GeriPal

  Cannabis use by older adults has increased substantially over the last decade, a trend that has paralleled the legalization of its use for medical and recreational purposes. In that same time, there has been a decreased perceived risk associated with cannabis use in older adults as noted in  a recent study published in JAGS . On today’s podcast we talk with Drs. Bree Johnston and Ben Han about what the health care providers role is in cannabinoid prescribing and advising when caring for older adults. We try to cover a lot in this podcast, including some of these topics: Epidemiology of cannabis used by older adults  ( including aspects of the JAGS study ) The basic pharmacology and dosing of cannabinoids The latest evidence for the efficacy of cannabis Specific risks and side effects that providers should be aware about, and how we should monitor patients using cannabinoid products Drug interactions we should be aware about

  In a new study in JAGS , Matthew Growdon found that the average number of medications people with dementia took in the outpatient setting was eight, compared to 3 for people without dementia.   In another study in JAGS , Anna Parks found that among older adults with atrial fibrillation, less than 10% of disability could be explained by stroke over an almost 8 year time period.  She also talked about the need for a new framework for anti-coagulation decisions for patients in the last 6 months of life, based on an article she authored in JAMA Internal Medicine with Ken Covinsky. In today’s podcast we talk with Matthew and Anna, joined by co-author Mike Steinman, to talk about polypharmacy, deprescribing, where we are and what we need to do to stop this freight train of ever more medications for older adults and those living with serious illness. We start by addressing the root cause of the problem.  Clinicians want to “do something” to help their patients.  And one thing we know how t

  Older adults often turn to institutional settings like nursing homes when they need more help than they can get at home. However, since the 1970s, there has been a program that allows older adults to receive nursing home-level care outside of nursing homes. That model of care is known as the Program of All-inclusive Care for the Elderly, or PACE. On today’s podcast, we discuss PACE with two leaders in the PACE community, Dan Drake and Jay Luxenberg. Dan is the President and CEO of Trinity Health PACE, the second largest provider of PACE in the country, and Jay is the Chief Medical Officer of On Lok, the very first PACE demonstration site in the nation. We talk with Dan and Jay about all things PACE, including: What is PACE and what is included in it that makes it able to care for nursing home level care in peoples homes? How is PACE paid for, what does it need to cover, and who is eligible? How did PACE start and what’s the evidence that it works? What are the challenges to PACE im

  We have made remarkable progress in reducing the use of feeding tubes for patients with advanced dementia.  This has been due to the leadership of people like Susan Mitchell and Joan Teno, among others.  One might hope that this reduction in use of feeding tubes has been in part due to advance care planning discussions that helped align care and treatment with patients goals.  How then, do we explain the concerning findings in a pair of recent papers demonstrating high rates of mechanical ventilation among patients with dementia?  In today’s podcast, we talk with Rashmi Sharma, who in JAGS found that rates of mechanical ventilation rose from 4% to 12% among whites with advanced dementia and 9% to 22% among blacks between 2001 and 2014.  One in five blacks with advanced dementia admitted from a nursing home received mechanical ventilation.  That’s startling.   And Zhi Jia found in a Medicare sample that Asians were more likely to receive mechanical ventilation than whites, and disp

  While palliative care most traditionally grew up with a strong association with cancer care and end-of-life care, more and more evidence is coming out about how to integrate palliative care into a variety of serious illnesses from heart failure to chronic lung conditions.  Another emerging field is the integration of neurology and palliative care, something that has been coined as “neuropalliative care.”  We had Benzi on a previous GeriPal podcast to talk about palliative care in Parkinson's disease . On this week’s podcast we go much deeper into the field of neuropalliative care by inviting leaders of the new field and in the International Neuropalliative Care Society (INPCS) , Benzi Kluger, Edward Richfield, and Christine Ritchie. INPCS connects clinicians, researchers, interdisciplinary team members, people living with neurological illness, family members, and advocates at the intersection of neurology and palliative care. In addition to talking about why INPCS was develope

  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 nei

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 tem

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

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

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 conti

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 as shown below: