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Showing posts from August, 2010

Advance Care Planning: A Paradigm Shift

What is the purpose of Advance Care Planning?

I have been taught to view the goal as helping patients define what they would want done if they became seriously ill. But there is an important article by Rebecca Sudore and Terri Fried that convinces me I should think about this very differently. Sudore and Fried propose a paradigm shift: Advance care planning is not aimed at prespecifying decisions. Rather it is aimed at helping patients and their families make the best possible in-the-moment decisions.

Sudore and Fried note several serious problems with the traditional goals of advance planning. Most importantly, patients goals and preferences change as their health and circumstances change. One reason is that patients have a remarkable ability to adapt to their circumstances. For example, many well elders would say living with disability is unacceptable to them. However, once elders become disabled they find they can adapt, view their quality of life as good, and change thei…

Length of Stay in Nursing Homes at the End of Life

One out of every four of us will die while residing in a nursing home. For most of us, that stay in a nursing home will be brief, although this may depend upon social and demographic variables like our gender, net worth, and marital status. These are the conclusions of an important new study published in JAGS by Kelly and colleagues (many of whom are geripal contributors, including Alex Smith and Ken Covinsky).

The study authors used data from the Health and Retirement Study (HRS) to describe the lengths of stay of older adults who resided in nursing homes at the end of life. What they found was that out of the 8,433 study participants who died between 1992 and 2006, 27.3% of resided in a nursing home prior to their death. Most of these patients (70%) actually died in the nursing home without being transferred to another setting like a hospital.

 The length of stay data were striking:

the median length of stay in a nursing home before death was 5 months the average length of stay was l…

Early Diagnosis of Alzheimer’s Disease: An Idea Not Ready for Prime Time

Generally, Alzheimer’s disease is diagnosed only after patients have progressed to major levels of cognitive impairment that results in substantial problems in daily functioning. But the brain changes that result in cognitive impairment start years, if not decades, before patients become symptomatic. So, wouldn’t it make sense to try to diagnose Alzheimer’s Disease in patients who have the brain changes, before they have clinical symptoms?

The answer would be yes if two conditions were met. First, there needs to be methods to accurately predict who is likely to get Alzheimer's Disease. Second, there needs to be reason to believe this early diagnosis will help the patient. Basically, this means treatments to prevent or slow down the development of Alzheimer’s Disease. Neither of these conditions are currently met.

Many persons who have early signs of brain or neurologic damage thought to be associated with Alzheimer’s disease never get the disease. In fact, it is well known that a…

Geriatrics Cultural Navigator: Free App from AGS

Free i-pod/i-pad/i-phone App from the American Geriatrics Society is available now for download.

This App is based on Doorway Thoughts: A three volume book series on the care of multi-cutural older adults, spear-headed by the AGS Ethnogeriatrics Committee.

For App, click here.

Some Random Thoughts on Geriatrics in Scotland from a US perspective

by: Bree Johnston

For the past two months (started July 2010) I have been in Scotland working in various geriatrics and palliative care settings. Most of my geriatrics (as opposed to palliative care) work has been at the Royal Infirmary of Edinburgh, Liberton Hospital in Edinburgh, and Western General Hospital in Edinburgh. My many hosts here have been extremely lovely and generous with their time (and tea) and I can’t thank them enough.

Here are some thoughts on geriatrics, presented in no particular order. Some of what I will say here is a repeat of my earlier GeriPal blog on palliative care.

NHS Scotland

Although funded centrally from national taxation, NHS services in England, Northern Ireland, Scotland and Wales are managed separately and have some differences in structure. Despite the minor differences, the NHS is similar in most respects throughout the UK and continues to be considered a single, unified system. One interesting difference between the NHS in Scotland and Englan…

Palliative Care Prolongs Life

A study published today in the New England Journal of Medicine by Jennifer Temel and colleagues at the Massachusetts General Hospital (MGH) showed that patients with advanced lung cancer treated with early outpatient palliative care lived longer than patients randomized to usual care. 

What?

A randomized controlled trial of outpatient palliative care showed a survival benefit.

Palliative care prolongs life?  Really?  REALLY???

Here is my take on the study, and I'm interested in yours.  151 patients with metastatic non-small cell lung cancer were randomized within 8 weeks of diagnosis to either monthly visits to an outpatient palliative care clinic plus usual oncology care or usual oncology care alone.  Patients in the usual oncology care group could attend the outpatient palliative care clinic if requested, but only 14% did.  The characteristics of the two groups looked similar before randomization for all of the things you would care about, like functional status, presence of br…

Debunking the “But I Already See Old People” Myth in Medical Education

What happens when you randomly assign medical students to either a mandatory two week rotation in specialized geriatric training or to a traditional non-geriatric clerkship that sees a lot of old people? Will there be any difference in the knowledge of geriatric conditions, the attitudes toward older adults, or geriatric clinical skills between the two groups?  Or does mere exposure to an aging patient population give students the training they need to care for older patients? These are the questions asked by Laura Diachun and colleagues in a recent article published in Academic Medicine.

The authors randomly assigned 262 Canadian medical students over the course of two years to complete either a clerkship year containing a two-week rotation with a combined geriatric medicine/geriatric psychiatry focus, or to a normal “But I Already See Old People” clerkship year. The geriatrics rotation included working with geriatric medicine and psychiatry specialists in various inpatient and out…

NEED YOUR IDEAS: US Preventive Services Task Force Topic Nominations

The US Preventive Services Task Force is soliciting nominations for clinical preventive health topics.  Nominations can be submitted by individuals or organizations.  I think it would be great to submit a GeriPal topic.  Can you think of Geriatrics and Palliative care issues in preventive terms?  There are recommendations for cancer screening in the elderly (mostly age based cutoffs), hearing and visual loss, but nothing about screening for chronic pain in the elderly (other than counseling for low back pain), falls, dementia, or advance care planning.  For a list of current recommendations for adults, click here.  Try and think of things that will spin the USPSTF in a very positive light.  After the disastrous press over mammography recommendations for women in their 40's last year, they're probably looking for topics that will play well with the public (or at the very least spin their topics better to the press).

The following details what the USPSTF is looking for in a nomi…

Random Thoughts on Palliative Care in Scotland through US eyes

I have been in Scotland since the beginning of July observing their health care system and working in a variety of palliative care settings. OK, I have been playing a little bit, too. I think I have too much to say for one blog, so I will just give a broad overview of palliative care in this blog, and save my other thoughts for other blogs (assuming you let me blog again). I should say that all of my comments are subjective, and although I am trying to be as accurate as possible, my observations and conclusions may not be generalizable to all of Scotland, and certainly not to the whole UK.

Let’s start broadly, although most of this is probably known to GeriPal readers. Although funded centrally from national taxation, NHS services in England, Northern Ireland, Scotland and Wales are managed separately and have some differences in structure. Despite the minor differences, the NHS is similar in most respects throughout the UK and continues to be considered a single, unified system.

N…

Task Force Medicine; 3 issues of palliative care

by: Robert Killeen MD

Task Force Medicine; 3 Issues of Palliative Care

In naval terms a “task force” is a group of ships assigned or “tasked” to perform a certain duty. The composition of the force may vary according to its needs. Carriers, battleships and submarines, for example, perform their respective roles in the group as air power, gun platforms or submersible operations. Much along the same way our primary care attending will gather together a force, a cadre of consultants in a case to assist with care. Their duty is to the patient but their directives are from the PCP. I remember this quip from my training concerning (medical) consultations.

“For what two reasons do you obtain a consult?
1) To have someone do a procedure.
2) To have someone hold your hand and tell you everything’s OK.”

So, for what reason does a PCP obtain a palliative care consult? We don’t perform procedures. What operations can a palliative care consultant be ‘tasked’? I’ve found, over time, three main operations…