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Showing posts from October, 2010

Life Space: Living Well Despite Disability

Geriatric Medicine is obsessed with functional status and disability. Much of the practice of Geriatrics revolves around the prevention or rehabilitation of functional status problems.

But what is functional status? Ironically, despite the importance of functional status to Geriatrics, defining what functional status is, or how it should be assessed is not so obvious. In practice, most functional status evaluations focus on assessing whether or not patients can do specific tasks important to day to day life. For example, can you do basic activities of daily living such as take a bath or shower, get dressed, or walk across a room with assistance? Can you do housework, manage your finances, and manage your medicines?

But there is increasing interest in more holistic views of functional status. These views focus not just on tasks you can or can't do, but on how well you live despite of functional problems. One of the most interesting of these new ways of thinking about functional sta…

Any Symptom in an Older Adult is a Medication Side Effect Until Proven Otherwise

Mike Steinman recently published a paper in JAMA about sensible medication managment in older adults.  I've had the opportunity to see him speak about this issue on a couple of occassions.  I wanted to share a few take home "GeriPal" pearls, leading with the title of the post:
Any symptom in an older adult is a medication side effect until proven otherwiseReview medication lists and sort by indication.  Most older adults are on at least one unnecessary medication, or one where the harms outweigh the benifits in light of the patient's goals, social and clinical circumstances, and life expectancy.If you taper it up, taper it downWhen starting a medication, start low, and go slowWarfarin, hypoglycemic agents, and digoxin account for one-third of all adverse drug event related emergency department visits by older adults.  Doesn't mean don't prescribe them, just prescribe thoughtfully and monitor for adverse side effects.Most adverse drug events are due to a failur…

Call for Nominations for Primary Palliative Care Improvement Expert Panel

I'm passing on this call for nominations from the American Board of Internal Medicine for an expert to serve on the Practice Improvement Module for Primary Palliative Care.  Please consider nominating someone, or yourself!

Call for Nominations Primary Palliative Care PIM
The ABIM requests nominations to its Expert Panel for a new PIM (Practice Improvement Module) focusing on Primary Palliative Care.PIMs are web-based tools that guide physicians through the collection of patient data to identify gaps in care and ultimately implement a quality-improvement plan for their practice.CME credit is available for this PIM, and panel members will be listed publicly as faculty.Disclosure of relevant financial relationships will be required.
This panel will be responsible for identifying or developing clinical measures that address important issues in primary palliative care for patients with multiple chronic conditions and functional impairment or with specific diagnoses such as solid tumors tha…

Palliative Chemotherapy

by: Robert Killeen MD
Is there anyone amongst the readership that can direct me to a list, a compendium of purely "palliative" chemotherapy regimens? I'm looking specifically for any reference on regimens (ie singlets, doublets, etc +/- RT) designed for non-curative symptomatic treatment. I've scanned EPERC, AAHPM, and the Feinberg Palliative Oncology sites, among others, without much success.
The best definition of a palliative chemotherapy regimen I've found had been derived earlier this decade by a European panel (1). Though their focus was on breast cancer their directive seems applicable across the board. Their opinion was that the optimum palliative regimen should control the disease (ie the response rate, RR) in at least 20-30% of patients and increase the progression-free (PFS) and overall survivals (OS). The regimen's toxicities should, ideally, minimally affect performance status while maximally eliminating tumor symptomatology. Quality of life, not c…

Dumb Medicine: Screening for Cancer in Patients already Diagnosed with Incurable Cancer

I used to get sports illustrated, and my favorite column was titled "this weeks sign that the apocalypse is upon us."  Well, today JAMA published the medical equivalent.

Sima and colleagues at Memorial Sloan Kettering used a population based dataset of patients with cancer to compare rates of cancer screening (mammography, PAP smears, PSA tests, colonoscopy) between patients who had advanced, incurable cancer (lung, colorectal, gastroesophageal, and breast cancers) and patients who did not have cancer.  Results
Mammography: 9% among patients with advanced cancer vs. 22% among patients without cancerPAP smears: 6% vs. 13%PSA testing: 15% vs. 27%Colonoscopy: 2% vs. 5%The good news - the rates are not equal.  At least a few docs are thinking enough to not screen patients with advanced incurable cancer for another cancer! 

The bad news - screening rates among patients with cancer are about a third to two-thirds of the rates of patients without cancer!  Keep in mind people need t…

A New Tool for Delivering Culturally-Competent Geriatric Care

By the middle of this century, one out of every three older Americans will be from a diverse group of minority populations. How can we provide culturally effective care for this growing heterogeneous population? VJ Periyakoil, fellow GeriPal contributor and director of palliative care education and training at Stanford, just came out with one way - the eCampus geriatrics portal.  eCampus Geriatrics is an educational website that offers a range of tools and resources to help health-care professionals provide culturally-competent geriatric care.

The site is currently split among three main components. The first is “Culture Med” – a collection of five ethnogeriatrics modules that include instructional strategies and a student evaluation guide. Topics include an introduction, an overview of patterns of health risks and mortality The second is “Ethno Med”, where one can find detailed information on specific ethnicities, as well as instructional and student evaluation strategies. The th…

Age Discrimination in Clinical Research: Time For Action

Older persons are often severely underrepresented in clinical trials of new drugs, therapies, and devices. Usually, their exclusion from these studies can not be scientifically justified. Some studies actually have age cutoffs, but more often the exclusion of older persons is more indirect. For example, most older persons have more than one disease. A study of a treatment for disease X may exclude a person who also happens to have disease Y, even though persons with disease Y will be part of the target population for therapy once the treatment is approved. Sometimes, the exclusion of the elderly is even more subtle---such as excluding subjects who need transportation assistance to get to the study center.


The exclusion of older persons from clinical studies, whether through direct exclusion of older persons, or indirect exclusions based on factors such as comorbidity or functional impairment is rarely justificable. If an elder would be a realistic candidate for the therapy being stud…

Caring.com: e-caregiving website and "customized" dementia information

As a practicing primary care geriatrician, I am always on the lookout for good resources that can help support my patients and their caregivers outside of the clinic visit. So I was pretty intrigued two years ago when a health writer approached me, saying she was writing for a website developed for adults caring for aging parents. And would I be willing to answer a few expert questions every month?

When I first became involved with Caring.com, I was impressed by the site’s attention to dimensions of the caregiver experience that physicians often only peripherally attend to, i.e. housing, legal issues, financial issues, caregiver self-care, and negotiating difficult conversations with a parent. The medical information, on the other hand, didn’t always seem to be quite what I wanted for my patients and their caregivers. Like most health information on the Internet, it was very disease-focused, with relatively little to link the information to a person’s function, co-morbidities, and ov…

Call for Action

Diane Meier asked us to post this call for action to GeriPal.  Please act!  Cross posted at Pallimed with terrific example feedback to the National Health Care Quality Strategy by Lyle Fettig.

Dear colleagues-

We have an important opportunity to influence the degree to which palliative care and hospice are integrated into our future health care system. There are currently 2 places requesting input from the public:  via the federal government's Department of Health and Human Services (HHS) National Quality Strategy initiative and the National Quality Forum calls for public comment on quality of care. Palliative care is the linchpin for quality among the highest risk highest cost patient populations in the United States and this is an opportunity for us to focus attention to the impact and priority of our work (or, as they say, "be at the table or be on the menu").

Deadline for HHS is October 14, 2010 and deadline for the NQF is October 19, 2010.

1.  The National Health Car…

Opportunity to Comment on National CLAS Standards

This year marks the 10th anniversary of the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care. To ensure that the CLAS Standards remain current and appropriate, the HHS Office of Minority Health (OMH) is launching an enhancement initiative of the CLAS Standards. As a part of this initiative OMH is seeking public input from individuals and professional communities across the country.

To comment online:

http://clasenhancements.thinkculturalhealth.org

by: VJ Periyakoil