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GeriPal

Author: Alex Smith, Eric Widera

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A geriatrics and palliative care podcast for every health care professional.

We invite the brightest minds in geriatrics, hospice, and palliative care to talk about the topics that you care most about, ranging from recently published research in the field to controversies that keep us up at night. You'll laugh, learn and maybe sing along. Hosted by Eric Widera and Alex Smith.
176 Episodes
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What if there was a tool that could break down a neighborhood’s socioeconomic measures, like income, education, employment and housing quality, to give us a sense of how those factors influence overall health, and maybe even inform where to target health resources and social interventions.   On today’s podcast we talk with Dr. Amy Kind from the University of Wisconsin School of Medicine and Public Health, who developed that tool, the Neighborhood Atlas.  The Neighborhood Atlas uses the “Area Deprivation Index,” which includes 17 measures of education, housing quality and poverty, and can be used free by anyone by going to the Neighborhood Atlas website (https://www.neighborhoodatlas.medicine.wisc.edu/). In addition to talking with Amy about the Atlas, we discuss some of the following questions: What is neighborhood disadvantage and what health outcomes is it linked to? How should providers use neighborhood disadvantage when caring for patients? How should health care systems use neighborhood disadvantage? How does the Atlas also identify areas of resilience in communities? So take a listen and if you want to read more about it, check out Amy’s NEJM article on the topic - https://www.nejm.org/doi/full/10.1056/NEJMp1802313
Harm reduction, as so clearly described by our guest Monica Gandhi on this podcast, began as a public health approach that guided management of HIV.  Harm reduction represented an alternative to an abstinence-only approach, which clearly did not work.  In the harm reduction model, you acknowledge that people will take some risks, and that the goal is to decrease risk, not eliminate it.    And yet, here we are with a fear-not-facts approach to the COVID-19 pandemic. Some are advocating for the use of masks in schools, hospitals, and nursing homes in perpetuity.  As in, forever.  Sounds eerily like an abstinence-only approach, right?  Science would dictate that now that we have vaccines, which Monica describes as “the solution,” we don’t need to engage in masking (with a few exceptions). Monica Gandhi, an infectious disease doctor at UCSF, has advocated strongly for a fact-based approach to school opening, early masking and now dropping masking, and global access to vaccinations (and temporarily dropping vaccine patents), among other things. You can and should follow her: @MonicaGandhi9 And from Ashwin Kotwal, geriatrician and palliative care doc-researcher, we hear about experiences caring for patients who are afraid to return to normal after a year of masking and forced isolation, despite the toll these experiences have taken on them (documented in his recent paper in the Journal of the American Geriatrics Society).   It’s time to get back where we once belonged. (song choice hint) -@AlexSmithMD
In your clinical experience, you may have cared for patients receiving palliative chemotherapy and wondered, hmmm, why is that called “palliative” chemotherapy? We’ve written about this issue previously here at GeriPal (“a term that should be laid to rest”) as has Pallimed (“an oxymoron”). Well, now we have “palliative” inotropes for people with heart failure.  And we have to ask, is this a fitting term?  And the answer is...complex...more so than you might think.  Recall that in one of our earliest podcasts, we talked with Nate Goldstein who memorably proclaimed “the best palliative care for heart failure is treatment for heart failure.”   To unpack the issue of palliative inotropes, we welcome back Haider Warraich, a cardiologist with a strong interest in palliative care.  We are joined again by Anne Rohlfing, palliative care fellow at UCSF who spent last year as a hospitalist on the heart failure service.  Please tune in to hear more about the role of palliative care in inotrope therapy, inotropes in hospice, Haider’s study on palliative needs of patients with heart failure, and a bit about Left Ventricular Assist Devices (including a shout out to Dan Matlock’s decision aids) and Haider’s Journal of Palliative Medicine paper on top 10 tips for palliative care clinicians on caring for patients with LVADs. -@AlexSmithMD
What is a care manager?  In this week’s podcast we talk with Chanee Fabius, who after a personal experience caring for a family member with dementia, became a care manager.  Chanee explains in clear terms what a care manager is, what training is required, and what training is required.  In essence, a care manager is a “glue person” who hold things together. After observing major race/ethnic disparities in caregiving, Chanee was inspired to obtain a doctoral degree in gerontology, and her research is now directed toward reducing disparities in caregiving, particularly for patients with dementia.  See for example, her recent paper in the Gerontologist describing Black and White differences in caregiving. We are also joined by Halima Amjad, a geriatrician-researcher, who, like Halima, is at Hopkins.  Halima is very interested in improving care for people with dementia.  As she notes, when we talk about outcomes for older adults, we often talk about the characteristics of the patient as predictors, but rarely do we consider how caregiver factors might influence important outcomes for older adults.  In a paper published in JAGS, Halima found that caregiver factors predict hospitalization.  For example, caregivers who are new to the caregiving role are more likely to care for someone who is subsequently hospitalized than someone who has been caregiving for longer. We talk about all things caregivers, including research issues around the need to assess the needs of caregivers, health policy issues such as how to provide more support for caregivers, and clinical issues, such as the fact that the identity and contact information for caregivers are not routinely captured in the EHR. -@AlexSmithMD
A September 2000 New York Times article titled, “Sometimes Saving the Heart Can Mean Losing the Memory” describes a relatively newly described phenomena of difficulty with memory and other cognitive tasks six months after cardiac bypass graft surgery, or CABG.  The syndrome was termed “pump head.”  A doctor is quoted in the article as stating that older patients he might have previously considered CABG for he would try to manage medically, with a stent.  Data on the impact of CABG on cognitive function over the subsequent 20 years has been mixed.  The problem with these prior studies is they enrolled patients at the time of the CABG.  They didn’t have a sense of what the cognitive trajectory was before the procedure. In this context, enter Liz Whitlock’s study published this week in JAMA comparing cognitive trajectories before and after CABG versus stenting procedures.  Liz finds no difference in the decline in memory before or after CABG vs PCI - in other words - their memory continued to decline at the same rate after each procedure as before.  Furthermore, a newer procedure intended to spare patients the risks of bypass, called “off pump” CABG, was found in this study to be associated with greater memory decline than on pump CABG. Pump head, it seems, is not a thing.  Those who get CABGs likely also had vascular disease in the brian that was leading to a steady cognitive decline before the procedure.   To contextualize these findings for practicing geriatricians and other PCPs, we are joined by Mike Rich, one of the early movers and shakers in the field of geriatric cardiology.  We are doing these cardiac procedures on ever older and older patients.  What should we be concerned about?  How should we counsel our patients? Listen to find out! -@AlexSmithMD
Frailty.  What the heck is it?  Why does it matter? How do we recognize it and if we do recognize it, is there anything we can do about it?   On today’s podcast we talk to Linda Fried, Dean of Columbia University's Mailman School of Public Health and world renown frailty researcher about all things frailty.   We talk to Dr. Fried about how she first got interested in frailty, how we define it including the difference between phenotypic frailty and a “deficit accumulation model’ frailty index”, and how we should think about assessing frailty and managing it. We also talk with Dr. Fried about how she thinks about resiliency and the analogy put forth by George A. Kuchel in a wonderful article published in the Journal of American Geriatrics Society (JAGS) that uses the Golden Gate Bridge to explain different definitions of frailty.
Though origins of the term “moral injury” can be traced back to religious bioethics, most modern usage comes from a recognition of a syndrome of guilt, shame, and sense of betrayal experienced by soldiers returning from war.  One feels like they crossed a line with respect to their moral beliefs.  The spectrum of acts that can lead to moral injury is broad, ranging from killing of an enemy combatant who is shooting at the soldier (seemingly acceptable under wartime ethics), to killing of civilians or children (unacceptable).  One need to witness the killing - dropping bombs or napalm can result in moral injury as well - nor need it be killing; harassment, hazing, and assault can result in moral injury, as can bearing witness to an event.  While there is often overlap between moral injury and post-traumatic stress disorder (PTSD), they are not synonymous.  Today we talk with Shira Maguen, psychologist and Professor at UCSF and the San Francisco VA.  One of the many fascinating parts of our discussion is when we talk about the moral injury faced by healthcare workers during COVID.  I encourage you to listen to the last podcast to hear what moral injury can sound like - being asked to care for patients under far less than ideal circumstances, care that is the best under the circumstances but is not standard of care, wondering if as a result patients may have been harmed or died.   One common feature of moral injury in combat is a feeling of betrayal by superior officers who order soldiers to act in a way that contravenes their self-conception of right and wrong.  One might say we in healthcare experienced a similar betrayal of leadership that flouted the science of mask wearing, stated that doctors were billing for COVID excessively to turn a profit, and touted unproven and potentially harmful medications as miracle cures.  We also talk about treatment (and it’s more than “I wanna hold your hand,” song choice hint) Links: Moral Injury Fact Sheet:  Moral Injury in Health Care Workers:  Health and Human Services: Moral Injury for Healthcare Workers:  Gender differences in Moral Injury Moral Injury in the Wake of Coronavirus: Attending to the Psychological Impact of the Pandemic on Healthcare Workers: Moral Injury
During the winter peak in coronavirus cases, things got busy in my hospital, but nothing close to what happened in places like New York City last spring or Los Angeles this winter.  Hospitals in these places went way past their capacity, but did this strain on the system lead to worse outcomes?  Absolutely. On today’s podcast, we talk with Brian Block, lead author of a Journal of Hospital Medicine study that showed that patients with COVID-19 admitted to hospitals with larger COVID-19 patient surges had an increased odds of death.   We talk about the findings in his study, which also included some variation in the surge hospitals as well as potential reasons behind these outcomes. We’ve also invited two other guests, Denise Barchas and Sunita Puri, to describe their hospital experiences in a COVID surge.  Denise is a ICU nurse at UCSF who volunteered in New York during the spring surge of COVID cases.  Sunita is the Medical Director of Palliative Medicine at USC’s Keck Hospital & Norris Cancer Center in Los Angeles.  She is also the author of numerous books and essays, including “That Good Night: Life and Medicine in the Eleventh Hour” (if you haven't read it yet you should!)  
We know from study after study that most older adults would prefer to age in place, in their homes, with their families and embedded in their communities.  But our health system is in many ways not particularly well set up to help people age in place.  Medicare does not routinely require measurement or tracking of disability that leads many people to move out of their homes, and many interventions that support people to age in place are unfunded, underfunded, or funded by philanthropy rather than the government. Today we talk with Sarah Szanton, who created the CAPABLE multi-disciplinary model to help older adults stay at home, and Kenny Lam, who used a national study to examine the need for home-modification devices.  And we preview another of the AGS songs for the literature update - this one to the tune of “My Get up and Go” by Pete Seeger. Enjoy! -@AlexSmithMD
There are no currently approved disease modifying drugs for Alzheimer's disease, but in a couple months that may change.   In July of 2021, the FDA will consider approval of a human monoclonal antibody called Aducanumab for the treatment of Alzheimer's disease.  If approved, it will not only make this drug the defacto standard of care for Alzheimer's disease, but will create a monumental shift in the usage of other currently limited diagnostic tests, including Amyloid PET scans and other biomarkers. On today's podcast, we talk about all things Amyloid, including Aducanumab and Amyloid PET scans with Gil Rabinovici.  Dr. Rabinovici is the Edward Fein and Pearl Landrith Endowed Professor in Memory & Aging at UCSF.    I could talk to Gil all day long, but we try to fit all of these topics in this jam-packed podcast: The heterogeneity of dementia and potentially Alzheimer's disease Where are we now with disease modifying treatments for Alzheimer’s disease The Role of Amyloid PET scans and other biomarkers both now and in the future The wild story Aducanumab and the controversy surrounding its pending FDA approval
One of our earliest COVID podcasts with Jim Wright and David Grabowski a year ago addressed the early devastating impact of COVID on nursing homes.  One year ago Mike Wasserman, geriatrician and immediate past president of the California Long Term Care Association, said we’d have a quarter million deaths in long term care.  A quarter of a million deaths.  No one would publish that quote - it seemed inconceivable to many at the time.  And now, here we are, and the numbers are going to be close. In this podcast we look back on where we’ve been over the last year, where we are now, and what’s ahead. One theme that runs through the podcast is that if this level of death, confinement, and fear occured to any other population, change would have been swift.  But nursing home residents, for the most part, don’t have a voice, they’re not able to speak up, they lack power to move politicians and policy.   Mike Wasserman is a provocateur.  He is a needed voice for the nursing home residents and the nursing home staff who often are not able to speak for themselves.  He is regularly quoted in major news outlets, and was in the Washington Post about opening up nursing homes to visitation the day of our podcast.  If you don’t follow him on Twitter @Wassdoc you should! -Link to Wassmerm and Grabowski’s article in the Health Affairs blog on the need for financial transparency in nursing homes. -Link to webinar about what to do about COVID in long term care from April 2020 -@AlexSmithMD
COVID has taken a devastated toll in nursing homes.  Despite representing fewer than 5% of the total US events, at least 40% of COVID‐19–related deaths occurred in older individuals living in nursing homes.  The good news is that with the introduction of COVID vaccines in nursing homes, numbers of infections and outbreaks have plummeted.   However, only about 2/3rds of nursing home patients and only about ½ of nursing home staff have been vaccinated, largely due to hesitancy about taking the vaccine. On today's podcast we talk about vaccine hesitancy with Sarah Berry, Kimberly Johnson, and David Gifford and the lessons learned from their “town hall” intervention they did that was just published in the Journal of the American Geriatrics Society.   A couple of take-home messages for me in this study was that vaccine misinformation was rampant, many nursing staff had lingering questions they wanted answered before getting the shot, and that sharing stories and personal experiences is an important way to overcome hesitancy.     In addition to listening to the podcast, we really encourage everyone to take a look at the JAGS article as it has two great tables for anyone willing to do similar town halls.  The first is a summary of the concerns of healthcare staff.  The second is sample responses to address some of these concerns. 
Hospice may not be a great match for all of the care needs of people with dementia, but it sure does help.  And, as often happens, when patients with dementia do not decline as expected, they are too frequently discharged from hospice, an experience that Lauren Hunt and Krista Harrison refer to in an editorial in the Journal of the American Geriatrics Society (JAGS) as feeling like being “expelled.”   We talk on this week’s podcast with Elizabeth Luth, author of a study in JAGS about her study of patients in a large New York Hospice with dementia who either are discharged from hospice or live longer than 6 months.  Turns out this happens - brace yourselves - nearly 40% of the time! And we talk with Elizabeth and Lauren Hunt, who helps us contextualize these findings in the setting of larger issues around the fit of hospice for persons with dementia and hospice Medicare policy. (We will add the link to the editorial when it’s uploaded to the JAGS website). -@AlexSmithMD
The COVID pandemic brought to light many things, including how society views older adults. Louise Aronson wrote a piece in the NY Times titled “‘Covid-19 Kills Only Old People.’ Only? Why are we OK with old people dying?”.  The ageist viewpoint she was rallying against was also brought to light in a study of ageism in social media.  When looking at those tweets that were related to older adults and covid, more than 1 in 10 tweets implied that either the life of older adults was less valuable or that it downplayed the pandemic because it mostly harms older adults.  So on today's podcast we are going to talk about the initiative to “Reframe Aging” with Patricia D'Antonio.  Patricia is a geriatric pharmacist, and the Vice President of Professional Affairs at the Gerontological Society of America (GSA).   The Reframing Aging initiative is a national effort, led by GSA and supported by Archstone Foundation, uses an evidence-based approach to communicating more effectively about older adults.  There are a variety of resources available, including research reports,  an online toolkit, and free instructional videos, to help us talk about our work in geriatrics and aging. For information about the Reframing Aging Initiative, please check out their webpage www.reframingaging.org.  In particular, check out these two helpful resources on their website:  Finding the Frame: An Empirical Approach to Reframing Aging and Ageism (2017): This report explains the process and research behind the development of the evidence-based reframing aging narratives shown to improve attitudes toward aging and to boost understanding of the structural and systemic changes needed to capture the longevity dividend.  Reframing Aging: Effect of a Short-Term Framing Intervention on Implicit Measures of Age Bias (2019) This article appearing in The Journals of Gerontology: Series B describes the effect of a reframing aging intervention on implicit age bias.
So what exactly does a hospice medical director do?  Why do some choose to become hospice physicians?  What additional training is needed, if any, beyond Hospice and Palliative Medicine fellowship and boards?  Who should take the new Hospice Medical Director Certification Board Examination?  A recent study in JAGS found high rates of hospice disenrollment (“live discharge”) for people with dementia - is that a good thing or a bad thing?  Hmmm… We address these and other questions in this week’s podcast with Tommie Farrell, hospice physician in West Texas and Chair of the Hospice Medical Director Certification Board, and Kai Romero, Chief Medical Officer for Hospice By the Bay (that’s San Francisco Bay). And I get a re-do attempt at REM’s “Everybody Hurts!”. Apologies for the first attempt!   -@AlexSmithMD
Where are we with Alzheimers?  Are we about to see a revolution in how we diagnose and treat it with Amyloid PET scans and the amyloid antibody aducanumab (which is currently on FDA’s desk for approval)?  Or are we still in the same place where there is no meaningfully effective treatment?  Or is it somewhere in between, given the data that we have on comprehensive dementia care? We talk today with Jason Karlawish, a professor of medicine, medical ethics and health policy, and neurology at the University of Pennsylvania Perelman School of Medicine. In addition to being a geriatrician extraordinaire, he is the author of the new book “The Problem of Alzheimer’s: How Science, Culture, and Politics Turned a Rare Disease into a Crisis and What We Can Do About It.” In addition to talking about PET scans and new drugs like aducanumab, we discuss with Jason about the history of Alzheimers, the history of how we care for a fund caregivers, and where we go from here. So take a listen and check out Jason’s book!
Nursing home residents have been devastated by COVID.  Somewhere around 40% of deaths from COVID have been among nursing home residents, though they make up just a sliver of the US population. Prognostication among nursing home residents who have COVID is important for a host of reasons - for counseling patients and families about what to expect, for making clinical decisions, and potentially for allocation of scarce resources such as treatments. In today’s podcast, we talk with Orestis Panagiotou and Elizabeth White, the authors of a JAMA IM study that finds that physical and cognitive function are key predictors of mortality prediction for nursing home residents with COVID.  We also talk with Marlon Aliberti, who authored a commentary.   Physical and cognitive function are easy to assess measures that should be routinely captured for older adults, in nursing homes and elsewhere.  Study after study document the importance of function to risk prediction. We also have a brief debate about how vaccinations should be allocated - according to a “one size fits all” age criteria, or a prognostic model that individualizes risk.  Though I’m an advocate for prognostic models (see eprognosis.org) I’m actually on the age criteria alone side of the debate, with generous distribution among hardest hit minority communities.  And sing along to This Little Light of Mine! -@AlexSmithMD
Lesbian, gay, bisexual and transgender (LGBT) older adults have lived through a lifetime of discrimination, social stigma, prejudice, and marginalization.  Is the care that we are giving them in later life changing any of that or are we pushing them back into the closet? This is what we talk about in this week's podcast with Carey Candrian from the University of Colorado School of Medicine, and Angela Primbas from Stanford University (and future geriatrics fellow at UCSF!).   Carey has published a wonderful article in the Gerontologist titled “She’s Dying and I Can’t Say We’re Married?”: End-of-Life Care for LGBT Older Adults, in which she describes how older LGBT adults may be at higher risk for having their health care wishes ignored or disregarded, their families of choice are less likely to be included in their decision making, and they may experience increased isolation, bullying, mistreatment, or abuse, which ultimately contribute to receipt of poor-quality health care.  We talk about the scripts that we use in medicine that may hamper open discussions about sexual orientation and gender identity (SOGI) including the term “family meeting”, the need to revise our intake forms to incorporate SOGI questions, and the need for education.  We also get a chance to hear Alex Sing “The Story” whose lyrics very much speak to the subject at hand: “All of these lines across my faceTell you the story of who I amSo many stories of where I've beenAnd how I got to where I amBut these stories don't mean anythingWhen you've got no one to tell them to…” If you want to learn more, please check out these wonderful resources: LGBT Resource Center https://www.lgbtagingcenter.org LGBTQ Resource List from GLAAD: https://www.glaad.org/resourcelist National Resource Center on LGBT Aging: https://www.lgbtagingcenter.org/ Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE): https://www.sageusa.org/  
On the one hand, every year we are fortunate to have new medications that help older adults and people living with serious illness.  New treatments for lung cancer with remarkable survival outcomes come to mind, for example.   On the other hand, the tremendous growth in medications has led to an explosion of prescribing, polypharmacy, with attendant side effects and harms.   In this week's podcast, we talk with Nagham Ailabouni, a pharmacist and researcher joining us from Australia (song choice: Down Under!) about her review of major articles on medication safety and quality for older adults.  Dr. Ailabouni summarized the top four hardest hitting in a recent publication in the Journal of the American Geriatrics Society, or JAGS.  The four articles are: Older Medicare Beneficiaries Frequently Continue Medications with Limited Benefit Following Hospice Admission Prescribing of oral anticoagulants in the emergency department and subsequent long-term use by older adults with atrial fibrillation Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events: A Cluster Randomized Trial Intensification of older adults' outpatient blood pressure treatment at hospital discharge: national retrospective cohort study Dr. Ailabouni’s pet peeve medication she sees prescribed to hospice patients?  High dose metformin.  Listen to the podcast for more! -@AlexSmithMD
Most of us know we are going to die.  How often though do we actually let ourselves really internalize that understanding?   To imagine it?  To feel it?  To try to accept it? On today’s podcast we invited BJ Miller back on our podcast to talk about death using as our guide his recent NY Times editorial What Is Death?  How the pandemic is changing our understanding of mortality.  In addition to being the author of this NY Times article, BJ is a Hospice and Palliative Care doc, and the founder of Mettle Health which aims to provide personalized, holistic consultations for any patient, caregiver or clinician who need help navigating the practical, emotional and existential issues that come with serious illness and disability. We start off with BJ appropriately picking the song "Ebony Eyes" as our intro song, which is a good analogy to talking about death, as it was initially banned by the BBC from airplay as its lyrics were considered too upsetting to play on the radio.  We then go into his thoughts on how we picture our deaths and dealing with those emotions we feel when we do, how we “live with death”, and... Also check out BJ’s article that is geared towards kids/students - https://www.nytimes.com/2021/01/06/learning/how-do-you-view-death.html.  As BJ put it in an email to us: “It’s fascinating to me how they’re taking care to reach out to younger minds, further proof that the idea that no one wants to think or talk about death - especially youngsters - is bunk.
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Comments (1)

Loyal R

Thank you for this.

Mar 26th
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