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Showing posts from January, 2010

What a nursing assistant will tell us...if we ask

A friend recently forwarded me an update to a story first reported in the Washington Post in May 2009 about a home care nursing assistant, Marilyn Daniel. (Here’s the update). Using quotes and photographs, the author describes a typical day of visits—from transportation challenges to detailed, moving stories of a few of her patients. It caused me to pause and reflect upon the caregivers closest to our geriatric patients. Nursing assistants provide the greatest amount of direct care to our patients whether in hospitals, nursing homes, or homes. For me, this article aptly notes the challenges of the job, the importance of continuity of care, and the difficulty for home health aides when given a next “case” right after a long standing relationship with a patient ends (or perhaps when hospice comes in and negotiations can’t be reached for keeping the same home health aide). The audience here at GeriPal is one that knows these issues well, but when a photographer/writer captures it so movi…

Mammograms in Women with Dementia: What's the Problem?

A study in the American Journal of Public Health examining mammogram use in older persons found that 18% of women with severe cognitive impairment had received a screening mammogram in the prior 2 years. These women had an average life expectancy of 3.3 years. Since one needs to live at least 5 years to benefit from screening mammography, most of these women had no chance of benefiting from mammography, but were subjected to all the potential harms.

The authors of this study, which included our UCSF colleagues Kala Mehta and Louise Walter, describe this as a good news-bad news finding. The good news was that women with severe cognitive impairment were much less likely to get mammograms. So doctors are to some extent individualizing screening decisions. The bad news is that this still represents a very large number of potentially harmful mammograms.

On the Newsweek website, Sharon Begley provides an excellent commentary on this study. This commentary was a pleasure to read. It explaine…

Morphine Sulfate oral solution is now FDA approved

Morphine sulfate oral solution is now FDA approved thanks to a concerted effort by many in the hospice and palliative care community. To give a little history, in March the FDA issued warning letters to nine companies telling them to stop manufacturing (within 60 days) 14 unapproved 'narcotics' that are used to treat pain, including morphine oral solution. As you can imagine this created quite a little stir in the palliative care community and in our blogosphere.

AAHPM, NHPCO, and the HPNA leaders came together, as well as online social networks that included blogs like Pallimed and networks like facebook. They expressed strong concern that taking liquid morphine off the market would result in hardship for terminally ill patients and their caregivers. Within 9 days of the announcement the FDA reversed their decision. At that point the FDA agreed to allow companies making and distributing the unapproved drugs to continue, until 180 days after any company receives approval to ma…

How do you treat your elderly clinic patients for chronic pain?

As noted on the Pallimed blog, a study published last week in Annals of Internal Medicine reports on adverse events associated with the prescription of opiates for chronic non-cancer pain.

In brief: they studied 9940 HMO patients (mean age 54) who received 3 or more opioid prescriptions within 90 days for chronic noncancer pain between 1997 and 2005. They used ICD codes with subsesquent chart review to identify "opioid-related overdoses", and found 51 events, of which 6 were fatal. After stratifying by categories of opiate exposure, they estimated that annual overdose rates were 0.2%, 0.7%, and 1.8% among patients receiving less than 20 mg, 50 to 99 mg, and more than 100 mg of opioids per day, respectively. (For more journal-club style details and analysis, check out the Pallimed post, which is good reading for those with a little more time and interest.)

I'll confess that when this article caught my eye, one of my first thoughts was "Argh! Now it will be even HARDE…

"Do not punctuate the end of your life with a senseless act of brutality!"

Words have power. Language has power.

The words we use may comfort or shock, allay or provoke, sooth or batter. Words often imply layers of meaning that are not explicitly articulated, yet rest beneath the surface:

“I worry that time is short for you” (You are dying) (I care about you)

“I wish we could have done more” (Nothing would have changed her death) (I am on your side)

“I hope with you that you’ll get better, but I think we should prepare in case things don’t go as we hope” (You are not getting better) (I support your hope)

I can think of no situation in which there is greater variation in how our choice of words varies than how we explain cardiopulmonary resuscitation (CPR). Many people, including me, vary the language we use depending on our recommendation for treatment. Some use more drastic language than others. Here are some examples I have encountered, again with possible implied meanings in parentheses:

“Would you like us to restart your heart if it stopped beating?” (Please …

Post Traumatic Stress in Late Life

Over the past year, I have had several 80+ patients, combat veterans of WWII, who have had very significant symptoms of post-traumatic stress. These symptoms included nightmares and flashbacks related to their military service almost over 60 years ago. In several cases, the patient told me of these longstanding symptoms after I had cared for them for several years. In another case, I learned of these symptoms from a spouse.

I am not so sure why it did not occur me to ask about post-traumatic stress. Without thinking about it much, I guess I just presumed that if they had no previously documented history of post-traumatic stress symptoms it would not present itself decades later. As I have thought about this, I have concluded that my view here was incorrect, and that I needed to be more alert to the possibility of post-traumatic stress in my older Veteran patients.

A very important study in the December issue of the Journal of the American Geriatrics Society , led by Dr. Lance Rintamak…

Making Our Voices Heard: A Year in Review

It has been 6 months since the start of this little experiment called GeriPal. I must admit, initially I had a lot of questions about the viability of a blog about geriatrics and palliative care. Did it really make sense to combine the topics of geriatrics and palliative care in one blog? Would anyone notice the blog? Would anyone care?

The good news is that the answer to all these questions appears to be a resounding yes. The interest and attention that GeriPal has received has been extraordinary given that we have been around for such a short amount of time. A vibrant community has developed that has brought people together to talk about common challenges that we share in our day to day work. Much like what makes both geriatrics and palliative care special, this community is interdisciplinary to the core. Just take a look at the top 3 most commented posts for 2009 for a good example of who posts and who comments:
A Rant on Terminology – by Patrice Villars (a nurse practitioner)Notes…

Evidence-Based Medicine in Clinically Complex Elders – Barking up the Wrong Tree?

For years, many academics (myself included) have decried the lack of rigorous clinical trial evidence to inform the care of clinically complex elders. Clinical trials of drug therapy routinely exclude patients of advanced age and those with multiple comorbidities, leading to a paucity of evidence in this vulnerable group.

However, perhaps we’ve been barking up the wrong tree. Evidence-based medicine is often ill-suited to the care of complex older adults, and more of the traditional sorts of randomized trials of drugs and devices will not give us the information we need. Consider the HYVET trial (http://content.nejm.org/cgi/content/abstract/358/18/1887). For years, observational evidence and limited trial data suggested that in the oldest old, high blood pressure was protective against mortality (the opposite of the relationship in younger people). HYVET, a randomized controlled trial which enrolled 3845 patients from 195 centers on 5 continents, found the opposite to be true. However…

Reviewing the Evidence for Opioids and Cancer Growth

Eric Widera recently posted about the media's irresponsible headlines implying that opioids cause cancer growth. This is our most read post to date (over 1000 direct visits plus email subscribers).

Why was this post so widely read? Because this issue touches on a critically important therapy and the media were clearly irresponsible in their treatment of this story. The media took a story about an opioid antagonist (methylnaltrexone) potentially inhibiting cancer growth in mice, and converted this into a story about morphine causing cancer growth.

As a follow up to Eric's post I emailed the authors of the study, asking them if they would like to comment or post a response. One of the authors called me to give his opinion. He said they have avoided talking to the media, declined multiple interviews with the press, and would not post a reply on our blog. However, he did state that he believed there is strong reason to suspect that opioids may promote cancer growth, and he wanted m…

Palliative or terminal sedation

There is much to say - both good and not-so - about last Sunday's (December 27) NY Times front page article on palliative sedation ("Hard Choice for a Comfortable Death: Drug-Induced Sleep"). The issue is provocatively presented with an inconsistent, but clear insinuation that something may be amiss. I wonder what you all think; however, I am most concerned about the photos (Photos: Ozier Muhammad/The New York Times) which may easily be taken in, without the benefit of reading the explicating text. Front page: "Frank Foster, sleeping under sedation to relieve pain and other effects of liver cancer..." He's all alone, no one at his bedside. One may wonder, is he being drugged to death and left to die? The article continues further on in section one, on 2 full pages. Three large photos on the first of those pages are of Gloria Scott, an African American "terminal cancer patient" being attended by a white doctor. In one of the photos Ms Scott is bein…

Overlooking the Frail Years

Paula Span raises a number of interesting issues in this post on the NY Times New Old Age Blog. She presents the story of an active 70 something man who was very comfortable discussing the possibility of his death, but seemingly unable to discuss the possibility of being frail and needing help caring for himself.


As the post notes, most people will have a period (often quite long) of frailty at the end of their lives in which they will need the help of another person for some tasks of daily living. I think the popular media and many in the medical profession sometimes try to suggest otherwise, suggesting that frailty is avoidable if you just do the right things. The evidence overwhelmingly suggests otherwise. It is certainly right to encourage good health habits, including good nutrition and exercise. But it is more likely that healthy living will delay frailty--not avoid it.


I think even in Geriatrics, we sometimes oversell our ability to prevent functional decline and frailty. In ou…