COVID Webinar Series: Transcript of session with John Newman, MD, PhD

John Newman, MD, PhD, Assistant Professor, Buck Institute for Research on Aging; Assistant Professor, Division of Geriatrics, UCSF Medicine
Recorded Monday, May 4th
His session is available for viewing online.  This is a transcript of the Q & A:

KRIS REBILLOT: You work at the VA Hospital. Fortunately, for all of us and for you, you have not been as busy as you were prepared to be. What’s the situation?

JOHN NEWMAN: That’s right, Kris. Hi, everybody at home. Thanks for tuning in.

If you had asked me six weeks ago what would I be doing on May 4th, I would not have guessed that I would be sitting in my kitchen talking to you in my socks. And I am so happy to be able to do this, because of what that reflects about what the state of the pandemic is here in the Bay Area locally, which is that you at home, you’ve probably been hearing people talking about how we’ve flattened the curve in the Bay Area, and you even heard some doctors talking about smashing the curve and hammering the curve. And we’ve done an outstanding job here in the Bay Area of making this… of avoiding the worst case. And my personal on the ground view of that is, you know, six weeks ago we were all signing up for our emergency surge duties. I wound up doing a bunch of extra work in the hospital the last six weeks, not to take care of COVID patients, but to take care of everyone else, so that other doctors could focus on building out the respiratory care teams, and the specialist COVID units, and the screening clinics, and all of the expansion of capabilities that we’ve been doing over the last six weeks. But, still, we were all expecting the surge to come sooner or later, and we all thought that by now we would all be taking care of COVID patients. And it’s such, such good news for the Bay Area that that hasn’t happened.

KRIS:  So you…

JOHN:  And that hasn’t happened…

KRIS:  Yes?

JOHN:  …because of you, and not just you, Kris, but all of you listening in the Bay Area, every one of you because of what you’ve done and not done in the last six weeks. You know, collectively, as a community, we beat back this virus for now. So I think every one of us should be proud of the part that we played in doing that, especially if your part was just staying home and just, you know, wearing masks and physically distancing yourself. Thank you for protecting all of us and helping us to be really an example here in the Bay Area of what we all could have done in the first stages of this pandemic.

KRIS:  The Bay Area’s taking a slower approach of opening. How long are we in for here? Do you have any advice for those of us who are of a certain age who might have to hang in a little bit more carefully than others?

JOHN:  Oh, this is... we should celebrate the good news and celebrate our success, but we should also remember that this is just the beginning. It’s not the beginning of the end. It’s the end of the beginning that we’re approaching. And we are, I think, coming into phase two. And here in the Bay Area and here in California, we’re in a good position to start to think about phase two, much better off than other places in other areas of the country or other areas of the world. But phase two is going to look pretty different. I mean, in a lot of ways, phase one was kind of simple, you know, we have to stop the spread, we have to stop this exponential growth, we all need to distance ourselves and stay at home. In a way it was very black and white, very, very straightforward, what we all had to do.

Phase two is going to be much grayer and much more challenging in a lot of ways, a lot more complicated. We’re all going to have to... it’s going to be different region by region, it’s going to be different individual by individual, and we’ll talk about some of that, and it’s going to go on for a while. So, you know, we now need to kind of dig in for the long haul. We knocked the virus back, but we have a long way to go until it’s… until it passes. So phase two we think is going to be getting ready for... you know, we started off with a sprint and now we’re getting ready for the marathon.

KRIS:  Advice to folks who want to do the best things for themselves and for their community during this phase two beginning of the long haul.

JOHN:  Yeah, I think start to…  so, you know, isolating ourselves, and sheltering in place, and not seeing our families, and often not going to the doctor, and often not leaving the house, this has been really hard for all of us, and it’s still going to be really hard as we move into the long haul. And I think now is a good time… well, especially while we’re still sheltering in place here in the Bay Area, to start to think about planning out for the long haul because we can do just about anything for a month, right? And we can do anything for six weeks or eight weeks. But if we’re now thinking about a year, you know, what is our life going to look like over the next year, and how can we arrange lives, especially if you’re an older adult, especially if you’re at higher risk for really getting hurt by this virus? How can you put together ways to keep your life in order, and keep yourself healthy and keep yourself sane, but also keep yourself safe for months to a year or more? So now is the time to really start putting together those plans as we’re moving from the sprint into the marathon.

KRIS:  We have talked about physical activity is important, emotional connection is important. What should people be doing?

JOHN:  Yeah, everything it’s… everything that’s so important to our health and our lives is exactly the sort of thing that gets curtailed when we’re trying to stop the spread of this virus, and that’s true of us living at home. It’s even more true of people living in nursing homes and assisted living facilities. So I think what we all need to do is figure out how to get those bits back in our life, while still minimizing our contact with others and staying at home as much as possible.

So exercise, exercise is a great example. Exercise is the ultimate… you know, ultimate way to fight aging, so the best way to stay healthy, to stay strong, to stay fit, to keep your mind strong. But how do you exercise if you’re trying to not go out so much, if you can’t go to the gym, if you can’t go to your... if you can’t go to a group yoga class, or to your, you know... so we all… I think is a great time to think about how to make your exercise program work for you at home, and work for you in a way that doesn’t put you in contact with too many other people. So a lot of us have been exploring our neighborhoods, for example, and learning how to… how to distance ourselves as we’re walking around the neighborhood. That’s a great thing to do. If you have ways that you can walk at home… walking is really the best exercise. And if you’re fortunate enough to live in a house with enough space to do a lap, you know, start counting those laps. If you have a backyard, even better. If you don’t, any sort of exercise is better than none at all. We don’t want to become couch potatoes because we know that’s going to harm our long-term health even if we don’t get the virus. So even simple things. Trying to arrange our day to day activities to be a little more active—going up and down the stairs more often during the day, you know, getting up from a chair more often during the day, every little bit we can do helps.

KRIS:  Somebody is talking about how to interact with relatives. This person who asked a question wanted to know if she could see a friend who had a heart valve replacement. I know we get questions about when is it going to be safe to hug my grandkids. My college daughter had it; she’s over it. Is it okay for us to have a meal? What advice do you have to say in those situations?

JOHN:  Well, right now, I think in the Bay Area, it’s still pretty simple. We’re still supposed to be sheltering in place and avoiding contact, close contact with others as much as we can, which doesn’t mean not seeing them. So we should get very creative in figuring out how to stay connected, especially with our families and loved ones, because we don’t want to emotionally or socially isolate ourselves. We just need to physically isolate ourselves a little bit. So there are a lot of folks who are learning how to… how to video chat with their family, and how to use FaceTime, use Zoom and all these things. And that’s wonderful, it’s a great way to see your kids and see your family. I saw an absolutely touching moment walking around my neighborhood a couple of days ago, where a neighbor was talking with her older neighbor from the window. So the older person was talking through their window from the second story and having a nice chat with their neighbor on the sidewalk. And that’s a great way to connect with while staying physically distanced. You can talk across fences or through doors.

Now… so… but this is going to get much more complicated as we move into phase two. And that’s, I know Kris, what you’re really asking.

KRIS:  Yes, I was. Right. So people.

JOHN:  …because as we…

KRIS:  People are going to have to weigh risks and benefits, right?

JOHN:  Yeah. I mean, you don’t... you can do anything for a month. You could not hug your grandkids for a month, and not like it, but we can survive it. But a year is different. So we’re all going to have to start making these individual decisions about our personal risk, about what’s most important to us, and about what the risk is in our communities. And this sort of balancing of goals and risks is kind of at the heart of geriatric medicine, in thinking about what’s really important to you, and how can you best accomplish that trying not to harm yourself in other ways. And we often think in that way about what sort of medicines to take or what sort of surgery to have. But in a way, we’re all going to have to think about that in terms of our physical contact, too.

And this is… this is… I’m not going to lie to you, this is really hard, and it’s going to be a very, very personal set of decisions.  And this virus doesn’t make it any easier, because, you know, one of the… one of the really difficult bits about this virus, in particular, is the long period that people can have it and not have any symptoms, but still be spreading it to others. And that can be a few days, it can be a week, in some cases, even two weeks. So it’s not just a matter of staying away from people who are sick, but you never know is this person already have the virus and just they won’t know it yet for a few days or a week, but I can still catch it from them. In a sense, every time you hug someone, every time you invite someone over for dinner, you’re going to be inviting over for dinner not just that person but everyone that they’ve been in contact with for the last week.

So one way to kind of start to think about this is, you know, what is the situation like in your community? Is there just a few people with the virus circulating or is it a lot of people with the virus circulating? You know, there are some communities in the US where it’s just a percent or two or even less than that. In areas… in the New York Metro area, that might be as high as 10- or even 20%. So your thinking of the risks is going to be very different if your community has a lot of cases right now versus if your community doesn’t have a lot of cases right now.

KRIS:  ‘As a senior, my own feeling is that we won’t really be able to participate in society until testing and tracing become widespread. What do you think?’

JOHN:  I think it’s going to take... well, so how is this going to end? I think that’s what the question is really asking.

KRIS:  Right.

JOHN:  When can we stop worrying about what’s the risk and just go about our normal lives, and go to... and, you know, I want to go to a baseball game again. When is that going to happen? And we don’t know. This is also a really hard and challenging question. How is this going to end? In my mind, there’s only a couple of ways that it can end, either we all get it or… I guess I’ll make that a little more nuanced… either we’re all immune to it because we’ve either gotten it or got a vaccine, or we managed to stop it before we all get it. And I think that’s what the questioner is alluding to with this idea of if you can slow the spread enough and reduce the number of cases enough, then you can do widespread testing and contact tracing to isolate the handful of cases that are left, and maybe contain it. There are countries that are doing this successfully. South Korea is the best example right now, where they had their… I know other speakers have talked about this in this series. They had their first case right around the same time that the United States did, but their course of the pandemic has been vastly different, and I think they’re now down to just single digits, single digits of new cases each day in a country of 50 million people. So it’s doable. And to me that’s the best case scenario, if we can damp this down enough, actually isolate it and stop it. And this is what we did with the original SARS epidemic, which everyone forgot until this year, about 15 years ago. So it’s possible.

To me, the other option, a vaccine would be fantastic, of course. If we can slow this down until we get a vaccine, that would be great, but we can’t count on that. So the other option of just letting everyone get it, this idea of herd immunity, to me, it’s really scary because this isn’t a cold and it’s not the flu. A lot of people who get this die and a lot of people who get it who survive will be disabled, and we should talk more about that. So the people who die are just the tip of the iceberg of how this affects us. So I really don’t like the idea of let’s just let it spread throughout all of our societies that we all get it because we’d be talking about literally millions of lives changed forever. So I hope that we can damp this down, widespread testing, isolate it and watch it whither out.

KRIS: Older adults have different symptoms. They don’t present necessarily as your ‘normal’ COVID-19 patient.

JOHN:  That’s right. And this is true of older adults, in general, for many illnesses, including other viruses. So older adults… older adults don’t step out of a textbook. This is one of the challenges of caring for older adults and being a geriatrician is trying to detective-out what’s really happening when the symptoms don’t match up with what you read in a textbook. COVID is another example of this. So the classic symptoms, of course, we all know, the fever, the cough, the shortness of breath. Even in younger people, those all don’t usually happen at the same time, but in older adults you may not see them at all, and there are physiological reasons for this. So, for example, our body temperatures tend to drop as we get older. So our normal temperature… everyone probably remembers learning as a kid, our body temperature is 98.6 degrees Fahrenheit. That’s not the case for older adults. Our normal body temperature actually drops. And so if you see a normal temperature in an older adult, it might actually be a fever if it’s a couple of degrees above where they normally are. And older adults don’t generally mount fevers as readily as younger people. So you often don’t see fevers or you might miss them because they look normal although they’re not. And older adults tend to present in confusing ways, often very subtle ways. An older person might just be a little bit off, maybe get a little bit confused, you know, even if their brain is normal. You know, we’re not talking dementia or anything. They’re living by themselves, taking care of things, but your child calls you up on the phone and just thinks that you don’t sound right today. You know, you don’t know what day it is or you thought we talked yesterday but that was a week ago. So… or being a little bit lethargic, more tired, not eating. These sorts of subtle non-specific kinds of symptoms are actually really common in older adults, and especially from infections. So family members and doctors really need to be on the lookout for this, that the first sign of a COVID infection, for example, in an older person might not be a fever, it might not even be a cough. It might be, you know, not eating very much for a day, and, especially, it might be getting a little bit confused, what we call delirium, which is one of the real… real scourges of acute illness and infections in older people.

KRIS:  Should older adults call their doctor right away?

JOHN:  Well, I think it’s a good idea for folks to check on the loved ones in their family who are older, or their friends, or their neighbors, because, of course, you know, they may not… if someone gets a little bit tired and lethargic and confused, they may not be able to ask for help. So it’s really important to check on people, even by the phone, even by FaceTime, and just have your spidey sense up where something seems off, and then talk about it with them. But, absolutely, if there is that sense of something might be off, I think that’s a great time to call the doctor.

And one of the amazing things... so we’ve heard a lot about how our healthcare system is so strained and how this has revealed many of the flaws in our healthcare system, and that’s definitely true. But it’s also revealed a lot of resiliency in the individuals who make up the healthcare system. And one amazing piece of that is I’ve seen tele-visits, you know, Zoom, FaceTime, like this, go from almost not even a thing in medicine or a very rare niche sort of thing, to actually making up a majority of visits these days in just a period of weeks. So, absolutely, figure out how to talk to your doctor virtually. And this, obviously, saves you all of the risk of going into a doctor’s office, going into emergency, and if there’s any question about something seems off, absolutely give them a call. Let them see you and talk to them. And it’s a great first step to figure out if you need more help.

KRIS:  What happens with the immune system as we age and is there anything we can do about it?

JOHN:  Oh, I’m sure, because, I mean, this is… this is a striking element of COVID-19. It’s true of other infections, too, even… you know, seasonal influenza, of course, affects older people, too, but affects younger people. And this… and COVID-19 really doesn’t affect kids in a broad way, at least. We know it does somewhat, but not in the same way that influenza does. So something is different about the immune system of older people, and we’ve known this for a while. There are terms from this called immunosenescence, the idea that our immune systems have a harder time doing the things they’re supposed to do as we get older. One obvious kind of common manifestation of that is that as important as vaccines are, really, really important for older people, especially the flu vaccine, especially the pneumonia vaccine, vaccines work less well in older people, and we need to use tricks like higher doses or a different vaccine… different adjuvants to try to get vaccines to work better in older people. So that’s one example of our immune systems don’t do what they’re supposed to do as readily as when we were younger.

 But then there’s a flip side of that, too, that many of our listeners have probably heard of this concept of inflammaging, the idea that dysregulated, abnormal, you know, not productive inflammation can increase as we get older, and in very subtle ways, but in subtle ways that we now think contribute to many of the chronic diseases of aging. Inflammation is a good thing when our body is using it to heal ourselves. You know, if we have a cut, if we have a surgery, we need inflammation to fix things. But when inflammation gets uncontrolled and can’t get turned off, that causes problems. So older people’s immune systems are in this strange state where they’re always a little bit too active and causing this inflammation, but then they have a hard time ramping up when they’re supposed to, to fight a virus. So we’re starting to understand the molecular mechanisms and the cellular mechanisms of why that is in the laboratory and in people, too. And I think that this… I know there’s a lot of researchers, a lot of my colleagues at the Buck Institute and around the country have been very interested in this idea of inflammaging and how to improve the immune system of older adults for years now. And I hope that in the not too distant future, we’re going to have interventions to specifically help the immune systems of older people work better, so when the next virus comes, even if it’s not the, you know, SARS-CoV-2 coronavirus, it’s some other virus, we’ll have things that we can do to help.

In the meantime, I know your… our listeners are wondering about, ‘Well, that’s great if we’ll have drugs in a year or two or three or five years, but what about today?’ Well, we already know some ways to keep your immune system healthier, and the most important one is moving. I won’t even say exercise, and we talked about this already, but just being more active in any way that you can be, and we know that that has beneficial effects on your immune system. Sleeping. I know a lot of us are pretty anxious these days. It’s hard to get a good night’s sleep. It’s even harder when we’re not as active as normal during the day. But whatever we can do to help ourselves to normalize our schedule and get a good night’s rest is going to be really important for helping our immune system, without using drugs, though. We should talk about that later. But natural good sleep. And food. You know, we know that a good diet can help your immune system, too. This is particularly hard, right? Because everyone… the advice is always eat lots of fresh vegetables and fruits, but that would mean going to the grocery store a lot, and we really shouldn’t be doing that right now for older people. This is a great way to help your neighbor and help your family. You know, make sure that they have fresh food to eat. Help them out. Drop things off at their doorstep, you know, if… or try to arrange for a delivery service if you need to. But it’s a great way that we can help our family members by doing what we can to help them eat healthy even through this crisis.

KRIS:  Sugar is not the greatest thing for our immune system. Right?

JOHN:  No, we probably shouldn’t be overdoing the sugar, and certainly not without having lots of other good food, too. I love a good cake and a good cookie. So I’m not exactly one to talk, but we should make sure that our quarantine diets, so to speak, our shelter in place diets, are still, you know, high in healthy grains, high in good protein, real food. And in a way, you know, I think that this might be… I don’t know about other listeners, but we’ve actually been cooking a lot more than normal for the last month and eating real food, you know, recognizable… not processed food, not frozen, but real food. And maybe that’s true of other people. We call it get back in touch with our chef side as long as we have access to that food.

KRIS:  What are the issues at nursing homes and assisted living, and then what considerations when you look at what’s the best thing to do for a loved one, and if they’re going to come home, what do you need to do?

JOHN:  This is such a great question. Thank you, viewer, for asking that. Everything that we’ve been talking about for older adults living at home in the community, it’s just amplified in a nursing home setting or an assisted living setting. And this is… and knowing what to do is a really, really hard question. We know that… and we know that nursing homes and situations where older adults are together, any situation where a lot of people are together... and you’re seeing this in prisons and jails, too... they’re just… they’re kindling for the wildfire of this pandemic. And we saw that in the very beginning. the first cluster of cases in the US was at a nursing home and several nursing homes in the Washington State, Seattle area. And it can just go through like wildfire. But knowing what to do about that is really hard. And our viewer alluded to one of the… one of the challenges is this double-edged sword of to protect, try to protect older people in vulnerable situations like nursing homes. We want to try to isolate them. So no visitors, no communal dining, you know, no gatherings. We’re trying to… you try to help them shelter in place, essentially, in their rooms and limit contact with each other and slow the spread. And that’s great for helping to limit the virus. It’s necessary. Over the long term, though, it’s not good for people’s health. You know, nursing homes, especially good nursing homes, have all sorts of programs to do all the things we were talking about—keep people mobile, keep them active, keep them walking, keep them socially interacting, keep their brains engaged with each other and with the staff, doing all sorts of group activities, you know, communal dining, trying to have a normal life within a nursing home or within an assisted living facility. And that is so important to health, but we can’t do it right now. So trying to balance this is going to be really, really challenging. And I know a lot of families are wondering, ‘Should I take my loved one out of a nursing home?’ And I… there is not an easy answer for that.

What I would say, what I would tell, you know, my own family if they asked them, and, fortunately, we’re not in that circumstance, you know, most… the decision to go into a nursing home or into an assisted living facility is often not an easy one to start with, and people usually make that decision for good reasons because that’s the setting… they just need help, and that’s the setting where they can best get the help that they need. It’s really hard to take care of an older person who needs a lot of help at home. Most families can’t do it. And families who want to try, I mean, God bless you, and good luck, and please plan it out carefully and even talk to the nursing home staff about exactly what your loved one has been needing, so that you can try to build that for yourself at home. But it’s a lot of work and it takes more than one person. It takes a whole family. It takes a whole team, just like the team that was taking care of them in the nursing home or assisted living center. And I… you know, it’s this individual trying to weigh the risks. If there is an outbreak in a nursing home, you know, boy, the chance that might spread to your loved one, unless they’re really, really doing everything just right, is scary. If there’s not an outbreak in the nursing home yet, you know, are they doing everything that we think we should be doing to try to prevent outbreaks?

But this is really hard to do. We can’t... you know, there’s a lot of people talking about ‘Let’s just isolate our vulnerable people and let everyone else, you know, go to the beach and go back to work.’ It’s really hard to isolate millions of people, and just think… you know, thinking concretely about trying to build a wall around a nursing home. How do we do that? By definition, people in a nursing home need hands-on help. They need help, often, walking. They need help getting to the bathroom. They need help changing and cleaning. So people have to be in close contact. Those people don’t live in a nursing home. Those staff members live out in the community with their own families. So, you know, the same way that when you invite someone over for dinner, you’re inviting over everyone they’ve spent time with for the last week, when a staff member takes care of some of the nursing home, they’re bringing with them everyone that they’ve been in contact for the last week.

So how do we protect people? We need a lot of PPE. I think that’s step one. I think it’s fantastic, by the way, that everyone in the country knows what PPE is now. We’re all learning certain bits of this medical jargon. But just think of how many millions of people that is. You know, the number of staff in nursing homes is more than the number of doctors in United States, for sure. And every single one of them, you would ideally want to be wearing PPE every time they interact with a patient. And that’s a huge challenge.

So knowing the right thing to do here is really complicated. But there are certain steps that we know nursing homes probably should be doing, and I’m really happy to see that in San Francisco we are doing some of these things. It was just announced a couple of days ago that every resident and staff member of a nursing home in San Francisco will get tested every two weeks. That’s a great first step. It’s probably not often enough, but at least it’s certainly better than not testing and waiting until cases happen. And we need a lot more PPE—we need a lot more gowns, a lot more masks, a lot more testing. Everything we’ve been talking about for our whole community applies ten times more in a nursing home setting.

KRIS:  There was a surprising finding that a very popular cough suppressant, , dextromethorphan, that actually encouraged viral infection. What is that chemical? And should people who are healthy at this point in time avoid it?

JOHN:  So I get to switch my hats now. Instead of talking like a geriatrician, I can talk about it… I can talk like a basic scientist. This is the fun being a physician scientist. I think one of the… some good, I hope, will come out of this pandemic, and one of those things, I hope, will be that I’ve never seen ordinary people so engaged in science and in medical research as I have right now, and it’s really incredible to see. I hope we can sustain that because, you know, science and biomedical research, they’re also a marathon, not a sprint. If we want to be ready for the next pandemic, we have to keep going and not stop. But one of the aspects of that is that we’re seeing the inside baseball of science. We’re seeing science happen in real time, which we almost never do. You know, we’re seeing experiments happening faster than we ever thought we could. We’re seeing them published on the internet on pre-print servers for the whole world to see, even before they are peer reviewed. We’re seeing people discussing these very early findings. And it’s exciting, and it’s fun, and it certainly seems directly relevant to our day-to-day lives. I would remind everyone, though, that there’s a lot of work to do between testing things in a test tube in the laboratory and having… and knowing what treatments do in people. And, usually, that’s a… you know, that’s a 10-year process, going from the test tube to having effective medicines in people, and it’s a very complicated process.

So, you know, Nevan Krogan and this international team of researchers are doing incredible work, faster than I think anyone thought humanly possible to understand this virus and to try to come up with new ways to treat it. But for all the laypeople, the non-scientists who are listening, follow this along, you know, see what happens, but take it all with a grain of salt, because there’s a lot of scientific space between testing things in a laboratory and giving them to people.

KRIS:  What’s with the cough suppressant?

JOHN:  So having said all that, so the cough suppressant... this is kind of interesting, and I’m actually… I’m kind of glad that dextromethorphan is the next example of this. Dextromethorphan is a commonly used cough suppressant. It’s in a lot of over-the-counter medicines. I use it myself when I get sick if I had a cough because it works.  It’s not a great drug for older people to take, though. It’s actually a drug that I would generally steer older people away from, because like a lot of… like a surprising number of over-the-counter drugs, it affects the brain. It’s a weak form of... it’s related to pain medicines. It’s not a pain medicine, but it’s related to pain medicines, and it can work on some of the same pathways in the brain, and it can actually make people… it can make people confused. In general, you want to… when you’re an older person, you want to avoid medicines that are going to mess with your brain. And dextromethorphan is not the highest one on that list, it’s not even the worst offender, Nyquil. Many, many cold medicines have very powerful antihistamines, mostly to make you sleepy. But in older adults they can very much make you confused, and we really want older people to stay away from strong antihistamines.

So I would probably steer away from dextromethorphan anyway. And I’m kind of glad that’s the example that has come from this and not something like Warfarin or Insulin or Metoprolol or beta blockers, you know, medicines that are really vital to keeping people healthy and alive. And I wouldn’t want people to risk their health by stopping a medicine that could be really helpful to them, because we’re worried that, you know, in 12 steps from now we might realize or not that this has some effect on the virus. Dextromethorphan is kind of low-hanging fruit. If you want to avoid it, by all means. If you’re an older person, you probably should avoid it anyway.

KRIS:  Your lab here looks at ketone bodies, but you’re also looking at ketone bodies as it might relate to this virus or immune response. What are ketone bodies? And what is your bit of looking at the big picture?

JOHN:  Yeah, so with my scientific hat, I study mechanisms of the biology of aging, molecular mechanisms, cellular mechanisms for why we age and how that affects our health. And the nitty-gritty bit that I focus on are ketone bodies. So these are normal molecules that our own bodies make, especially when we’re fasting, or if we’re not eating very much, or if we’re not eating very much sugar, carbohydrates, and we’re realizing that they have powerful actions in our bodies. They’re not just energy to help us sustain a fast, but they actually reprogram our genes. They can affect inflammation, they can affect metabolism in really interesting ways that we think are relevant to chronic diseases of aging. And I’m especially interested in studying ketone bodies in the context of the aging brain, you know, what role do they play in maybe helping to protect us from dementia, from Alzheimer’s disease, or protect us from delirium, this acute confusional state I mentioned earlier, which is a common and severe side effect of illness in older people. So  I study, you know, what ketone bodies do. But, you know, like everyone, I’m not a virologist. I wasn’t really paying attention to virology a whole lot until the last few months. But like everyone else who’s a scientist or a physician, I want to know what can I do to help. And as a clinician, you know, that was pretty clear. I helped out however I could, however they needed me in the hospital. As a scientist, I want to try to help out, too.

So, you know, the… so we don’t know anything about this yet. No one has really thought about it, but we’re starting to explore, you know, what… if ketone bodies can affect inflammation. There’s a few of the molecular mechanisms that may turn out to be relevant to how the virus replicates. Some of them on paper might help. Some of them on paper might hurt. So this is another example of, you know, the early stage. We’re just starting to explore things, science, but we’re trying to do some very simple experiments to just answer the question, does it look like the ketone bodies made by our body, might they be relevant in helping to… in effecting the virus, or might they be relevant to the clinical illness that the virus causes, inflammation in the lungs, inflammation in the brain, inflammation in blood vessels. And could we think… you know, could this lead to new approaches for helping to, if not stop the virus, at least helping to mitigate some of the effects of it? But that’s certainly a long way away. But we’re going to start off.

KRIS:  What do you have to say about ageism and COVID-19?

JOHN:  Well, it’s a big question, and I think the first step in unpacking is it just acknowledge what we’re seeing and hearing. You know, the… crises like this pandemic, they bring out the best in us, and you’re seeing that all around us, but they can also bring out the worst in us. And I think this is an example of bringing out something that has always been there, ageism in our society, that we, as a society, collectively, and often individually, we value older people less. And this is strange if you step back a bit because age is the one thing that will affect every single one of us. You know, we’re devaluing ourselves when we think an older person is less worthy, or their life is less worthy of saving. I think it really... it breaks my heart and just twists me to hear just how overt some of this has become as we’re talking about the pandemic. People just... leaders, saying out loud, in front of microphones, ‘Why don’t we just let old people die? Let’s just let a few hundred thousand, a few million people die.’ For what? Or that older people aren’t worth saving. And this is… and I know it’s not everyone, it’s just a… hopefully, just a few people, but even hearing those things said out loud, it’s just awful. And I think it is affecting the way that we think about this pandemic. You know, you’ve heard a lot of people say, ‘Well, it only affects old people. It’s just old people.’ And, of course, it’s not, it very much affects younger people too, especially with the chronic diseases that we know are risk factors, like high blood pressure. A lot of Americans have high blood pressure. Diabetes, you know, cardiovascular disease, plenty of younger people have these things. If you look at who belongs to a, quote/unquote, high risk category, it’s something like almost half of adults in the United States, so… but, still, just saying that phrase, ‘It’s just old people,’ as if millions and millions of us, ourselves, are not human beings anymore, is just really painful.

And I think it also reflects… even though we’re all going to get old ourselves, it reflects some strange blinders about the life of older people, and the life in the older people. You know, to a geriatrician, at least, 70 is young, you know, and most people who are 70 will make it to 85. You know, and most... and 85 doesn’t seem that old to geriatrician. Most people who are 85, most people, will make it to 90. You know, people have a lot of life left and a lot of good to do and a lot of life to live, and I just can’t stand that this bubbling strain of, you know, older adults are not human beings.

KRIS:  There’s differences among older adults health-wise, and can you help them?

JOHN:  Oh, absolutely. And the diversity in older adults is one of the joys and challenges of being a geriatrician. So the saying, I guess maybe it’s a joke, is that if you… you know, if you’ve seen one 25-year-old, you’ve seen every 25-year-old, but if you see one 80-year-old, you’ve seen one 80-year-old. Everyone is different. One of my favorite patients in my primary care clinic at the VA years ago celebrated his 80th birthday, 80th birthday, by base jumping in Norway. You know, there’s… and we’ve all seen pictures, of course, of the tennis-playing older people. And that’s not to devalue people who are not that healthy because it’s not often up to us if we get a chronic disease, if we get a cancer, if we have a stroke, and there’s value in life in old people, no matter what their health state is. 

But, certainly, as we get older, our diversity spreads, and so there are… you know, there are some 70-year-olds, some 80-year-olds, some 95-year-olds who act and medically and biologically are much younger than their years. And there are some 45- and 55- and 65-year-olds who medically and biologically are much older than their years. So it doesn’t make much... and we’ve learned this in the last 20 years in geriatrics and medicine, not to judge people by their age, but to try to judge... to try to make decisions based on their goals and their health state. And there’s this concept of the physiological age. So age is not a number, you know, age is… age is how you act, and how you feel, and how your health is. And we definitely need to... I certainly wouldn’t want to make any decisions or lump all old people together just based on their age. That’s doing everyone a disservice.

KRIS:  I think I saw a video of somebody who was 103, who was leaving the hospital. Older adults can survive COVID-19 right?

JOHN:  Absolutely. Absolutely.

KRIS:  What are the dangers of dysfunction or disability following COVID-19, and what can somebody do to give themselves the best shot at coming out of it in a positive way?

JOHN: That’s a great question. And so as a geriatrician, this worries me just as much as people dying. And I think it’s sort of the… it’s the… under the surface of the iceberg, but it’s something that I haven’t heard a lot of people talking about. You know, what happens if you survive? What happens to people who get really sick and survive? And it often changes their life, even if they survive. So this is… this is, also, where my clinician and my scientist hats merge, because my goal in studying, particularly, delirium in the laboratory and my goal in when I work in the hospital, is to try to prevent people from being harmed by their illness when they’re in the hospital and help them get out of the hospital in good shape. So I have a firsthand look at just how hard that can be. You know, half, maybe more, even up to 80% of all new disability in older adults happens in the context of a hospitalization, and a lot of that is because of the reason why you’re in the hospital in the first place, but some of it is also from complications and side effects that happen when you’re really sick.

Two of the prime examples of that are delirium, which I’ll bring up again, this acute, confusional state that’s very common in older adults in the hospital. All comers, all older adults in the hospital, probably half the people get delirious. Many of our listeners may have seen this in a family or a friend. They go into the hospital, they’re sick, and they’re crazy. They’re not themselves. They’re all confused. They’re paranoid. They’re saying strange things. That’s not… they didn’t go crazy. They have a medical condition called delirium, which is related to inflammation, there’s that word again, and metabolic problems affecting the brain. So… and delirium is not just a problem in the hospital. You can imagine that it’s hard to take care of someone who is very confused and doesn’t know what’s going on. But delirium can take a long time to go away, even if you do everything right. And delirium increases the risk of dying in the year or so, or two years after your hospitalization, and it increases the risk of progressing to cognitive impairment or dementia. So delirium is a big deal.

So is immobility. So we’ve talked so much about the importance of activity and exercise. In the hospital, people often stay in bed, for a variety of reasons, but we know how bad this is for their long-term health. Every day that you spend in bed in the hospital is probably the equivalent of a year of getting weaker. Like the change… you know, as we get older, on average, we gradually get weaker. About a year of that happens within just a day if you’re in bed in the hospital. So we know how important is to prevent that. We know how extremely important... so in the ICU, when people are sick in the ICU, and you’re talking about COVID, you’re talking of being in the ICU, maybe on ventilators, this is all amplified. Everyone in the ICU gets delirious. You have to work really, really hard to try to prevent that as much as you can. And everyone in the ICU needs to move. There are these amazing pictures you’ll see of people actually walking while they’re on a ventilator, because we know just how important every bit of movement is to keep someone from becoming disabled, even if they survive.

So I’m really worried that, you know, if we’re talking about millions of people getting this, and already tens of thousands of people dying, that becomes hundreds of thousands of people. Hundreds of thousands of millions of people will survive serious illness, but many of them are going to have long-term effects. And in the older adults, many of them are not going to be the person they were, and many of them may not be able to go back to living by themselves. And I think we need to do everything we can, not just to try to, you know, treat the virus better in the hospital, but to make sure that we’re treating the older person better in the hospital.

KRIS:  If I’m an older person, which I am, and I end up having to go to the hospital, what can do I do to give myself the best shot?

JOHN:  Well, number one, is try not to get the virus. The best cure for this virus is to not get it in the first place. Then you’re certain that you’re not going to wind up in the ICU or wind up thinking about disability.  But in the event, so this is… this is, again, an important reason, too, why we need to, if nothing else, spread things out a little bit and try not to overwhelm our hospitals, because all of this… we know how to prevent delirium, we know how to walk people in the ICU on ventilators, but it is really complex and time-consuming to do.  And if your hospital is flooded with… you know, every operating room and every hallway is becoming an ICU, you can’t do these things, as much as we know that they’re utterly necessary. So don’t get it in the first place, cooperate as a community to keep slowing it down, so that hospitals can do things the best possible for every person.

But, Kris, you’re asking about what, if any way… what if we wound up in the hospital.  So two things to think about ahead of time, and it’s not fatalistic to think about things ahead of time. It’s just being prepared, and this pandemic has taught us, you know, we need to be prepared, ourselves and as a community.

So go-bag. Go-bag is a great idea. When you’re sick, the last thing you want to be thinking about is ‘Where are my eyeglasses?  Where are my dentures?  Where are my hearing aids?  Where’s my cell phone charger?’ So those things all go in your go-bag. Probably, you know, if you have a tablet or a phone, this is even more important than usual, because that’s going to be your lifeline to your family and to the outside world.

And the other element to think about is advanced directives. This is an uncomfortable thing to talk about, but it is really, really vital. And it is not fatalistic, it’s just… you know, it’s like health insurance or life insurance. It’s just thinking to the future and making sure you’re prepared, because when you’re really sick is not when you want to be deciding who you want to help make medical decisions for you if you’re unconscious, and it’s not the best time to be thinking about what sort of medical care you would or would not want to receive, and you need to start thinking about how you would like to die, where you would want to die, and in what circumstances.  We all need to think about and talk about these things ahead of time with our family. And it’s a service to you, yourself, so that in the event, you know, things will happen the way you want them to, because you are always in control in the hospital. But it’s also a service your friends and your family, to give them some clues about, you know, if you wind up, for example, on that ventilator, so that they know what you would want your life to look like after that.

So prepare yourself with a go-bag, make sure it’s got the things you need to do to, you know, take care of yourself during the day, make sure it has glasses, make sure it has hearing aids… people forget these all the time… make sure it has dentures, make sure it has, you know, phones, and tablets, and chargers, and batteries. And think about your advanced directives. There’s a great website for this, from a fantastic colleague of mine at UCSF, Rebecca Sudore. The website is called Prepare for Your Care.  You can Google it, or just type it in, one word, PrepareForYourCare.org. And it’s a great, very friendly, you know, layperson, understandable approach to how to think about making medical decisions, who you want to help you make decisions, and what sort of medical care you would or would not want in the event that you got really sick.

KRIS:  Is it safe to drive to another state? When can I see people again and the people I love?

JOHN:  Yeah, it matters to all of us.  You know, it matters to me and you too, Kris, and every one of our listeners. And this is what we’re missing the most in this pandemic, is just being able to be together, and, you know, being together in the sense of giving each other a hug. So let’s kind of… I’m not going to have a good answer for this, and I’m not going to be able to tell anyone yes or no, but maybe I’ll just kind of brainstorm how I might think about it. 

So keeping in mind that, you know, I would think about your… first of all, your goals, what’s most important to you because that will be different from person to person; your personal risk based on your health status, you know, if you got COVID-19, what would your odds be, knowing that their just odds. Some young people… some healthy young people are dying. Like you were saying, 103-year-old walked out of the hospital. So it’s just odds, but, still, it’s odds. So your goals, your personal risk. Your immediate family, you know, the people that you’re interactive with, what has their… you know, what’s their risk of getting the virus, and talk about that, and in the community as a whole. So I… you know, probably wouldn’t go visit family in an area where this is circulating a lot right now, and I think, you know, we know what some of those areas are just from watching the news. You can look up state-by-state or city-by-city rates. In areas that are less affected right now, it makes more sense to go visit people while rates are low, and, hopefully, they stay that way. And how… and this is… this going to be a bit awkward, but thinking about, you know, when you go visit someone, and you’re going to spend hours in doors with them, that’s very high risk for getting it from someone, so what are the odds that the coronavirus is in that group, in your family, in the group of people you’re going to visit? And that’s back to, again, you know, you’re visiting and spending six hours, and hugging everyone that they have spent a significant amount of time with in the last week or two.

Now, the good news is that it does seem like you need a reasonable amount of time to have a high chance of catching this from someone. You’re pretty unlikely to get it, you know, passing someone walking on the street, or from a very brief contact if you’re all masked. You’re much more likely to get it if you’re unmasked in close contact indoors… close contact, meaning within, you know, six, 10 feet with someone for more than 10 minutes. So it’s a little awkward, but maybe you’ll ask, you know, what have your relatives been up to for the last week? Have they been going to… have they been wearing their masks? Have they been going out and being in close contact with lots of other people, or are they sheltering in place and being pretty careful about their physical distancing?

And then, ultimately, it’s… it, you know, it goes up that chain—community, family, personal risk, and goals—to what’s most important to you. You know, if you’re… if it’s… if you think I would… I really, really need to hold my grandson, and I haven’t done that in two months, and this is the most … this is the most important thing to you right now, you know, who is going to say that’s not a bad decision. But just try to make it the safest possible decision for yourself.

The hard thing about the virus… so this is the last point… is that it’s not just you, it’s not just a decision about you. Even if you say to yourself, ‘I don’t care if I die. I don’t care if I wind up on a ventilator and wind up not being able to take care of myself. I really… it’s important to me to be with my family. I’ll accept that risk.’ You’re not just accepting it for yourself, you’re accepting that risk on everyone that you’re around, so all of your close family members.  If you’re a young person, but you live with an older relative, your actions are directly affecting your older relative’s risk. So maybe there’s ways to mitigate that, and maybe you think about how you can… if you can take a bit of a risk yourself, that’s okay, but make sure you mitigate that risk for the others around you.

So this is… this is why phase 1, Kris, is so much harder than phase 1. Phase 1 is simple, don’t do it. But phase 2 is trying to weigh all of these personalized thoughts, and we all have to do it ourselves.

KRIS:  Phase 2 is going to involve some degree of social/physical isolation.  What should people do to be able to thrive as much as possible during what is turning out to be a difficult time?

JOHN: Well, we’ll end maybe with three specific suggestions. We’ve already talked about one of them, which is figure out how to active lifestyle while you’re sheltering. Get creative, you know, have some fun with it. Stairs, backyards, living rooms, you know, do a… maybe do Zoom exercises with your friends, since you can’t go to a gym together. But get creative on how to have an active lifestyle while you’re sheltering.

Number two is figure out how to talk to your doctor. So a lot of us have probably postponed an awful lot of our usual medical stuff, and that’s good, because we want to stay away from hospitals unless necessary, and we want to stay away from doctors’ offices unless necessary. But most doctors now are figuring out how to do virtual visits, and are starting to now, you know, figure out how to triage who really needs to be seen in person, and then to do that safely. So if you haven’t yet, figure out how your doctor is doing virtual visits, how to visit, check in, see how things are going, and make sure that you’re keeping up-to-date on your regular stuff again.  So number two.

Number three is figure out how to connect with your family and your friends as much as you can without physically being together for a long time. And get creative about this, too, about… about videos, and about, you know, meeting across a door, or meeting over a fence, doing things online together. There’s all sorts of ways that we can stay socially connected and socially together, while staying physically distanced.  And this is the time when we all need to figure out how to do that.

KRIS:  What should people do when they see news about what’s going on in the world?

JOHN:  Oh… oh, goodness, and now… and we’re all sheltering in place, and a lot of us aren’t working, and, you know, we have nothing else to do but watch the news all day. And this might not be good either. You know, we all need to stay up-to-date on what’s happening in our communities, you know, what’s… how is… how is the virus going, what are… what is… what is the local government recommending. So we need to stay in touch, but a lot of us are probably overdoing it, or hanging a little bit too much on everything on cable news, and on the twitter, and on the internets, and all that. And that’s not great for our health either. This is a long haul. You know, we’re going to be with this for months, to a year, or more, and we’re going to wear ourselves out if we… if we’re just seeing nothing but coronavirus and COVID 24/7. So for your own mental health, take breaks. 

And, you know, in the Bay Area, maybe this is a good time to take a break. You know, we’re still sheltering in place for a couple more weeks, things are looking okay. It’s a good time to unplug and maybe focus on that social connectiveness, you know, spending more… trying to spend more time getting in touch with your friends again, getting in touch with your family again, learning something new, and just distracting yourself a little bit from the 24/7 news cycle.

KRIS:  Thank you.

JOHN:  Thanks, Kris, and thank, all of you, for listening, and I hope this is helpful. Stay well.

KRIS:  Great.

JOHN:  And stay connected.