Geripal-podcast

Acute Care for Elders (ACE Units) have been around for over a quarter of a century. Randomized trials of ACE units date back to 1996 when Seth Landefeld and colleagues published a study in NEJM showing that they improve basic activities of daily living at discharge and can reduce the frequency of discharge to long-term care institutions.  But if ACE units are so great, why do so few hospitals have them? On today's podcast we talk about ACE units with geriatricians Kellie Flood and Stephanie Rogers.  They recently published a paper in JAGS looking at the current landscape of ACE units in the US. In the podcast we go over these issues and more: What are ACE units and what structural elements go into them (see the picture below for a nice summary)?  Which patients are eligible to go to an ACE unit? What are the benefits of an ACE unit? If ACE units are so great, why are they not so common?  What does the future look like for ACE units and how does it differ (if at all) from Age Friendly Health Systems? If you

Today’s podcast may be a stretch for our listeners.  Please stick with us.  No matter what your position on medical aid in dying (I’m ambivalent) or abortion (I’m pro-choice), this is a bioethics podcast, and I hope that we can all agree that the ethical issues at stake deserve a critical re-think.  All three of today’s guests are well established bioethicists.   Let me start by quote/paraphrasing one of today’s guests, Mara Buchbinder, who puts her finger on the issue we talk about today:   “Typically when we think about conscience in medical ethics we think about it in terms of  a negative claim of conscience, where a clinician refuses (or objects) to provide care.  But what we know from my research and those of others, people also articulate a positive claim of conscience: they feel compelled to provide a service - whether it’s abortion provision or medical aid in dying -  because of a deeply held conviction that this is the right thing to do.”   I’ll continue by quoting Lisa Harris, who wrote in the NEJM

From discussing “taking away the keys to the car” for a cognitively impaired older adult to decisions to limit life sustaining treatments at the end of life, conflict and disagreement permeate everything that we do in medicine.  How well though are we taught to handle conflict and disagreement?  I’d say not well as I don’t think I’ve ever received a formal talk on the issue. On today’s podcast we take a deep dive into the topic of Negotiation and Dispute Resolution training with Lee Lindquist and Alaine Murawski.   We’ve had Lee on before to talk about her Plan your Lifespan project.  We invited her back along with Alaine to talk about their work around negotiation training, including their work on NegotiAge, an online, AI based training intervention designed to teach negotiation skills to caregivers. For an ever deeper dive into the subject of negotiation and dispute resolution, check out the following links (and for any caregivers interested in participating in the randomized clinical trial of the NegotiAge

We’ve talked at length on prior podcasts about the failures of aducnumab, Biogen, and the FDA’s decision to approve it.   But wait, there’s a shiny new anti-amyloid drug, lecanemab!  (No it’s not just the French version of Aducanumab).   In an article in the NEJM (a published article this time, wonder of wonders!) lecanemab was shown to slow the rate of cognitive decline by 0.45 points on an 18 point cognitive scale compared to placebo.  Wow!  Wow?  Wait, what?   On today’s podcast we talk with Jason Karlawish, who we’ve had on previously talking about his book The Problem of Alzheimer’s and with Aaron Kesselhim, to discuss FDA approval of Aducanumab, as well as frequent guest and host Ken Covinsky.   They debate today’s central question: is it time for geriatricians to get on board with lecanemab?  Along the way we address: Is this degree of slowed cognitive decline meaningful to patients or care partners? What about the burdens, risks, and harms? Every 2 week visits for infusions, regular monitoring for

Eric and I weren’t sure what to call this podcast  - storytelling and medicine? Narrative medicine?  We discussed it with today’s guests Heather Coats, palliative care NP-scientist, and Thor Ringler, poet.  It wasn’t until the end that the best term emerged - storycatching.  Because that really is what this is about.  Clinicians “catching” patient life stories.    What’s in a story?  Well, as we learned, everything.  Our patients aren’t “the 76 year old with heart failure in room 202,” as Heather Coats astutely noted.  They’re people, and what makes us people if not our life’s stories?  Our loves, our triumphs, our failures, our work, our families.   Thor Ringler helped start the My Life My Story project at the Madison VA in Wisconsin.  It’s since spread to over 70 VAs.  VA “gets” the importance of storytelling in medicine, without the need for reams of research to back it up.  As Thor notes, capturing patient stories has face validity as positively impacting the patients who share their stories and have them

What would it take to transform dementia care?  While a lot of hope and money is being put into new monoclonal amyloid antibodies like lecanemab, the evidence is that while they are great in reducing amyloid in the brain for those with early Alzheimer’s disease, the effects are at best modest in slowing down the decline in cognition and function (more to be said on that in an upcoming podcast). In order to truly transform dementia care we need to think much broader than the amyloid hypothesis.  So on today's podcast we invite four brilliant individuals to talk about their perspective on how to change how we as a society and health care system partner with individuals with dementia. These amazing guests include: Susan McFadden, PhD, retired professor emerita (psychology and gerontology) at the University of Wisconsin, Oshkosh, an experienced researcher and practitioner in the field of dementia, and creator of the Fox Valley Memory Project. Her most recent book is Dementia Friendly Communities: why we need th

Assisted Living Communities (no longer preferable to call them Assisted Living Facilities, as we learned on the podcast) are…what, exactly?  That’s the central question on today’s podcast.  The problem is the tremendous heterogeneity in services offered and quality of care.  If you’ve seen one Assisted Living Community you’ve seen one Assisted Living Community.  To address this question, we talk with Sheryl Zimmerman, author of a recent study in JAMA Network Open that used a Delphi process to ascertain what experts thought were the essential services an Assisted Living Community should offer to residents.  The experts settled on a range of key services, from more palliative care focused (e.g. end of life care and advance care planning) to more geriatrics focused (e.g. toenail trimming) to things in between (e.g. staff training in person centered care).  The problem, as Kenny Lam and Ken Covinsky, authors of an accompanying editorial, state on the podcast: there is an inherent tension between the motives of

Health care professionals are human, and as humans we experience loss both in and out of work.  You’d imagine though that our professional expertise and experiences in helping patients and families cope with loss and grief would be helpful in managing our own personal losses.  Turns out, it’s maybe not. That was the lesson I learned from reading a new book edited by Matt Loscalzo along with Marshall Forstein called “Loss and Grief: Personal Stories of Doctors and Other Healthcare Professionals”.  It’s a collection of personal stories of a small number of health professionals, including Craig Blinderman and Susan Block, who have been struck by personal illness and loss. On today’s podcast, we’ve invited Matt Loscalzo and Craig Blinderman to talk about their book and the process they used to create these stories, which all stood out for their openness in talking about things that we as healthcare professionals often keep so very private.   We also brought in Vickie Leff to talk about the work she does with Well

Dr. Faith Fitzgerald once quipped that prognostic modeling is the “punctilious quantification of the amorphous.”  She has a point.  Prognosis is inherently uncertain.  As Alex Lee says on our podcast today, all prognostic models will be wrong (in some circumstances and for some patients); our job is to make prognostic models that are clinically useful.  As Sei Lee notes, the argument for developing prognostic models has won the day, and we increasingly use prognostic scores in clinical decision making.  What makes prognostic models for mortality different from models used for anticoagulation or risk of renal injury?  James Deardorff replies that there is something inherently different about predicting mortality.  Death is different.  For some reason clinicians who might be perfectly comfortable using an anticoagulation risk calculator might be skeptical of a mortality risk calculator (see this recent terrific JAMA IM study from Nancy Shoenborn on this issue).  And yet, the only thing that may be worse than a

The Department of Health and Human Services helps to guide billions of dollars in investment and direction in research, policy, and health care. The Assistant Secretary for Planning and Evaluation (ASPE), within the HHS, is the principal advisor to the Secretary of HHS on health policy, ranging from legislation to strategic planning to research. How does this relate to aging policy and research? How does coordination occur between the federal, state and local level in aging health policies? And, who within ASPE guides aging policy and connects policy to every day health challenges experienced by patients and clinicians?    On today today’s podcast, we are joined by guest host and UCSF geriatrician Ashwin Kotwal as we welcome Dr. Tisamarie Sherry (Deputy Assistant Secretary for the Office of Behavioral Health, Disability, and Aging Policy (BHDAP), appointed by the Biden administration). This office is tasked with providing aging policy research and recommendations within ASPE, including long term care and the

When I’m on service these days there is inevitably a moment when a resident says “Patient so-and-so is on X” - and I have absolutely no idea what X is.  Modern subspecialist practice advances at such a remarkably rapid pace, it can be hard to keep up. In this context, we’re excited to hear from infectious disease experts and nephrologists about updates in the care of older adults.  Sonali Advani and Lona Mody talk about their recent JAGS article highlighting three recent articles that every clinician caring for older adults should be aware of in the treatment of infectious diseases (hint: I’ve never finished a course of antibiotics, and maybe your patients don’t need that full course either).  Devika Nair and Rasheeda Hall talk about their JAGS article highlighting updates from nephrology in the care of older adults, including a link to this new eGFR calculator that does NOT include race.  We have a discussion about the decision to remove race, a social construct, from clinical risk calculators (though I’m

Earlier this year palliative care was the correct response to the following clue on the game show Jeopardy: From a Latin word for “to cloak”, it’s the type of care given to seriously ill patients to provide comfort without curing What struck me most was not that palliative care was a question, nor that it made it seem that palliative care isn’t provided alongside care directed at curing, nor was it that hospice was the first buzzed in response, but it was that palliative care was the $2000 question in the Double Jeopardy round!  The fact that palliative care was the hardest of questions told me that we have a massive messaging problem in our field. So what do we do about it?  Well, on today’s podcast we talk with Marian Grant and Tony Back, who with support form the John A Hartford Foundation and the Cambia Health Foundation, have done a deep dive into the research on layperson perceptions of palliative care, hospice, and advance care planning.  The result is a new toolkit to help us fix our messaging &

Have you had difficulty managing a particular type of cancer pain?  For me it’s radiation induced mucositis/esophagitis.  Janet Abrahm is one of the world’s experts in pain and symptom management for patients with cancer joins us to talk about (among other things): Ketamine for hyperalgesia and allodynia, how to treat dissociative side effects Lidocaine: worth the hype? Strengths and weaknesses of buprenorphine for cancer pain Fentanyl patch: often missed issues Hypnosis: uses and how to get training via the American Society of Clinical Hypnosis Janet is the author of the 4th edition of the book Comprehensive Guide to Supportive and Palliative Care for Patients with Cancer, along with co-authors Molly Collins and BR Daubman. This book is terrific, truly comprehensive, and is a go to resource for when I’m “stuck” taking care of patients with cancer.   And yes, this would be a great one for CME.  Eric and I are working on it…maybe by 2023?   Finally, can you believe this is our 236th podcast and, I believe,

Have you ever had that moment when talking to a patient, when you realized that the phrase you just uttered, which you’ve uttered a hundred times before, came out rote and scripted?  Maybe some phrase you learned from a prominent podcast or VitalTalk?  And in response, the family or patient looked at you like you were from another planet?  Yeah, I’ve been there too. Josh Briscoe, our guests on today’s podcast, argues that you’ve entered the Uncanny Valley.  In robotics, the Uncanny Valley is that strange almost-human-but-not-quite territory in which humanoid appearing robots repulse us with their close yet still “off” appearance.  Coming off as rote and scripted during a serious illness conversation can have a similar off-putting impact on patients and families.  Today we talk with Josh about how to anticipate and avoid the uncanny valley.  And talk about times when we’ve fallen into it.   Key message: Listen to the music.  All the time. ;) Links: -Uncanny Valley post on Josh’s fantastic substack Notes from a

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of valvular heart disease for patients with severe aortic stenosis, a condition that affects one in ten adults older than the age of 80.  The rates of TAVR have also risen dramatically in the last decade. In 2019, the number of TAVRs exceeded surgical aortic valve replacement (SAVR) in the US for the first time.    On today’s podcast we talk with two amazing cardiologists and researchers - Gwen Bernacki and Ashok Krishnaswami - about TAVRs in the elderly, including what it is, who gets it, and what the outcomes and complications look like after the procedure.    We also discuss Gwen and Ashok’s mixed-method study in the Journal of the American Geriatrics Society (JAGS) where they interviewed TAVR coordinators across California and Washington State about how code status is managed within their programs, and compared programs according to their policies to assess differences in outcomes.  What they found was fascinating: Most progr

Holly Prigerson recalls the moments in which she started investigating prolonged grief disorder.  She recalls being “a social scientist [Holly] in room a full of psychiatrists,” who recognized a diagnostic gap in people experiencing profound and potentially harmful grief far after the death of a loved one.  This led her on a remarkable journey.  Holly has accumulated mountains of evidence for the diagnosis of prolonged grief disorder as a specific condition primarily notable for a yearning over a year after the death.  Prolonged grief is associated with increased risk of suicide and other negative health outcomes.  This accumulation of data over her career led ultimately to the inclusion of Prolonged Grief Disorder first in the ICD, then in the DSM-V.   And yet, despite mountains of evidence, Holly has taken a tremendous amount of heat for this work.  “Everyone has experienced grief, which makes everyone the expert.”  Today we offer Holly a chance to answer her critics, including assertions that: Grief i

In day-to-day practice, It’s hard to imagine providing excellent hospice or palliative care services without access to a team social worker.  Social workers augment a team’s ability to provide whole-person care, often aiding to identify and meaningfully address the wide variety of challenges and unmet needs faced by individuals and families facing serious illness. But are we really taking full advantage of ALL social workers have to offer our field? On today’s podcast, we are talking with Barbara Jones – a national hospice and palliative care social work leader whose many accolades include being a founding member of the Social Work in Hospice and Palliative Care Network (SWHPN), a Professor of Direct Social Work Practice and Associate Dean for Health Affairs at the Steve Hicks School of Social Work at UT Austin. Barbara highlights social workers’ inherent leadership qualities and tasks us to consider whether our own team and organizational structures are allowing for optimal social work engagement and influen

Two major shifts are transforming the landscape of hospice. First, private equity firms are gobbling up hospices.  As Melissa Aldridge, a health services researcher and former banker explains, we should be very concerned.  Private equity firms try to turn companies as profitable as possible within 3-5 years.  Thus, they have little in the way of long term vision for hospices, instead focused on cutting costs and maximizing profits.  Second, Hospice was originally designed for patients with advanced cancer, but the fastest growing admitting diagnosis is dementia.  People with dementia make up about half of hospice admissions.  And yet, we know little about the clinical experience of people with dementia in hospice.  Krista Harrison found, to her surprise, that caregivers of people with dementia who died rated hospice as well as similar patients without dementia who died on hospice.  And yet, disenrollment from hospice, either due to patient/family revoking the benefit or stabilization of illness (extended pr

Today we have the honor of interviewing Susan Block, MD, one of the pioneering leaders in the fields of palliative care, particularly psychosocial aspects of palliative care.  Susan led the Project on Death in America’s Faculty Scholars program, used her dual training in internal medicine and psychiatry to shine a light on psychosocial aspects of palliative care, and founded the Department of Psychosocial Care at the Dana Farber Cancer Institute and Brigham and Women’s Hospital.   We talk with Susan about how far the field has come, from early days when the attending physician would decide which patients were DNR and place a black “no code” dot in the chart.  We talk about challenges facing the field today.  In particular, she reminds us that when we think about the most challenging of our patient encounters, they almost always involve a complex psychosocial dynamic, and this has received far less attention than communication and symptom management issues.   We delighted to be joined by Brian Block, pulmonar

A year ago we did our first “Deprescribing Super Special”.  Today we are coming back for more (or less given the content), talking about the following articles with their lead authors: First up, we talk with Ariel Green about her article in JAMA Network on preferred phrases a clinician may use to explain why they should reduce or stop the medication.   My take home from this is that while the most preferred explanation for deprescribing statins and sedative-hypnotics is one focused on the risk of side effects, we also need to individualize it to the patient and the medication that they are taking. Next up, we chat with Liz Bayliss about her JAMA IM article that studied whether increasing awareness about deprescribing prior to primary care visits can reduce the use of potentially inappropriate long-term medications for individuals with cognitive impairment.  While the study was largely negative, it does bring up important implications about how we should think about deprescribing in older adults (added bonus