters mentation, medication, mobility, those four. Now they're a set. Some people say to me, Well, Terry, you know, this for the next six months we're gonna work on mobility. And I say, please, please don't work on all four at the same time because interactive, if your medications are wrong, your mobility will be off, and so will your mentation.

SPEAKER_02 16:31

Right.

SPEAKER_01 16:32

Uh so then I turn right around and I say, if that works for you, and if you want to do your M's one at a time, as long as you collect them together uh as a set and think of them as a set because they are interactive, and if one goes wrong, they will all go wrong.

SPEAKER_02 16:50

Right.

SPEAKER_01 16:51

So you you also said, and let's shift to the consumer perspective, right? What should they be thinking about when it comes to their interaction with the healthcare system? It's very powerful for an older adult to use their agency in each healthcare encounter. And I'm proud of the work that's been done by CVS Minute Clinics and the Francis Payne Bolton School of Nursing at East Western, where they have worked together and created this magnificent uh forum care at every CVS Minute Clinic. And millions, literally millions of assessments have been done. There are over 1,900 uh advanced practice clinicians who work at these CVS Minute Clinics, and and literally hundreds of thousands of people who access it on a regular basis. So when you go into a CVS Minute Clinic or a health hub, and if you're over 65, you will get screened for 4Ms. And they also have cards that they have in the waiting room, or they also have them online that that that says, Here are your 4Ms. Ask your provider about your 4Ms today. And so if I go into my uh clinical appointment and say, I'd like to talk about my 4Ms today, that's gonna shift the conversation instantly into what I want to talk about. So, what are my goals of care today? I'd like to tell you about my mood and my memory. I've been kind of depressed lately, and so I'd like to talk about that. My mobility, my hip hurts, and uh, I'd like to make sure that you I can do everything to prevent further deterioration because walking is so important to me. I live in the city and walking is everything.

SPEAKER_02 18:43

Right.

SPEAKER_01 18:43

Then thinking about my medications, I don't like to take them, and so you you gave me a medication that I'm supposed to take three times a day, and I know I'm not going to. I can take my pills once in the morning, so can we talk about how to adjust them? And so really saying what it is you need, what's your problem, and how you want to get it adjusted.

SPEAKER_00 19:04

Right. No, that's that's a wonderful example of how the you know, uh an actual application of the 4M when you go to your doctor and you're talking about, and I like the fact that you said that it all has to be looked at together, you know, not in isolation. And and that example clarifies it for me because um I I one thing that I want to dig a little bit deeper on is the mobility. You know, there's been you know, I had a previous guest on that was talking about the importance of exercise, where you are, you know, and and I think a lot of people have the mindset or misinformation that oh, I am too old to do exercise, or my mobility is limited, so I cannot improve it. Can you speak to the importance of, you know, I I like what you say. You said mobility and enhancement where you are. Can you speak a little bit about that and why that is so important?

SPEAKER_01 20:04

Sure. And um, you know, that immediately makes me think of a couple of things. Dr. Cynthia Brown is a world-class expert in mobility, and uh she often talks about barriers to mobility during hospitalization, for example. So I want to point out that mobility will be different depending on where you are. If you're if you happen to be in a long-term care facility, if you're in uh the city, in an apartment, if you're in the country, in a rural area. So we have to be really thoughtful about um our context when we're trying to address mobility. Uh and and that that is everything. Now, I'd like to make a point about mobility in the hospital setting. That is, you can in before I was let me say that I've seen a lot of progress with mobility in hospitals since we started our age-friendly health systems. Okay, it was not unusual for an older adult to come in, get into bed, and stay in bed for maybe several days. And that decreases your function, increases sarcopenia, which is muscle wasting, makes you weak, makes you tired, sends you home deconditioned, and puts you at risk for falls. So we've seen wonderful success with mobility techs in the hospital setting. And I'm thinking about the work that um has been done at Rundle, which is now it has a different name, and I think it's Meredith, but I have to look it up. But in Rundle in Baltimore. And and really the work that they have done with their tech mobility people, making sure everybody gets up, having strips of tape on the floor in the hallways and hospitals. I need, I, you know, I want to, our goal today will be. 20 feet, and tomorrow we'll do 50 feet, and then next we'll do 100 feet. Just because you're in the hospital does not mean that you can't be up and mobile. And we all know that open patients now get up the same day. People who get orthopedic surgery are up the same day. And so it's a new paradigm for mobility in hospitals. Now let's talk about uh the city, for example, and with many cities in this country. So that's almost easier if you have an elevator. If you don't have an elevator, you might be in trouble. So let's talk about both. If you have an elevator, you can drop and down and out into the street, and and there's an awareness, generally speaking, the public has an awareness of older adults. And but and I say to older adults, bring a cane with you, even if you don't need it. Because what that does is it signals the community around you that you might need to go a little slower than they are going. That you'd appreciate it if they don't bump into you and you over.

SPEAKER_00 23:01

Right, right, right. So I like I like that. I like that, yeah.

SPEAKER_01 23:05

Right. Now let's think about a rural community. I grew up in uh Hercomberg County, upstate New York, and uh the uh little towns around it are quite rural, and most of your mobility is going to be in a car. And so it's getting yourself out of your house and into your car. And sometimes that's easy and sometimes it's not.

SPEAKER_02 23:25

Right.

SPEAKER_01 23:26

Now I haven't my Aunt Rita is 99 and she just stopped driving this year, but my Aunt Ann drives her everywhere. My Aunt Ann is a 93. And so we watch very carefully. They have to take tests on a regular basis to make sure that they are qualified. But but it is their lifeline.

SPEAKER_02 23:46

Right.

SPEAKER_01 23:46

It's their community, it's their social uh entree. And and there are not a lot of Ubers in these very small communities sometimes, but often neighbors, neighbor to neighbors will be helping, and and so and helping people go to their appointments, for example, if they can't get them online. So I think that your question about mobility is spot on, and we have to think about context, community, what the supports are.

SPEAKER_02 24:16

Right.

SPEAKER_01 24:16

Sometimes you'll hear us give speeches and we talk as if one size fits all.

SPEAKER_02 24:24

Yeah.

SPEAKER_01 24:24

And I try I make sure that I edit myself and and within my community say, now let's really talk about what it looks like on the ground with this person.

SPEAKER_00 24:38

Yeah, yeah. So if there's one thing you would say to all the people listening about mobility, if something like a carrying message they can really take with them, what would that be?

SPEAKER_01 24:49

Mobility is magical, mobility is medicine, mobility is essential, and and it is the cornerstone of staying healthy.

SPEAKER_00 25:02

That's that's awesome. Now, you mentioned Anne Randall. We're I'm here in the Baltimore area, so I you know, I when I heard that, I'm like, is it is it Maryland? So I I'm definitely gonna research that and see because if I can bring them on to come and talk about that because that is important research that is close to home. So I I wanna I want to they are fantastic.

SPEAKER_01 25:22

I have seen nothing but great work out of that health system, and uh it's very, very uh exciting.

SPEAKER_00 25:29

Awesome, awesome to hear. Um, so you know, memory. Next, I want to talk about memory. Since we are on the I want to, you know, so my understanding, you know, and and and when we're talking about memory loss, I think a lot of people um the distinction between the recognizing early patterns of dementia, right, versus just the memory, I don't want to say memory loss, but the memory um challenges that come with aging, you know, like you know, and and I think family members sometimes confuse the two, they can't do that. And so that dementia uh signals are missed until it's like you know, way into it. What can people look for in a family member when it comes to those early warning signs and what can they be doing proactively about it?

SPEAKER_01 26:31

You just let's unpack what you just said because there's a lot of components to it, right? The first word that comes to mind when I think about memory deterioration is safety, a hundred percent safety. Because when you have changes and you have some um limits in your memory, all of us do. Where's my car keys? Where'd I put my phone? What you know, but when you start leaving the stove on, when you get out of the car and you leave it running, uh, these are things where you go, uh-oh, now we need to really check it out. People are afraid to really check it because they're afraid they will uh become demented. That's a scary, scary thought, and lose their agency, lose their capacity to choose what they want to do and how they want to do it. And that's not wrong, that does happen. I like to talk about uh my brother-in-law, who uh is now 79, and he has been diagnosed with dementia, with Alzheimer's with dementia. Now we began to see changes a few years ago, um, and some of them were are simply repetitive stories, um, sometimes seeing things that weren't there. But he still had a lot of life to live and a lot of capacity to enjoy. As time has progressed, he is less able to do some of the things that he wanted to do, and sometimes his now hallucinations are very uh frightening to him and to all of us, really. So what could we have done to prevent this for him? We couldn't. His mother died with Alzheimer's disease, his aunt died of Alzheimer's disease. There is a pattern in his family, which is not to say it is completely hereditary, but that does seem to be a part of it. And he, when he had his cognition, he said, I already know what this is. I saw it with my mother, and I'm just, you know, he said, We'll just ride it out. And that was when he could tell us his story. Now he can't. When he sees me, whoever he he has known me since I was probably nine years old, he can't name me, but he knows that he knows me. So it is a trajectory that everybody does differently.

SPEAKER_02 29:30

Right.

SPEAKER_01 29:31

It's all about the family supports and their reaction. There's a researcher, her name is Dr. Jean Teresi, and she has done studies to s to talk about disturbing behaviors. And those disturbing behaviors with people who have dementia might be shouting, they could be um combative behavior, it could be spitting, kicking, yelling. Those are disturbing behaviors, and they are a part of the disease. So the question that Dr. Trasse asks is, Do you have you seen these behaviors? And the caregiver says yes or no. The next question is, what do you do about it? Now that's an important question for a clinician to ask.

SPEAKER_02 30:17

Right.

SPEAKER_01 30:18

Because sometimes you say, What do you mean? What do I do about it? She's my mother, I love her. I just hold her in my arms and wait until she feels better. Another person might say, I'm exhausted, I could I could scream, I just want to leave her in the apartment and and go out to dinner and just leave her. So both of those are reasonable reactions. The second one worries all of us. But if but at least that person tells the truth.

SPEAKER_02 30:49

Yeah.

SPEAKER_01 30:50

Because they might feel that way and never say it, and then we really couldn't help, could we?

SPEAKER_02 30:53

Right.

SPEAKER_01 30:54

So I think that it when we when it cuts to memory loss, it is an individual journey. It it's one where an early partnership with your your primary care provider is so important because they will be with you uh from start to the end.

SPEAKER_00 31:11

Right, right, right, right. You know, and um I think that the the part that you talked about that I I have I have come to realize as a patent is that people would not both parties, the person who is experiencing the memory issues, and the family members are both kind of scared of the elephant in the room, um, because act quote unquote activating the truth then means that everybody's life is forever changed.

SPEAKER_01 31:48

That's right.

SPEAKER_00 31:49

And so, you know, so I I like to bring this out that you know if you're seeing these patterns, it's important to begin to, you know, ask the questions of okay, what should I be doing about this? You know, and we don't necessarily be, you know, but educating yourself about it and knowing that, hey, I'm seeing these patterns, am I seeing what I'm seeing is so critical because of the safety um question that you talked about? Because left left on its own, it could also be a safety issue.

SPEAKER_01 32:20

That's right. Yeah, I love the way you say activating the truth. That's a frightening thing because what if you lose your health insurance? What if you lose your driver's license? Yeah, what if you lose your apartment? Yeah, you know, all of these things are in fact realities, and so we can't gloss that over. Yeah, and as you say, letting the the jack out of the box, right, can be painful, yeah, helpful, and not helpful. So right now there are blood tests for Alzheimer's disease, and everybody is saying, I wonder if if we should take that test or not. Well, thinking it through, yes, it'd be great to know that's what's coming, but as you just said, that changes life forever. So, do I want to live as a person with a diagnosis, or do I want to live with my maximum functional capacity and see how things go?

SPEAKER_02 33:19

Yeah.

SPEAKER_01 33:19

Um, we know that you can you can have a quite a long trajectory with some mild memory loss. Um and so I think it's a complicated, and you definitely there are wonderful uh experts in this field who help us untangle that.

SPEAKER_00 33:34

Right, right, right, absolutely. And one more thing, and then we're gonna move on from the four M's medication. We touched on a little bit about that, but I feel like this is the first time somebody has really narrowed this down about your age, even your agency in the medications you're taking. Because a lot of us, the doctor prescribed it, so I'm gonna take it. And if I'm not taking it, maybe I don't want to tell the doctor because the doctor is gonna be mad or is gonna be unhappy that I am not following. And you have opened my eye today that you know, if if it's not working for you, or you know, and you also said there are things that older adults shouldn't be taking. There are certain medications that should so can you speak a little bit about our agency in helping our primary care physician or whoever we're working with manage our medications?

SPEAKER_01 34:23

Yeah, and this is such a good question. In the 90s, I was funded by Merck to do a study on medication uh compliance in the elderly. We don't like the word compliance because it's it's a dictatorial term. We don't like adherence very much either. But but but somehow we have to figure out whether or not the medications we prescribe are being filled and taken as we thought they were. In that study, we found that less than half of all prescriptions written are filled. Um and of those that are filled, only half are taken. So so it's it's very interesting. You you and and something that I believe nursing has the complete authority around this as they work with patients. Now, we have expert pharmacists who give us a lot of knowledge, but they're not the ones who are going to be like the visiting nurse we talked about, or the hospital home clinicians who say, I see you have a number of pills. Of these eight bottles, which ones do you like and which ones don't you like? Let's get real about this and figure this out.

SPEAKER_02 35:32

Yeah.

SPEAKER_01 35:32

Um, and and as as prescribers, we don't necessarily want to hear it because it's gonna make things hard. What do you mean you're not taking your blood pressure medicine? What do you mean? You know, it's really hard. I was listening to a case study at Dartmouth this morning at the Geisel School, led by uh Dr. Serena Chow, who's awesome. And and they were talking about this person who had psychotic episodes, and it was um the nurse who found out that it was problematic for the person to take a med in the morning. So the medication was prescribed again, you know, breakfast, lunch, and dinner. And this person didn't like to get out of bed until noon, so they didn't take any of the morning meds. And so once she understood that and shifted all the meds to noon, the person took the vacations and the the mentation cleared. Right. That's that's a really uh Nicole did just such a great job with that. So again, knowing your patient, knowing their their goals and preferences, and but you gotta ask, and you gotta, it's not a one-time, let's talk, and then I'll see you in six months. You have to follow up. And that might be through the electronic health record, it might be through visiting nurses, it might be through other elements of conversation to say, okay, I have these meds, they're not working for me, or you know, to be honest with you, I'm not taking them.

SPEAKER_02 37:02

Yeah, yeah.

SPEAKER_01 37:04

The other example, you know, there's these pharmacy benefit programs that have been around for years and they they mail you medications. And I promise you, when you walk into the home of an older adult, you can open a closet and have like 85 buckets of pills fall out because they're being mailed, right? Not being taken.

SPEAKER_02 37:21

Right.

SPEAKER_01 37:22

And that's that's really um that always bothered me because the meds are being delivered, the government was paying for those pills, yeah, and they were all wasted. Yeah, but it was to the benefit of the pharmacy pharmacy benefit company.

SPEAKER_00 37:39

Yeah, yeah.

SPEAKER_01 37:39

So shame on them, and I think trying to address that now.

SPEAKER_00 37:43

Yeah. So I wanna I want to touch a little bit about your um academic career, and then I want to come back to caregiving and social isolation to wrap up, if that's okay. Sure. So I noticed that in I think in 2011, I'm not sure if I have the date right, you went back and got um, you know, in the middle of your career, I went back and got an advanced degree in nursing. Um and and that kind of I I I've I figured something must have triggered that. Sure. So can you talk a little bit about that and what that led you to?

SPEAKER_01 38:21

So I was a full professor at NYU, and I had my PhD, I had my master's already, and you're talking about the fact that Dak and I got a certificate as an advanced practice nurse at geriatrics.

SPEAKER_02 38:36

Yep.

SPEAKER_01 38:37

That was 2001. And I did that because I realized that um I would be left behind without that additional credential and content. That advanced practice was becoming incredibly important and a powerful movement in this country. So it doesn't matter to me how old I am, it matters that I keep up with the credentials of that full autonomy and authority over my practice. And so uh that was, yeah, you're right. I I as a professor, um I might have even, I don't think I no, I wasn't. Soon I was dean. But anyway, as a professor, uh I I still get a kick out of it. Sherry Greenberg was one of my main professors, and she used to laugh and and say that I knew more geriatrics than she did, and I said, doesn't matter if I don't have the certificate. So I think the lesson to all of us is you can you can kick and scream all you want, but at the end of the day, if your profession has spoken and if they agree that a particular uh uh program is important to the advancement of your work, then do it.

SPEAKER_00 39:48

Yeah, no, no, uh 100%, right. And so then let's talk about just the field of like where the industry is moving. I think like all of us, I I maybe it's just because I am paying attention to it more now. I see a shift in just you know elder care, even with with um I was I had a guest on recently, and she said we don't want to call our places facilities. We want to she gave me a word that I I actually forgot because that the sensitivity around so the question I want to explore is that we're living longer, and so the word senior, you know, is is is not a lot of people don't want to, you know, be called that, and rightly so because and part of what the work I do now is that I'm looking at reimagining, you know, the old retirement was you know, you retire 65, you live maybe 10-15 years, and the show is over, you know. But now conceivably you could have another career, you know, and so the idea that retirement is slow, a slowdown period or a shutdown period, or a period to just like just wind down is being challenged in a lot of areas, and rightly so. And so the question I want to talk about is is the is the care and the industry catching up to that that that fact because it's it's data that we cannot refute that the average person can have another successful, you know, and I'm talking to my audience because you know, the idea that at 65, I've seen people who are being pushed out of teaching at 65, and they're like, uh, I have another, I probably have another 10 years to give, you know, why do I have to retire? So can you speak to what you're seeing there and if there's any any research you've done that that can really support this idea that we are pushing people out too fast and too soon into a life to slow down that they necessarily have the energy and don't want to?

SPEAKER_01 41:57

Yeah. Again, multiple components to your your your comments, honey. So let's let's you started by saying senior and do people like and I'd like to point out to the audience that if you go on a website called frameworks and type in aging, you will get this wonderful material. I'm reframing aging.

SPEAKER_02 42:21

Okay.

SPEAKER_01 42:21

The support we need to age well, and and it gives us the research that says we need to make sure that when we think about aging, we are talking about us. It's not them, it's us. We are all aging, we are all aging, and we need policies to support every life stage, including, and we have to explain ageism as harmful and inaccurate. Ageism is is inaccurate stereotypes and beliefs, and so we have to change that. And so we really have to think about reframing aging, and I I really hope that people will take a look at that incredible work done by that team that uh I've had the great privilege to work with over time. So, reframing aging and thinking about capacity and opportunity instead of losses and limits. Yes, of course, there'll be some changes and there will be some losses and limits, but there's also incredible capacity and opportunity. To your point about mandatory retirement and pushing people out, um that's intergenerational conflict, right? We have younger people say, I wish they'd leave because I really need a job. And older people saying I have all this energy capacity and knowledge and skill that will go to waste. So I think that all of us need to keep that conversation going. I think AARP does a great job in kind of convening some of those conversations. And I what we're seeing for older adults is Yes, I have capacity, but also there's a lot of fear about um if I don't get my paycheck, will I be able to afford old age? Let's hit what the issue is.

SPEAKER_00 44:13

I mean, yes, I love my job, but I need I need the money. Yeah, yeah.

SPEAKER_01 44:18

I need the money. So let's let's be real here.

SPEAKER_00 44:21

Yeah, no, you're right.

SPEAKER_01 44:22

You know, what if so Social Security goes bankrupt? I'm you know, people read that and they're terrified.

SPEAKER_00 44:27

Yeah.

SPEAKER_01 44:28

And you know, it's not unfounded.

SPEAKER_00 44:30

We don't no, no, it's not. I I I have I I just released my book, The Social Security Playbook. One of the things I addressed about that was the shortfall that is coming in 2032, and how you know, not only that, that is a cliff that is going to be devastating, but also the purchasing power of social security checks because of inflation has been minimized over the and the the um the the the national I'm I'm blanking out, um, but there's uh an advocacy group that has been doing a lot of work on that, showing just how purchasing power has diminished over the last 15 years. Right. You know, so you put all that together and people have to continue to work because one, the money is not gonna stretch as far, and the costs pile up. So I I I like the way you're framing it. The thing is that we don't know, and as some people like me who are also talking about it, we don't know where to go necessarily to really tap into this research and and see the leading people that are talking about it. So that's my mission is to like get people who are exploring these topics and bring them here to talk about it because I have I'm watching, I have a friend, um I'm in part of an entrepreneurial group, and you know, one of my friends just turned, she's about I think 61, and I cannot imagine her slowing down for the next 15 years. You know, she's an entrepreneur, and like so it's it it that alone in my own sphere shows that there is so much that people can offer, yes, and the the fact that we're trying to push people to like oh slow down is doing a lot of disservice to the economy, but also financially to themselves.

SPEAKER_01 46:16

And so I look forward to reading your book. Tell me at the at the end of your book, you said so, therefore, based on all of this, what are we gonna do? What do you tell us to do?

SPEAKER_00 46:28

Well, I I I I think that the solution has the we have to address two things. Number one, you know, just from the macro picture, we have to address the fact that um people are living longer, and so the focusing on the cliff by itself, it's the bare minimum. I think that we should also focus on the fact that the purchasing power of this the benefits is not what it used to be. You know, a lot of people on my comments come in and they are barely surviving. The average social security benefit is about two thousand dollars. In today's economy, that is not and then and 40% of people depend at major, you know, majority of income comes from that. So I think it's a it's a conversation of one fixing the issue, but also having a broader conversation about the fact that retirement is longer and the money is not going as far as it used to.

SPEAKER_01 47:26

Very frightening and important, and I hope it's part of the midterm discussion and part of the selection. Yes. So, and by the way, you said by 2032, which is six years from now.

SPEAKER_00 47:39

Yep.

SPEAKER_01 47:39

People go, oh, yeah, yeah, that's then, that's later, it's now.

SPEAKER_00 47:43

No, it is now, you know, and and people have to vote. Yep, yeah, no, it is because and I uh we know on my daily show, I'm talking about the fact that look, when when politicians come to you and they're talking about they want to fix this, the solutions have been there. It's just the political will to do the things that would fix it, it's not there, and so they keep kicking the can, but the solutions have been there, you know. Um so but I have two questions for you, and then we'll wrap up. Um, the first one is caregiving. I think that um as a society, we are entering an era where the issue of caregiving and how we fund it and who does it. Um, there's a lot of unpaid ARP has done studies about the volume and magnitude of free and unpaid caregiving, and then the fact that the the burden of caregiving hits people at a very unexpected time, and all of a sudden, probably the closest sibling to the parent is the one that has to take it on, and then there's all these dynamics that are are we thinking about caregiving the right way?

SPEAKER_01 48:56

Yeah, um, so I for the first time in my life, I published in Harvard Business Review, and that's because I was working with my fabulous colleague Ken Dijkwald, who leads AgeWave. And our paper was about telling the business community, wake up, you most of your executives are going to need sick time because they have to be home with their older family members. And it it really got an enormous uh response, that paper. So I point that out because you have to talk to employers, you have to talk to family members. You can't just keep it uh at the dinner table. This has to be on the news every night. So caregiving. I think the John A. Hartford Foundation has done a magnificent job with their family caregiver portfolio. We know that 63 million adults in the United States regularly provide care to a family member or friend. 63 million people. So we've support the national strategy to support family caregivers, which details federal actions. Uh, and so that's been really, really important. And um we also uh, and I say we because I I have such a powerful relationship with the John A. Harper Foundation, uh, we have learned through the national um groups like ARP and the Center for Healthcare Strategies, and also um groups that uh are more local in communities, all the different ways that we have to support family caregivers. The RAISE Act recognize, assist, include, support, and engage family caregivers is something that AARP Susan Reinhardt really took off with an enormous uh success. So look at the John A. Harford Foundation webpage on family caregiving. You'll see great papers, you'll see grants that have been made, you'll see resources for all of us uh that that we need on a regular basis. Um so so I highly recommend that.

SPEAKER_00 51:03

Oh, thank you. And then my last question is um isolation, loneliness, social isolation. I think that that is a silent thing that's happening because it has a lot of tentacles to it, you know what I mean? And and and the tension between aging in place and aging at home, which a lot of people have to whether by choice or not, yeah. Um what what would you tell somebody right now who is at home feeling isolated, and are there resources out there that they can tap to just re-engage um and and and combat some of that isolation?

SPEAKER_01 51:52

Yes. Social isolation and loneliness are two different things. Social isolation is the objective lack of social contacts, while loneliness is the subjective feeling of being alone or disconnected. So you can have someone tell you they're extremely lonely, and you say, What do you mean? You know, your family and friends are around, different than social isolation. Some people like social isolation and they they they're they really uh are not lonely. So I think unpacking that, uh the Center for Disease Control, uh the CDC, has written about health effects of social isolation. We talked about that, and that it can have a terrible toll on your health and well-being. And as an elder abuse researcher, I'll tell you that if you are isolated, you are at risk for abuse and neglect, particularly neglect. And so it's something that all clinicians need to take uh heed of. And when you when you're having your goals of care and when you're having your conversations, you'll say, you know, are there times when you feel isolated or lonely? Sometimes older adults will say to you, I'm not at all, I'm perfectly fine. And others will tell you that they really need some help. And so that's when our wonderful colleagues in social work and psychology come in and can be so incredibly important in thinking about our home-based community support services. So use your resources, but again, tailor it to the person in front of you.

SPEAKER_00 53:21

Yeah. Uh, Dr. Fulman, um, there are there's so many things I wanted to explore with you. Maybe we'll have a a second uh version of this. I wanted to talk about elder abuse. I wanted to talk about the the this chair rocks, um, the book by Ashton Um Applewhite and um explore some of the topics in there. But this has been such an insightful. I feel like you've mentioned so many resources. I have to go back to the notes so that I dig back into it. But this has been such an insightful conversation. Is there anything that you wanted to talk about that I didn't ask you about?

SPEAKER_01 53:53

I would say thank you. Keep going. Your work is so valuable. I say yes to podcasts like you because you are a trusted voice, and I can channel my knowledge through you, and people will listen to you. So thank you and keep working on our Social Security playbook. And congratulations on that wonderful book. Thank you for the opportunity today and have a great day.

SPEAKER_00 54:18

Absolutely. Thank you.

SPEAKER_01 54:19

Okay, bye-bye.

SPEAKER_00 54:20

Bye. And to our listeners, thank you for spending part of your day with me today. Part of the selfish reason why I host this podcast is to expand my own knowledge in some of these areas. There is so much change happening in the world of aging and caregiving in the retirement space in general, and bringing on top experts like Robert is how we all learn and expand our knowledge and see the role we can play in helping push these problems to solutions that work for everybody. So, if you like what you heard today, consider subscribing to the Retirement Navigator Podcast. You can also listen to us on YouTube. The full video is posted there. Now, if you are retired or have entered your next chapter, I have something special for you. We have a show called The Morning Step. It is a morning show, it is three minutes long, tops, and it's supposed to give you daily inspiration, encouragement, and wisdom to get your day started. You can listen to it wherever you listen to your podcast, or you can watch episodes on YouTube. We are about episode 30 right now as I record this video, and so you can join us. Now, I also want to encourage you to follow us on all the social media channels. Links are in the show notes and share this podcast with anyone you think will benefit from the today's conversation. Until the next time, take care and remember retirement is not the end of the road, it is a new season to navigate with clarity and confidence.