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Showing posts from 2011

MMSE and Copyrights Part II: Is the MMSE Derivative of Some Other Work?

A couple of days ago we covered Dr. John Newman's NEJM perspectives piece that focused attention on how a company, PAR, is trying to charge clinicians everytime they use the MMSE in clinical practice. To make matters worse, PAR is also trying to take down other tests, like the Sweet 16, that are thought to be derivative of the MMSE. As upsetting as this is, it does beg the question of how the originators of the MMSE, Marshal and Susan Folstein, came up with their test, and whether it is derivative of any other previous cognitive screens.

The origin of the MMSE, as claimed by the Folsteins and PAR, is as follows (taken from the PAR blog):

"We developed the MMSE to solve a clinical problem on a geriatric psychiatric inpatient service. The diagnoses of patients on our unit included depression, dementia, delirium, and occasional late-life schizophrenia. We needed a practical quantitative cognitive exam in order to aide clinicians in determining the severity of cognitive impair…

Copyrights and Copylefts in Medicine: The Case of the Wayward MMSE

The Mini-Mental State Exam (MMSE) is the most widely used cognitive screening test. Many have attributed this to the relative simplicity, portability, and brevity of the MMSE, as well as its ability to track the change in cognition over time. However, undoubtedly the biggest reason is that for most of its nearly 40 year life span, it has been free for anyone to use and reproduce, as the creators of the MMSE never enforced their copyright.

Our previous GeriPal post on the MMSE's copyright describes how times have changed:

“This test used to be freely available online, in books, and on pocket cards that were distributed to medical students and residents throughout the country. This all changed in March of 2001 when MiniMental, LLC (the current owners of the MMSE copyright) granted Psychological Assessment Resources (PAR) the exclusive rights to publish, license, and manage all intellectual property rights to the MMSE. Suddenly, after decades of neglect, PAR began enforcing the co…

'Tis the Season: The BMJ Christmas Edition

It's the most wonderful time of the year. No, not because those damn kids jingle belling and everyone telling you "be of good cheer". And not because of those holiday greetings and gay happy meetings when friends come to call. It's the hap-happiest season of all because I just got the BMJ christmas edition in my inbox! 

What, you were not so lucky?  Well, I guess someone is on someone else's not so nice list.  Don't worry though, I'll recap the three key lessons I learned after perusing the issue:


1) Never write "Stable Vitals" or "Observations Stable" in a Chart 

There are a lot of meaningless rituals that make it into physicians’ notes. One of the most common is using the term “stable” to refer to all aspects of patient care. The most common in the US is the term “stable vitals”. In the UK, “stable observations” takes "stable vitals" place. No matter which you choose, both convey little valuable informatio…


Sometimes the best ideas are so simple that you both marvel at their eloquence and wonder why you never thought of them.

In a perspective in the New England Journal of Medicine, Dr. Dan Wolpaw, a General Internist and Educator at Case Western Reserve University presents a simple and eloquent idea that can transform the quality of medical care and medical education. Dr. Wolpaw suggests we add a portable stool to the equipment we carry on patient care rounds.

Morning walk rounds are a long standing part of medical culture. Teams of doctors walk the halls going from room to room to see each of their patients and develop care plans. But Wolpaw notes that less and less time is spent truly talking to patients. Team members talk to each other outside the room. Then the team approaches the patient, often standing around the patient who is lying in bed. We don't see the patient eye to eye, but literally look down on them. Wolpaw observes that after rounds, the team does take time to sit …

Discussing Prognosis When Longevity Is the Only Life Limiting Condition

I think we all probably agree that health care providers should give patients with a life limiting illness the option to discuss their prognosis. But what about discussing prognosis with those patients who may not have any particular life limiting illness, but have just lived a long life? Are we as forthcoming about prognosis in this population as we are with a population of patients with advanced cancer? Should we be?

In this week's New England Journal of Medicine (NEJM), Alex Smith ventures outside of the blogosphere to give his perspectives on discussing prognosis with very elderly patients who may not have a dominant terminal condition.  Along with Brie Williams and Bernie Lo, Alex lays out in this perspectives piece the importance of and the barriers to having these types of discussions.

I won't recap the article here, except to restate the overarching recommendation that clinicians should “routinely offer to discuss the overall prognosis for elderly patients with a l…

Potpourri from Clinical Work V

The following observations and questions came up during my recent work as palliative care attending.  Thoughts and responses are welcome:

How well do so-called "bridge" programs work? These are the home-care programs for patients who qualify but whose goals do not align with hospice, or who have serious illness but a prognosis outside of the hospice criteria (e.g. 1 year rather than 6 months).  I have heard rumors that bridge programs may drop patients who do not "cross the bridge" to hospice, or who do not have profitable insurance.  Does anyone know of any studies desribing these programs, and critically evaluating the quality of their services?  This seems to be a potentially important avenue of research.Problems with VA hospice contracts for residential hospice.  A number of area SNF/nursing homes are not accepting the VA hospice contract, or prioritizing it so low as to effectively not accept it.  The fact that the VA will pay for residential hospice care (inc…

Treating Pain to Reduce Behavioral Disturbances in Dementia

There have been a lot of pharmacologic and non-pharmacologic interventions proposed for the all too common behavioral complications of dementia. Some non-pharmacologic methods have shown to be successful in reducing not only the number of troubling dementia related behaviors, but also in improving caregiver burden (read about the REACH VA here).

Pharmacologic interventions have not had similar success, although you wouldn’t guess that based on current prescribing habits. Many health care providers still write for mood stabilizers, like valproic acid, despite a high risk of side effects when used in this population and the paucity of evidence showing any effectiveness in improving behaviors. Antipsychotics, on the other hand, have shown some modest efficacy for the treatment of aggression and psychosis over a short 6–12 week course. However, they also have a nasty little habit of causing death in those who take them.

What if, instead of trying to treat the symptom of aggression or…

Too Much of A Good Thing

There is an estimated 6.7 million emergency hospitalizations every year in the US. One out of every 67 of these hospitalizations is due to an adverse drug event.

This is just one of the many interesting, although somewhat questionable points made by Daniel S. Budnitz and colleagues NEJM article titled “Emergency Hospitalizations for Adverse Drug Events in Older Americans”.   It's a compelling article that, in part, attempts to persuade the reader that most emergency hospitalizations for adverse drug events in older adults are not the result of physicians prescribing inappropriate medications like those listed in the Beers criteria.  Rather, the vast majority of hospitalizations are the result of a few commonly used medications, like warfarin, aspirin, plavix, and insulin.   This would be an interesting finding, if it were true.  Unfortunately, after reading this article I'm not sure it is.

Let's start with the primary outcomes that the authors looked at - "hospital…

The Hospital Disability Syndrome

Ken Covinsky previously posted on GeriPal a while back about the dangers of hospitalization in older adults.   Ken notes in that post that hospitalization is a vulnerable period leading to major new disability for many older adults.  More recently, Ken, GeriPal contributor Bree Johnston, and honorary GeriPal member Edgar Pierluissi authored a terrific article about hospital-associated disability in one of those pre-blogging era, old-fashioned periodicals...JAMA.

I'm not going to be able to sum up this meaty piece of scholarship in this post.  Let me say only that if you care for hospitalized older adults, and can only read one article that changes for the better how you care for them, this would be that article.   Let me relay some of the disruptive perspectives offered:

Move over traditional geriatric syndromes, and make way for the newcomer:  hospital-associated disability should be considered a geriatric syndrome (the "hospital disability syndrome").  Hospital-associa…

Quality Indicators Can Cause Harm in Older Patients: An Inconvenient Truth

Quality indicators are used to measure the quality of health care delivered to patients. Quality indicators are used extensively in the VA health system, and efforts are underway in Medicare to tie reimbursement levels to performance on quality indicators.

The motivations for using quality indicators are guided by the best of intentions. There are many problems with the quality of health care in the US, and quality indicators aim to improve this care. When put to their best use, quality indicators can improve care.

However, a recent commentary in JAMA from our UCSF colleagues, Geriatricians Sei Lee and Louise Walter raise serious concerns about unintended harms from quality indicators. Lee and Walter make a compelling arguement that quality indicators, when used indiscriminantly, can actually harm the quality of care provided to the older persons. This is particularly true for the most frail and vulnerable elders.

How is it possible that something designed to improve care can actuall…

What Drugs Should You Avoid In the Elderly: An Update on the Beers Criteria

Should you always avoid the use of metaclopromide in the elderly (I still use it in some circumstances)?  What about scopolamine - avoid always or consider for some instances like motion sickness?   And what about Megace - yet another drug to always avoid?

According to the new draft guidelines for the new AGS Updated Beers Criteria the answer for these questions and for many other medications is a clear "avoid".  Now is your chance though to both read these draft guidelines and to give your opinion before they are finalized (click here for the AGS site).

Why spend your time doing this?

It’s been two decades since the original Beers Criteria was published by the late Dr. Mark Beers. The original list comprised of drugs that were potentially inappropriate for elderly patients residing in nursing homes but have been subsequently revised to include elderly patients in all settings.

The drugs listed in the Beers Criteria have side effects that were thought to be far more harmfu…

Is hospital observation status the new pathway to frailty?

Have you noticed that your hospital is using the observation status more instead of simply admitting the patient? Three recent cases (from both a University hospital and a private hospital) have me interested in this question. It appears that this is a national trend which the American Medical Directors Association (AMDA) has apparently confirmed with the Centers for Medicare and Medicaid Services (CMS.) Per CMS the most recent data show claims for observation care rose from 828,000 in 2006 to more than 1.1 million in 2009. At the same time, claims for observation care lasting more than 48 hours tripled to 83,183.

Observation services include short-term treatment and tests provided in the hospital to help doctors determine if the patient should be admitted for inpatient treatment and whether the patient meets the admission criteria (eg. Interqual criteria). Medicare considers observation services outpatient care, which requires beneficiaries to cover a bigger share of drug costs and…

Geriatric Palliative Medical Education – Yeah! There is a place tostart from…

Have you heard of the Portal for Online Geriatric Education (POGOe)?

The Portal of Geriatric Online Education ( is a free public repository of geriatric and palliative care educational materials (i.e. OSCEs, games, web-based modules, and lectures) developed by leading educators.Launched in 2004, the site boasts over 7,800 registered Users, visitors from over 150 countries, and contains over 650 educational materials.

Here are a couple key POGOe offerings that may interest our GeriPal community:

Lots of great NEW FORUMS! There’s one for geriatric fellowship directors (called ADGAP), GACA recipients, and one for both the AAHPM Geriatrics SIG & AGS Palliative Care SIG (it’s called the GeriPal forum). These forums provide a venue for educators around the world to participate in an online discussion with their peers. Come join the discussion!
Repository of Critically Acclaimed Papers (ReCAP) – An online journal club for geriatrics and palliative care fellows and facu…

Some days I hate POLST

There are days I hate the POLST form (Physician Orders for Life Sustaining Treatment). In concept, it’s significantly better than the pre-hospital DNR and a generic Advanced Directive. But here in the state of California where I work, the POLST form is misguided, poorly worded, and highly charged with negative connotations. Don’t get me wrong, I still use the POLST all the time. But I have decided it’s time to update the form.

Let’s start with the name of the document: Physician Orders for Life-Sustaining Treatment. The first thing we learn as geriatricians and palliative care providers who regularly have “goals of care” and “end of life” discussions with our patients is to avoid terminology which is medical jargon or laden with weighted connotations. We know that for many of the frail and ill patients with whom we have these complex discussions, cardiac resuscitation and mechanical ventilation often do not actually sustain life in the way most of them would define the quality of lif…

The Biggest Questions in Palliative Care and Geriatrics Finally Answered

Every week we have been posting a lot of questions on GeriPal about some of the biggest issues in geriatrics and palliative care. These range from how to define our professions (both in geriatrics and palliative care), how to communicate with patients and family members, and how best manage serious progressive illness. The thing is, it turns out to be a lot of work to think through these questions. 
What if there was a better way? An easier way? Well, thanks to the power of Alex’s new iPhone 4s, there may be. We found that Siri, the new iPhone’s personal digital assistant, can tackle some of the biggest issues in both geriatrics and palliative care.  Do you think we're kidding?  Maybe this conversation will sway you (and yes, the italicized print are real responses to real questions)

What is palliative care? “I found seven hospices fairly close to you.”What is the difference between palliative care and hospice? “I don’t know that. Would you like to search the web for it?My …

Jane Gross on the Failings of Medicare

In the most recent Sunday New York Times, Jane Gross gives a devastating critique of Medicare's Failure to support the needs of the most vulnerable elders. It is must reading for all who care for frail elders, policy makers, and Medicare officials.

Ms. Gross brings interesting perspectives to the workings of Medicare. She is one of the nation's best health journalists, who has long focused on the needs of older persons and their caregivers. She is founder of the wonderful New Old Age Blog at the New York Times. But she also has a deeply personal perspective, stemming from years as a caregiver for her mother who was severely disabled from numerous health problems.

Ms. Gross indicts Medicare for generously funding many services that are harmful to frail elders, but providing little support for services that would actually help improve their quality of life. She notes that Medicare will pay for virtually any traditional disease focused treatment, irrespective of whether the trea…

Take the "H" out of AAHPM/HPNA? Let's Discuss.

Should the word "hospice" be taken out of the professional society names: "American Academy of Hospice and Palliative Medicine," and "Hospice and Palliative Nurses Association?"  AAHPM would become AAPM.  HPNA would become PNA.

This idea is completely new to me so I don't feel informed enough to give an opinion yet.  Let me present some of the arguments as I understand them.   I'll start with reasons for keeping the H.

Reasons to keep the H:

Palliative medicine grew out of the hospice movement in the US.  There are strong historical reasons to recognize the powerful role of hospice in nurturing palliative medicine.  There is no need to shoot hospice in the foot.Many people in these professional societies work for a hospice.  Many identify as a "hospice" provider first and foremost.  They may not feel included in an organization that did not include the name hospice in the title.  Perhaps they would splinter.Hospice is distinct from palli…

Inappropriate prescribing

It's been a while since I posted but I had to share frustration! This week I saw a new patient who has been receiving prescriptions for Librium and Serax (benzodiazepine) from her dentist/oral doctor. That was only one of a long list of issues this woman had which were concerning to me. But when there's a trickle, there's a flood. I also just received notice of a new referral for a woman needing geriatrics care whose ophthalmologist has been filling her ativan.

These specialists may very well be well-meaning, trying to help these women's anxiety in the face of either poor or lack of primary care. But the unintended consequences of such prescribing is frightful to think of.

It raises for me the profile of:

The lack of knowledge most practicing providers have on inappropriate medications for older adultsThe likelihood that there are probably countless more patients who are receiving prescriptions for medications which not only should not be prescribed to them but should…

Poster Sessions at Medical Meetings: A Better Approach

The poster session is a ubiquitous part of most medical and scientific meetings. The format is pretty much always the same. The presenter prepares a large poster describing their research project and findings, tacks it to a board, stands by the board, and waits for meeting participants to come by and talk to them about their work.

It's kind of an open secret that the typical poster session at most meetings is not useful for either the presenter or the attendees. For many of the attendees, the poster session ends up being more of a social gathering than a scientific session. There can be dozens (sometimes hundreds) of posters to see. The posters one visits may be guided more by which friends are presenting than trying to learn anything new. For the presenter, the randomness of the event means that only seldomly does one get good feedback on your work.

Poster sessions can be painful for junior researchers early in their career who may not know many people attending the meeting. It …

What We Can Learn While Driving to Work

Here is today’s GeriPal puzzler: what can medicine learn from Click and Clack, the Car Talk guys?

Give up? I did after guessing that maybe it's how to fix a patient’s carburetor. Lucky for me though, last weeks JAMA gave me the answer in the first sentence of an editorial by Gurpreet Dhaliwal:
“Students learn reasoning by listening to others reason.” 
And there is no better example of problem solving and clinical reasoning than Tom and Ray Magliozzi, the hosts of Car Talk. Dr. Dhaliwal gives us some specifics in his editorial about how Click and Clack demonstrate elements of clinical reasoning, including:

Building the rapport that is critical to eliciting a good history and using humor to do soGenerating and selecting hypotheses by initially making many diagnoses based on the history then verifying or rejecting those hypotheses by further questioningShowing how experience and study provide the potential solutions that lead to efficient information gathering.Demonstrating "p…

Three times higher rates of surgery before death in Munster, Indiana than Honolulu, Hawaii

Following up on our previous post about study that hinted at substantial regional variation in the effectiveness of advance directives, a new study in the Lancet describes considerable regional variation in surgical procedures right before death.  The authors examined claims for nearly 2 million Medicare recipients over age 65.  They found:

32% had surgery in the last year of life18% had surgery in the last month of life8% had surgery in the last week of lifeThe good news is that rates of surgery before death varied by age, with the lowest rates among the oldest patients, suggesting some discretion on the part of surgeonsThe bad news is the tremendous regional variation in rates of surgery before death.  Rates of surgery before death were 3 times higher in the highest region (Munster, IN) than the lowest region (Honolulu, HI).  As a Hawaiian who was transplanted to the midwest for my formative years, can I say this is just one more reason that Hawaii is superior? Amy Kelley writes in …

Advance directives reduce end-of-life costs in New York and Los Angeles

When have advance directives ever been shown to do anything?  They were a complete failure in SUPPORT.  Study after study demonstrates that few people fill them out, rarely are they used, and that health care proxies don't have a great idea of what their loved one want anyway.  As Angela Fagerlin and Carl Schnieder famously opined: "Enough: Failure of the Living Will."

And yet, over the last few years a series of studies have breathed new life into advance directives (see here and here).  A new study published today in JAMA adds another piece to the puzzle.  The challenge is that it's a somewhat puzzling piece.

A terrific group of researchers from the University of Michigan used a nationally representative survey of older adults followed through death.  They examined variation in medical expenditures for persons with advance directives that state treatment should be limited in certain situations, to those without advance directives or advance directives stating no l…