Geripal-podcast

Insomnia. We’ve all had it. Lying in bed at 2 am staring at the ceiling, getting anxious every hour that you’re not falling asleep as you have a busy day coming up. Insomnia sucks.  Chronic insomnia sucks even more. For those with serious illness, sleep problems and insomnia are all too common.  Instead of reflexively jumping to melatonin or ambien, on today's podcast we talk with two sleep experts, Cathy Alessi and Brienne Miner, about a better approach to sleep problems and insomnia. We will go over epidemiology of insomnia, how these experts think about work up including which medications to avoid or discontinue, non-pharmacological treatment such as cognitive behavioral therapy for insomnia (CBT-I), and what if any is the role of pharmacological therapy in including newer agents like melatonin receptor agonists (ramelteon) and dual orexin receptor antagonists (like suvorexant).

There’s a saying, “never let a crisis go to waste.”  The pandemic was horrific in many ways.  One positive change that came about was the lifting of restrictions around the use of telemedicine.  Clinicians could care for patients across state lines, could prescribe opioids without in person visits, could bill at higher rates for telemedicine than previous to the pandemic.  Many patients benefited, not only those isolating due to covid, but also patients in rural areas, patients who are homebound, and many others.  So now that the emergency response has ended, what’s to be done?  In this podcast, Joe Rotella, Chief Medical Officer of the American Academy of Hospice and Palliative Medicine, Brook Calton, Palliative Care doc at Massachusetts General Hospital and Medical Director at Devoted Health, and Carly Zapata, Palliative Care doc at UCSF and fellowship director, talk about the importance of maintaining access to telehealth for the good of patients with serious illness.  This DEA is taking 6-months to consid

Today’s podcast is a follow up to our 2018 podcast with Randy Curtis about the Jumpstart intervention.  On that podcast he and collaborators tested a combined patient and clinician facing communication priming intervention to promote goals of care conversations.  Today we discuss a new paper in JAMA that tests a stripped down version of the clinician only facing intervention in a pragmatic randomized trial for older adults with serious illness and those 80+.  They found a difference of 4% in documented goals of care discussions.  Is 4% meaningful?  You’ll have to decide for yourself, though it likely is meaningful on a population basis.  Intriguingly, in a sub-analysis, they found a much higher rate of difference among minoritized older adults - more like 10%.  In a compelling editorial, Doug White and Sarah Anderson argue that even a 4% difference is important on a population basis, and that higher rates of difference among minoritized older adults demonstrate the potential of the intervention to address lon

You may have heard of Area Agencies on Aging, but do you really know what they do or how they do it?  What about State Departments of Aging or state master plans for aging?  Do you know how these agencies fit in with programs like Meals-on-Wheels or other nutritional support programs? Is your brain hurting yet with all these questions?  No?  Ok, what about Aging and Disability Resource Connection (ADRC) services? Well, if you are like me, you’ve probably heard of these programs but are at a loss to know exactly what they do.  On today's podcast we dive deep into how state and local governments are addressing the needs of older adults, answering all of these questions and more thanks to our three amazing guests: Susan DeMarois (the Director of California Department of Aging), Greg Olsen (the Director of the New York State Office for the Aging), and Lindsey Yourman (the Chief Geriatric Officer for the County of San Diego). It’s a fun podcast with our guest bringing in a ton of knowledge and passion for the work

I don't know 'bout religion I only know what I see And in the end when I hold their hand It's both of us set free These are the ending lyrics to Bonnie Raitt’s song “Down the Hall”, an ode to the Pastoral Care Workers who care for their fellow inmates in the hospice unit at the California Medical Facility in Vacaville, California. On last week’s podcast we interviewed the medical director and the chaplain of the prison’s hospice unit (Hospice in Prison Part 1).  This week we turn our attention to the inmates. Pastoral Care Workers are inmates who volunteer time to care for the dying who come from all around California to spend their last days, weeks or months in the prison’s hospice unit, fulfilling a mission that “no prisoner dies alone.” On today's podcast we talk with three of these Pastoral Care Workers, Jerry Judson, Jeffrey Maria, and Allan Krenitzky. We discuss with them why they decided to volunteer for the hospice unit, what a day in the life of a Pastoral Care Worker looks like, and among other th

    In the early 1990’s, California Medical Facility (CMF) created one of the nation’s first licensed hospice units inside a prison. This 17-bed unit serves inmates from all over the state who are approaching the end of their lives. A few are let out early on compassionate release.  Many are there until they die. Today’s podcast is part one of a two-part podcast where we spend a day at CMF, a medium security prison located about halfway between San Francisco and Sacramento, and the hospice unit housed inside its walls.  We start off part one by interviewing Michele DiTomas, who has been the longstanding Medical Director of the Hospice unit and currently is also the Chief Medical Executive for the Palliative care Initiative with the California Correctional Healthcare Services.  We talk about the history of the hospice unit, including how it was initially set up to care for young men dying of AIDS, but now cares for a very different demographic – the rapidly aging prison population.  We also talk about the el

Artificial Intelligence, or AI, has tremendous potential.  We talk on this podcast about potential uses of AI in geriatrics and palliative care with natural language processing guru Charlotta Lindvall from DFCI, bioethicists and internist Matt DeCamp from University of Colorado, and prognosis wizard Sei Lee from UCSF. Social companions to address the epidemic of loneliness among older adults Augmenting ability of clinicians by taking notes Searching the electronic health record for data Predicting mortality and other outcomes We talk also about the pitfalls of AI, including: Recapitulation bias by race and ethnicity, and other factors, exacerbating disparities Confidentiality concerns: do those social companions also monitor older adults for falls? 24/7?   Hallucinations, or when the AI lies or bullshits, then denies it When the AI approaches sentience, is it ethical to unplug it? I’m sure this is a subject we will return to, given the rapid progress on AI. Enjoy! -@AlexSmithMD     Links

Diabetes is common.  When I’m on nursing home call, the most common page I receive is for a blood sugar value.  When I’m on palliative care consults and attending in our hospice unit we have to counsel patients about deprescribing and de-intensifying diabetes medications.  Given how frequent monitoring and prescribing issues arise in the care of patients with diabetes in late life, including the end of life, Eric and I were excited when Tamryn Gray emailed us requesting a follow up podcast on this issue.  Our last podcast was with Laura Petrillo in 2018 - 5 years ago seems ancient history - though many of the points still apply today (e.g. Goldilocks zone).  And yet we’re also in a different place in diabetes monitoring and management. To answer our questions, we invited Nadine Carter, a current hospice and palliative care fellow at Dartmouth who previously worked as an NP in outpatient endocrinology, and Alex Lee, an epidemiologist at UCSF interested in diabetes monitoring and management in the nursing home.

Our guests today present an important rejoinder to the argument that we should refocus away from advance care planning (ACP).  Sarah Nouri, Hillary Lum, and LJ Van Scoy argue that diverse communities are asking for ACP.  Sarah Nouri gives an example from her work in the LGBTQ+ community of a trans woman who was buried as a man because existing laws/rules did not protect her wishes.  Others cited the call from communities to meet them where they are - be they senior centers, Black-owned businesses, or churches (we have a podcast planned in the fall with Fayron Epps and Karen Moss on the church setting).  It does seem that if communities, particularly historically marginalized communities, are interested in ACP, that fact should carry some weight in how resources are allocated to research and health care financing.  We additionally have a debate/discussion about which outcomes of ACP matter most, including Terri Fried’s commentary in JAGS that caregiver outcomes matter more than goal concordant care (the “holy

Hot off the press is a brand spanking new updated 2023 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.  The Beers Criteria is one of the most frequently cited reference tools in geriatrics, detailing potentially inappropriate medications to prescribe to older people. We’ve invited two members who helped update the criteria including Todd Semla and Mike Steinman.   We discuss a little history of the Beers criteria, including the original Beers Criteria that was published by the late Dr. Mark Beers, and how it has evolved over the last three decades.  We also discuss specifics about how to use and not use the Beers Criteria, how medications are selected for inclusion in the criteria, and specifics about certain medications. And of course, take a deep dive by downloading the JAGS paper on the updated Beers Criteria or any of the great links from AGS including the: 2023 AGS Beers Criteria App  Beers pocket card  

We’ve had multiple GeriPal episodes about treatments for dementia, including aducanumab (here, here, and here) and lecanemab (here).  As today’s guest, Kristine Yaffe notes, part of the reason for that emphasis is that in the US we prioritize treatment, whereas other countries are ahead of us in prioritizing prevention.  Deb Barnes and Kristine Yaffe published a landmark paper in Lancet Neurology finding that up to half of dementia risk is due to modifiable factors.  If we focused on prevention, from a public health standpoint, we would achieve far more than spending millions billions on treatment. Today we talk about steps we can and should take to reduce the risk of dementia, including: Education and cognitive games (I reveal my embarrassingly poor average time on the NYT mini cross word) Physical activity Sleep Depression Smoking Social isolation Blood pressure control (listen also to our podcast on Sprint Mind with Jeff Williamson) We also delve into an exciting new trial Kristine led w

I haven’t worked with many adolescents and young adults (AYA, roughly teens to twenties).  But when I have, I find that they’re often some of the hardest patients to care for.  Why?  We talk about why it’s so hard with Abby Rosenberg (chief of PC at DFCI and Boston Childrens), Nick Purol (clinical social worker at DFCI and Boston Childrens), Daniel Eison (pediatric PC doc and co-host of PediPal).  We are grateful to Andrea Thach (PC doc at Sutter East Bay) for bringing this topic to our attention and for asking questions as a guest host.  Here are just a few of the explanations for why it’s so hard: They are closer in age to some of us (younger clinicians).  Countertransference hits hard. There’s an in-between space between adolescence and adulthood - and there’s something that we identify with in that in-between space, tugging at our heart strings Everyone has been a teenager.  Everyone has lived through their early 20s.  Every member of the interdisciplinary team.  Adolescence and young adulthood is a

We have a special extra podcast this week.  During the last AAHPM - HPNA meeting in Montréal, we went around asking attendees what one thing that they are most worried about and one thing they are most hopeful for when thinking about the future of our field.  We couldn’t fit everyone’s responses in but came up with the big themes for questions and edited them into this weeks podcast / YouTube video.  Eric and Alex   DISCLAIMER While we filmed in Montreal during the Annual Assembly, all opinions expressed in this podcast are independent of AAHPM and HPNA, or the Annual Assembly.  Furthermore, direction to external websites is not an endorsement from AAHPM or HPNA, or the Annual Assembly.  Palliative Care the Next Generation: How the Service May Grow and Evolve https://hospicenews.com/2023/04/14/palliative-care-the-next-generation-how-the-service-may-grow-and-evolve/ AccentCare, a portfolio company of private equity firm Advent International, is another example. The company has expanded its palliative care s

In 1990 11% of homeless persons were older than 50.  Today half are over age 50.  Today we talk with Margot Kushel about how we got here, including: That sense of powerlessness as a clinician when you “fix up” a patient in the hospital, only to discharge them to the street knowing things will fall apart. Chronic vs acute homelessness What is the major driver of homelessness in general?   What is the major driver of the increase in older homeless persons? Why do we say “over 50” is “older” for homeless persons, why not 65?  To what extent is the rise of tech in San Francisco to blame for our local rise in homelessness?  What are the structural factors and individual factors that contribute to homelessness? How has the history of redlining and the federal tax subsidy of wealthy (mostly white) people in the form of a mortgage interest deduction contributed to racial inequalities in homelessness? What can we do about it?  What are the highest yield interventions and policy changes? What should

Social connections impact our health in profound ways, whether it is the support we receive from family and friends in navigating serious illness, the joy from shared social activities, or connecting with our community. Experiencing social isolation, the objective lack of contact with friends, family, or the community, or loneliness, the subjective feeling of lacking companionship or feeling left out, may be signs that our overall social life is struggling. But, should we as clinicians care about the social lives of our patients? Are there meaningful ways of assessing loneliness and social isolation in clinical settings and connecting patients with interventions? How can public health and policy experts address these needs, particularly in light of the COVID-19 pandemic which turned our social lives upside down? On today today’s podcast, we are joined by guest host and UCSF geriatrician Ashwin Kotwal as we welcome three renowned scholars in the field: 1) Dr. Julianne Holt-Lunstad, Professor of Psychology and

Do we need an RCT to establish the worth of chaplaincy? Einstein once said, “Everything that can be counted does not necessarily count; everything that counts cannot necessarily be counted.” A friend of GeriPal, and prior guest, Guy Micco commented today that we need an RCT for chaplaincy is like the idea that the humanities need to justify their value in medical training: “It’s like being told to measure the taste of orange juice with a ruler.” On the other hand, all of our guests agree that chaplains are often the most vulnerable to being cut from hospital and health system budgets.  These studies are important. Today we have a star-studded lineup, including Lexy Torke of Indiana University, who discusses her RCT of a chaplaincy intervention for surrogates of patients in the ICU, published in JPSM and plenary presentation at AAHPM/HPNA.  To provide context, we are joined by Karen Steinhauser, a social scientist at Duke who has been studying spirituality for years (and published one of the most cited papers

Two weeks ago on the GeriPal podcast we talked about why and how to write for the general public.  This week we’ve invited three guests to share their stories about storytelling that’s written for healthcare providers. The first guest is Liz Salmi.  Liz wrote a fabulous perspectives piece in the NEJM titled “Deciding on My Dimples” which talks about her experience as a patient doing shared decision making during neurosurgery for resection of an astrocytoma.   In addition to this being a fascinating story, Liz brings in a great perspective as a patient, advocate, researcher, and a punk rocker. Our second guest is a recurring star of GeriPal, Anne Kelly.  She just published an essay for JAMA Piece of My Mind titled “The Last Visit”.  In this piece Anne describes her experience with the expressions of love she and her mother shared in the last days of her mothers life. Lastly, but certainly not least, we’ve invited Preeti Malani.  Preeti is the editor for JAMA’s Piece of My Mind section.  We’ve asked Preeti to

In November of 2022, Ava Kofman published a piece in the New Yorker titled “How Hospice Became a For-Profit Hustle.”  Some viewed this piece as an affront to the amazing work hospice does for those approaching the end of their lives by cherry picking stories of a few bad actors to paint hospice is a bad light. For others, this piece, while painful to read, gave voice to what they have been feeling over the last decade - hospice has in some ways lost its way in a quest of promoting profit over care. On today’s podcast, live from the American Academy of Hospice and Palliative Medicine Annual Meeting, we invite two thought leaders in the field, Ira Byock and Joseph Shega, to discuss among other things: Is hospice losing its way? Is there a difference between for-profit and not-for-profit when it comes to quality of care? What is our role as hospice and palliative care providers in advocating for high-quality hospice care? If you are interested in signing the position statement “Core Roles and Responsibilitie

So you want to write a book. So you want to write a book!  So…you want to write a book?!? Today we talk with two geriatricians: Rosanne Leipzig, author of Honest Aging: An Insider's Guide to the Second Half of Life; and Louise Aronson, author of Elderhood: Redefining Aging, Transforming Medicine, and Reimagining Life. (You can hear our prior podcast on Louise’s book here).  We talk with them about writing for the lay public, including: Why write a book for the lay public? Why write about aging? Was there pushback from publishers (hint: hell yes) What terms to use to describe the “old age” time period? How did they start writing a book? How do you find time to write and also be doctors and academic professors? Revisions and working with editors Writing an Op Ed - how to start, what to write, where to send it  TheOpEdProject as a resource for learning more We look forward to the books and op-eds our listeners will write!   In all seriousness, you don’t actually have to want to write a book to

Psychedelics are having a moment.  Enthusiasm is brimming.  Legalization is moving forward in several states, following the lead of Oregon and Colorado.  FDA is considering approval, shifting away from Schedule I restrictions, paving the way for use in clinical practice.  Potential use in palliative care, chronic pain, and for mood disorders is tantalizing. Early data on efficacy in patients with anxiety and demoralization are promising.  Research is exploding.  Two of our guests today, Stacy Fischer and Brian Anderson, are involved in large multicenter trials of psychedelics for patients with advanced cancer (Fischer) or life-limiting illness (Anderson).  Theora Cimino conducted an observational study (publication in the works) of marginally housed/homeless persons many of whom had experience with psychedelics. And yet there are reasons for caution.  In our prior podcast with Ira Byock on psychedelics in 2019 we talked primarily about the potential of psychedelics.  Today we largely focus on reasons for ca