GeriPal

An age friendly health system is one in which everyone, from the doctors to the nurses to the people cleaning the rooms are aware of the unique needs of older adults.  These needs are categorized around the 4 M’s - Medication, Mentation, Mobility, and What Matters Most.   But we cannot achieve the ideal of an age friendly health system without, well, changing systems.  In this week’s podcast, we talk with Julia Adler- Milstein about the ways in which the electronic health records in hospitals and skilled nursing facilities are set up (or not set up) to document and track the 4 M’s.  We also talk with Stephanie Rogers about her work toward creating an age friendly health system at UCSF. Enjoy! -@AlexSmithMD

Many GeriPal readers may be familiar with Eric's 2011 JAMA article " Finances in the older patient with cognitive impairment. " But many of you may not be. Despite Eric and co-authors' groundbreaking JAMA piece, there is a surprising absence of literature on health care providers' role in assessing their patients' ability to manage their finances and non-health affairs. There is a parallel void on how (and whether) health care providers should counsel patients about planning for incapacity to manage financial affairs. We are conducting an informal survey of health care providers to glean preliminary information about whether providers engage with patients about financial planning. We would greatly appreciate your interest and time to answer this brief (6 question) anonymous survey. The survey should take less than one minute to complete. The survey will be open until November 20th. https://uchastings.co1.qualtrics.com/jfe/form/SV_bl5Fm0CauFxLk6V Thank you very

  The Emergency Department (ED) is a hard place to have serious illness discussions, whether it be goals of care or code status discussions, or whether or not to consider intubation for a seriously ill patient.  Emergency physicians often don't have the time for in-depth discussions, nor have been trained on how to do so.  There often is limited information about the patient, their functional status, or their prognosis.  These are some of the most challenging and some of the most important conversations in medicine, as 75% of older adults visit the ED during the last 6 months of life ( data thanks to this Alex Smith publication in Health Affairs! )  So how do we have these urgent conversations in a time of crisis to ensure that patients receive care that aligns with their goals?  We have Naomi George, researcher and ED physician extraordinaire from the University of New Mexico, and Kai Romero from UCSF and Hospice by the Bay to help answer this question. Naomi discuss her practical

In this week's podcast we talk with Kieran Quinn, author of a systematic review and meta-analysis of palliative care for non-cancer illness , published in JAMA.  We also talk with Krista Harrison, first author of an accompanying editorial .   JAMA editors cut out some of my favorite parts of Krista's editorial , possibly because they were more like a blog post than a JAMA editorial.  (I was senior author; go figure how it ended up reading like a blog post!) So here is the submitted introduction, unedited: "As with many people’s best ideas, inspiration struck in the shower. Dr. Balfour Mount, a urologic-cancer surgeon at the Royal Victoria Hospital in Quebec, Canada, needed a name to differentiate a new hospital-based service he created for people with serious life-threatening illness from Dr. Cicely Saunders’ English hospice programs. Dr. Mount coined the term “palliative care” to connote the core goals of the service: to improve quality of life and to mitigate sources of

There are a lot of large numbers that involve heart failure, starting with the sheer number of patients diagnosed (6.5 million and counting), to the cost of their care (~$70 billion by 2030), to the amount of money invested by the NIH into research ($1 billion annually). But the smaller numbers deserve attention too - 50% of patients die within 5 years of their diagnosis, those older than 65 in the hospital die even sooner at ~2.1 years thereafter, the median survival on hospice since hospital discharge is 11 days, and <10% of patients with heart failure receive a palliative care consult. So what can we do to bridge the gap between heart failure and palliative care? As a current palliative care fellow and former hospitalist on UCSF's Advanced Heart Failure service, I have a strong interest in this question. This week I was lucky to have Alex and Eric let me join in interviewing Haider Warraich, Associate Director of Heart Failure at the Boston Veterans Affairs Hospital and Assoc

On todays podcast, we have Lauren Moo, a cognitive behavioral neurologist who has been doing video visits well before the COVID-19 pandemic to decrease the need for travel and to decrease the agitation in older adults with dementia that commonly occur when a clinic visits disrupts the usual routine.   Now with COVID among us, Lauren talks to us about her recently published JAGS article titled " Home Video Visits: 2‐D View of the Geriatric 5‐M s."   In the article and on the podcast, Lauren walks us through assessing the Geriatric 5M framework : mind, mobility, medications, multicomplexity, and what matters most.   Lauren gets very practical with us about how she does things like a cognitive assessments in this new medium of telemedicine.   One thing I'd like to note that we didn't talk about in our podcast, but Joe Ouslander wrote in the accompanying editors note to Lauren's article: "I recommend that you discourage patients and families from using the backgr

Last month we published a podcast with Sean Morrison that garnered a great deal of attention, in which Sean Morrison argued that Advance Care Planning is an idea that is “clear, simple, and wrong.” This week, we have a fresh updated counterpoint from Rebecca Sudore and Ryan McMahan.  These two published a paper this week in the Journal of the American Geriatrics Society , or JAGS, that argues that the field of advance care planning has come a long way.  Early studies of advance care planning evaluated it with advance directives, and studies of advance directives showed little to no difference.  However, In their review they find recent (since 2010) high quality trials demonstrate the potential of advance care planning by using modern conceptions of advance care planning as a longitudinal conversation to help surrogates prepare for in the moment decision making.  These studies evaluated a broader (and more fitting) range of outcomes than prior work, including surrogate preparedness.

  By: Matthew Gonzales and Eric Widera Many of us in the GeriPal community are dubious about the benefits of using thickened liquids for dysphagia. If you haven’t read prior posts on this, head on over to see a great analysis illustrating the limited evidence . (Side note – if you need a pick me up for these days of 2020, be sure you revisit this video of the GeriPal team trying thickened liquids for the #ThickenedLiquidChallenge ).  Despite the lack of robust data, dysphagia-based diets with thickened liquids remain a standard of care. The hope is that it is easier for people to coordinate swallowing with a thick liquid versus a thin liquid and thus less aspiration events occur. To achieve the desired thickness, one adds a powdered thickener to any thin liquid (water, juice, coffee, etc.), stir, and voilà you have a thickened version of that liquid. There are two types of powder typically used to thicken liquids. The original is starch based (i.e., cornstarch) while the newer

In 1968 a committee at Harvard Medical School met to lay down the groundwork for a new definition of death, one that was no longer confined to the irreversible cessation of cardiopulmonary function but a new concept based on neurological criteria.  Over the next 50 years, the debate over the concept of brain death has never really gone away.  Rather cases like Jahi McMath have raised issues of the legitimacy of the neurologic criteria.   On today's podcast, we talk with one of the leading international thought leaders on Brain Death, Dr. Robert Truog.  Robert is the Glessner Lee Professor of Medical Ethics, Anaesthesiology & Pediatrics and Director of the Center for Bioethics at Harvard Medical School.  He has also authored multiple articles on this topic including the Hastings Center Brain Death at Fifty: Exploring Consensus, Controversy, and Contexts and these from JAMA: The 50-Year Legacy of the Harvard Report on Brain Death  Understanding Brain Death  Brain Death—Moving

Chris Callahan (of Indiana University) and Lee Jennings (University of Oklahoma) have some righteous anger.   Why do we have comprehensive cancer care centers and not comprehensive dementia care centers?   We have a body of evidence dating back 30 years to support people with dementia and their caregivers with Comprehensive Dementia Care. Lee Jennings added to this robust body of work with a study published in the Journal of the American Geriatrics Society demonstrating that a comprehensive dementia care program based out of UCLA reduced ED visits, hospital length of stay, increased hospice enrollment, and delayed time to admission to long term care.   As Chris Callahan notes in his accompanying editorial in JAGS , a fundamental problem with our healthcare system is that savings from Comprehensive Dementia Care accrues not to the dementia care program, but to the hospital and Medicare (ED visits, hospital length of stay) or Medicaid (long term care admission).  Our fragmented healthca

Every year, about a third of older adults fall.  About one in five of those falls result in moderate to severe injury.  What can we do to help not only prevent those falls but also the complications of them? On todays podcast, we talk to Tom Gill, one of the authors of the recent Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study published in the NEJM.   The STRIDE study was huge, 5,451 patients in 86 primary care clinics from 10 different health care systems.   Individuals assigned to the interventions worked with a “falls care manager” whose goal was to help identify and make plans about risk factors for falls and fall-related injuries.  What did it show?   Well, the conclusion of the NEJM abstract states that this multifactorial intervention "did not result in a significantly lower rate of a first adjudicated serious fall injury than enhanced usual care."   We talk to Tom about whether that is the right take home from this pragmatic study and ho