GeriPal - Geriatrics and Palliative Care Blog

Back by popular demand!
The Third Annual  Interactive Educational Exchange at the Annual Assembly of the American Academy of Hospice and Palliative Medicine (AAHPM) will be back in 2012!!
Don’t miss this great opportunity to share your scholarly work in education …all while enjoying Colorado in March of 2012!
2012 Interactive Educational Exchange - Call for Submissions

Abstract submissions for this session are being accepted through Tuesday, August 2, 2011 at 5 pm Pacific Time (PT). This will be the third year running for the Exchange, and AAHPM has decided to make the Exchange an annual offering at the Assembly. The Exchange provides a structured, interactive, and hands-on forum for palliative care educators from all disciplines to present, share and exchange materials and methods from model educational initiatives, including curricula, program development, educational process, assessment tools, online materials, and research in teaching and evaluation.

Submission information and materia…

It's July, and that means teaching new fellows how to explain palliative care to patients and family members.  For inpatient consults, that means we usually we introduce our names, say we're from palliative care, and then ask if we can sit down.  At that point the patient or family - eyebrows raised - says, "Who are you again? You say you're from palliative, what is that?"

A recent national survey commission by the Center to Advance Palliative Care (CAPC) suggests that three-quarters of the lay public don't know what the term palliative care means.  We have much explaining to do.

Here's what I say, and teach fellows to say:
Palliative care is care for patients with serious illness, like yourself.  We focus on three things:1. Symptoms.  Patients with serious illness often have symptoms like pain, shortness of breath, nausea, constipation, lack of energy, depression, anxiety, nausea, or difficulty sleeping.  We are experts in the treatment of those symptoms.…

I was very disappointed with the recent New York Times Article “Concerns About Costs Rise With Hospices’ Use.” The article paints an unbalanced picture of the Medicare Hospice Benefit highlighting “the concerns about excessive costs and misuse” while omitting many of the safeguards in place that are effectively working to prevent fraud. The Medicare hospice benefit is currently a misunderstood and underutilized benefit and unfortunately articles such as this can only perpetuate this problem.
The author states “once a patient is enrolled in hospice, Medicare pays a flat fee ranging from $147 to $856 a day, depending on the level of care, regardless of whether a hospice actually provides services” implying that Medicare will pay for all hospice patients for an unlimited amount of time regardless of whether they receive care. The article failed to mention that hospice agencies currently are subject to an aggregate financial cap. The Medicare cap amount is approximately $24,000 per hospice…

Recently, a group of distinguished neuroscientists commissioned by the Alzheimer’s Association and the National Institute on Aging updated guidelines for the diagnosis of Alzheimer’s disease. The new guidelines view the pathology that leads to Alzheimer’s disease as process that occurs over many years, if not decades. As a result the panel developed different guidelines for different disease stages. Perhaps the most novel and interesting guideline is for a newly identified stage: preclinical Alzheimer’s disease.

The concept of preclinical Alzheimer’s disease recognizes that the brain damage that leads to dementia starts to develop many years before patients develop cognitive problems. For example, it is generally believed that amyloid deposits in the brain play a key role in the development of Alzheimer’s disease. Modern imaging methods can detect this protein in the brains of persons who are completely asymptomatic. Biomarkers in the blood and cerebral spinal fluid also suggest patho…

"Doctor: I am having trouble sleeping."

This has got to be one of the most common complaints we here from our older patients. Older patients often feel doctors don't take their sleep problems seriously. And perhaps this criticism that doctors dont take sleep complaints seriously enough is justified. After all, insomnia has major effects on quality of life in older persons. It is incredibly anxiety provoking to lay in bed night after night and not be able to fall asleep. And the general fatigue one feels after a sleepless night is awful.

One reason health providers may downplay sleep complaints is because they few sleep problems as less serious, and more minor than the diseases on a patient's list of diagnoses. But often, insomnia may have greater effects on quality of life than the diseases on the diagnosis list.

But another reason may be the discomfort health providers feel with the medicines used to treat insomnia. In particular many providers are concerned with…

There is probably no one disease that so fully encompasses the intersection between geriatrics and palliative care as does advanced dementia. There is a high prevalence of distressing symptoms such as pain and dyspnea, which only become more common as the disease progresses. There is significant functional decline, caregiver distress, and great need for advanced care planning. There is also a very high likelihood that individuals with very advanced disease will undergo burdensome interventions that offer little evidence of benefit.

A great example of one intervention that offers little in the way of benefit and yet is commonly performed in advanced dementia is the feeding tube. Despite a complete lack of evidence to show any benefit in regards to preventing aspiration pneumonias and pressure ulcers, improving comfort, or prolonging life, feeding tubes are still placed.

One reason I often hear why feeding tube prevalence is high in individuals with advanced dementia is that ma…

There's an interesting story developing that I want to bring to GeriPal reader's attention.  Several researchers are under investigation for not reporting potential adverse effects of a hip-protector study.  There is a great deal of background reading for this study for those who are interested - I've just read the following three web-pages: this article in the Boston Globe, this Department of Health and Human Services (HHS) letter, and this press release from HipSaver.

Here are the outlines of the issue, as I understand it:
In 2004, Dr. Douglas Kiel, a researcher from Hebrew Senior Life - a terrific nursing home and research institution affiliated with Harvard (also not so shabby a place) - were conducting a study of hip protectors.  At the time, evidence that hip-protectors prevented hip fractures was unclear.  Previous studies were vulnerable to confounding - those in the group who wore hip protectors may have been different in important ways from those who did not wear …

It's July, and that means new housestaff, students, and fellows.  Interns, fresh from medical school, and newly minted residents.  Medical students starting the wards.  Fellows brimming with enthusiasm.

July is also the time when these early trainees are taught the "basics."  I have the pleasure of giving the introductory lecture this week about pain management, a very GeriPal bread and butter topic.

I'm hoping to inject a little bit of humanism, in the form of poetry into the lecture.  One poem I've selected is called Pain Work-up, by Jeremy Nobel (thanks to Guy Micco!).  See what you think:

Tell me about the pain.
Is it sharp or dull?
What brings it on?
What makes it go away?
Does aspirin seem to help?
Does it feel better after eating?
Can you tolerate greasy foods?
Does it get relieved when you lie down?
Is it worse in the morning or evening?
Put your finger on the spot that hurts most.
Does it come and go or is the pain constant?