When Rachna Valvani, MD, started practicing medicine in Delhi, India, she worked as a “respiratory physician.” She had earned her medical degree at Netaji Subhash Chandra Bose Medical College in Jabalpur and completed a Tuberculosis and Chest Diseases residency at Mahatma Gandhi Memorial Medical College in Indore, a city in the Indian state of Madhya Pradesh.
“I decided I wanted to have a more holistic practice – not just restricting myself to the lungs,” she recalls. So she joined her brother and uncle in the United States, and secured an internal medicine residency at NYC Health + Hospitals/Metropolitan Hospital in Manhattan.
It was during this second residency that Dr. Valvani was introduced to the field of geriatrics, which isn’t a developed medical specialty in India. “Even when I was practicing in India, my COPD (chronic obstructive pulmonary disease) patients were mostly beyond 65, and my patients with advanced tuberculosis were old and frail, so I always had more empathy and sensitivity to that age group,” she says.
When Dr. Valvani realized that she could specialize in caring for the older population, she pursued fellowship training in geriatric medicine at Montefiore Hospital in the Bronx.
Dr. Valvani joined Hartford HealthCare Medical Group and the staff of Charlotte Hungerford Hospital in July. She was intrigued during her interviewing process to learn that there hadn’t been a geriatrician in Torrington for many years. “There was a large unmet need in northwest Connecticut, given that 20 percent of the population here consists of older adults,” she says. “I thought, why not invest my skills and training in an area that would really benefit?”
Separating normal aging from impairment
Dr. Valvani serves as a geriatric medicine consultant – that is, she helps existing primary care providers in the region with expert consultations in geriatric medicine. “The scope of my practice primarily includes cognitive assessments, and extends to comprehensive geriatric assessments, functional assessments, and consultations on polypharmacy” – patients who are on five or more medications at a time. She notes that in older patients, too many drugs can cause significant interactions, resulting in cognitive decline or memory loss as well as physical decline and falls.
When dementia or another major neurocognitive disorder is suspected in an older adult, Dr. Valvani says, a cognitive assessment is done to identify any kind of cognitive decline. There are five key areas of cognition, she explains, including memory, speech, concentration or attention, planning/strategy, and calculation/problem solving.
“Memory loss is a very concerning symptom for most people,” Dr. Valvani says. “When older people living independently start forgetting things, like where they put their keys, or previously known vocabulary, it is alarming because it comes with a threat that they will lose their independence.”
Even if patients don’t exhibit obvious memory loss, they might have functional deficits which interfere with complex tasks, she says. For example, she says, they can no longer confidently manage their finances, or they are losing ability to drive on the highway. Part of Dr. Valvani’s job is to distinguish between what deficits can be attributed to normal aging, versus which are due to mild cognitive impairment or, at the more extreme end of the spectrum, dementia.
“Forgetfulness is quite common as we age, so it’s okay that a person forgets where they put their keys,” says Dr. Valvani. “But healthy individuals are able to recall and describe how they forgot about it – they were too rushed or had too many things going on. A person with dementia might not even recall after finding them that they put them there.” A normally aging 95-year-old, Dr. Valvani continues, may be able to walk but walks slowly, can talk, but speaks slowly – or they might have trouble with the recollection of an idea. A person with dementia, on the other hand, will have difficulty performing simple tasks, like grooming or dressing appropriately; they will forget to do things that were formerly habits. “They are going down their milestones,” as Dr. Valvani puts it. “Whatever they have learned, they are unlearning it.”
Mild cognitive impairment and dementia
Mild cognitive impairment (MCI) is a slightly noticeable but measurable decline in functional and cognitive abilities, according to Dr. Valvani. Mild cognitive impairment is broadly divided into two types, amnestic (memory is
mainly affected) and non-amnestic (other cognitive functions are affected). “If patients have amnestic impairment, they may have word-finding difficulty as a prominent symptom; if they have non-amnestic impairment, they may not be able to multitask,” she explains.
People with MCI are at higher risk of developing dementia. However, Dr. Valvani says if MCI is identified early, symptoms in as many as 50 percent of patients revert back or improve, which makes it treatable, if not curable.
Alzheimer’s disease is the most common kind of dementia, affecting 60 to 65 percent of patients with dementia. While genetic and environmental factors play a role, Alzheimer’s is a neurodegenerative disorder in which certain proteins (tau and amyloid) accumulate and form plaques in the brain. These plaques, in turn. lead to nerve cell death and inflammation.
Vascular dementia, which accounts for 10 to 20 percent of cases, is caused by cholesterol-related plaques that block blood vessels in the brain, preventing tissue from getting sufficient oxygen. “This is the most treatable form of dementia,” Dr. Valvani notes.
Dementia with Lewy bodies (abnormal deposits of a protein called alpha-synuclein in the brain) tends to present with hallucinations, tremors, gait problems, and fluctuating cognition rather than memory problems. (The Lewy body protein is also associated with Parkinson’s disease.)
Fronto-temporal dementia can cause personality and behavior changes, as well as language problems.
Some people suffer from more than one type of dementia at the same time.
“Dementia is a chronic, progressive disease,” says Dr. Valvani. “Diagnosing dementia early is important because you can prevent progression.” It’s important to note, she adds, that other conditions can cause dementia-like conditions that are reversible. These include depression, drug-induced delirium, infection, and post-operative cognitive decline. Other reversible underlying causes include thyroid hormone imbalance, vitamin deficiency, and increased brain pressure, according the Centers for Disease Control and Prevention.
Some of the same healthy lifestyle choices that prevent cardiovascular disease can also prevent vascular dementia. These include weight loss, age-appropriate exercise, adhering to a Mediterranean-style diet (rich in vegetables, fruit, legumes and whole grains), and managing diabetes, high blood pressure and high cholesterol.
There is also some truth to the old adage, “If you don’t use it, you lose it,” says Dr. Valvani. “A lot of older adults, especially during the pandemic, have become very socially isolated. They stop interacting and attending community activities, and they stop using their brains as often as they were. Some also become depressed.” Treating depression, and staying mentally alert by learning new hobbies, reading, doing puzzles, and staying socially engaged – even if via Zoom – can help prevent cognitive decline.
“I had a patient with mild cognitive impairment who always wanted to learn a musical instrument,” says Dr. Valvani. “He was retired and had a lot of free time so he started taking online guitar lessons. Not only was he happier, because he was doing what he always wanted to do, but he improved cognitively.”
While age is the strongest risk factor for cognitive decline, she notes that hearing loss is also a risk factor. “When people can’t hear, they stop participating in social interactions and stop getting the stimulation they need.” She says that ongoing studies are evaluating whether hearing aids and other interventions can alter the trajectory of cognitive decline among older adults.
Treating the elderly in the age of COVID-19
A recent study suggested that COVID-19 might increase the risk of cognitive decline. Seniors in general are more likely to suffer serious complications – and die – from COVID-19, so Dr. Valvani advises her patients to stay home as much as possible. Still, she stresses that it is important that they continue to interact with friends and family through FaceTime or Zoom, or stay connected via telephone or letter-writing – “old school style,” as she puts it.
“It’s not a good idea for older adults to just watch TV all day, it’s not good for their brains because they don’t interact with the TV.” Using a stationary bike while watching TV can help. She also suggests that older patients try to get outside in their yards or sit by a window for part of the day.
It is crucial, she says, that older adults get flu shots this year, if they haven’t already. Like COVID, flu poses a higher risk to the elderly. “It’s going to be very scary and risky for older adults to have both, so prevention is key,” she says. Though the two illnesses have many overlapping symptoms, flu tends to present as a mild, dry cough, while COVID is more likely to begin with generalized body aches, fatigue, chills, and fever. “What is more unique to COVID is the shortness of breath or difficulty breathing and the loss of taste or smell,” she says. Older patients with COVID may also present with generalized confusion or loss of appetite.
“This season, I would recommend that if they have fever or concern that they might have flu or COVID, older adults should stay home and call a care line or consult with a doctor via a virtual visit. The doctor or nurse practitioner will be able to identify whether they need to be tested in person.” Early detection, she says, could prevent pneumonia and other complications.
Dr. Valvani says that she finds working with older adults to be extremely rewarding. “This is a population that needs help – they have multiple chronic illnesses on top of other psychosocial and functional problems,” she says. “I feel really gratified when I am able to support or manage their medical problems and give them tools to get back closer to their previous level of independence.”
Dr. Valvani admits that sometimes when with her patients, she feels like she is treating her own grandmother or grandfather. “Seeing an elderly person smile just makes my day.”
Lori Miller Kase is a freelance writer living in Simsbury.