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Showing posts from September, 2011

Too Little Care? Too Much Care?

I wanted to get this community's thoughts on a recent article that made some headlines (see ABC news and New York Times for example).

In the Sept 26 issue of Archives of Internal Medicine, Brenda Sirovich and colleagues from Dartmouth report a survey of primary care physicians, where they found that PCP felt they were providing too much care more often than too little care.

First, I want to concede the point that the ideal answer is that we need to individualize decisions and that even if most patients are getting "too much" care, there will be some patients who would benefit from getting more care.

Focusing on averages and a population perspective, I've become interested in this topic since I felt a slight tension between younger and older geriatricians about the care for older adults. It seems that in a previous generation of geriatricians, the primary concern about the care of older adults was that we were not providing enough care. For me, this is highlighted by…

Opioid Dysmotility Dance Video

If you see just one YouTube video where a doctor uses his own body to teach, then see Cardiac Arrhythmias.   In this silent movie, a physician does a cardiac dance to teach about arrhythmias.  My favorite: ventricular tachycardia.

If, however, you see two YouTube videos where a doctor uses his body to teach, then see our video: Opioid Dysmotility Dance.  In this video, an anonymous GeriPal contributor wearing a local disguise (Fear the Beard!) imitates the effects of opioids and laxatives on everyone's favorite organ, the colon.



by: Alex Smith

Social Isolation Faced by Many Gay Elders

We have written several pieces in GeriPal about issues such as isolation and loneliness. One aspect that we haven’t really explored is how there may be communities of elders that may be at increased risk for isolation, especially near the end of life.

Luckily, a fellow geriatrician of ours, Manuel Eskildsen, just had a piece that came out in the NY Times titled “For Many Older Gays, a Toll of Time and Isolation.” In this piece he tells a story of a nursing home patient whose death continues to gnaw at him. There were many things that may have gone differently the day CPR was performed on this elderly resident. What mattered most for Dr. Eskildsen though was how this “kind, erudite and generous” elderly gay man died alone.

Dr. Eskildsen goes on in this piece to describe how this patient’s death underscores a difference between older and younger generations of gay, lesbian, bisexual and transgender individuals. He writes:
“Maybe my strong connection to this patient was related to th…

China Making it Illegal Not to Care

When I was 16 years old, I decided to volunteer in a nursing home.

On my first day, I visited with a woman whose son was supposed to come and take her to church. While she sat in her Sunday best, we flipped through a family photo album, looking at pictures of people whose names she had forgotten. After a couple of hours, I asked the geriatric aide if we should call the son to see if something had happened to him. I was told, “He stopped coming last year, but she doesn’t know – she has Alzheimer’s disease.”

I remember feeling upset with this woman’s family for neglecting her. I vowed then to always care for my mother, especially as she would need the support once my brother and I reached adulthood and pursued our respective paths away from home.

Well, that was 12 years ago and a lot of my childish naiveté has faded. Don’t get me wrong - I love my mother and care very much for her well-being, but I have professional and personal duties to which I am committed that make it difficult for me …

Befuddlement at Hospital Discharge

Hospitalizations present a host of dangers to an older patient, and perhaps one of the most hazardous parts of hospitalization is the discharge home. All sorts of things can go wrong as health care is transferred from the controlled environment of the hospital to the outpatient setting. Often, health care plans after hospital discharge are poorly communicated to the patient and outpatient providers. The days after discharge to home are also a period of high risk for medication errors. Perhaps it is no wonder so many seniors need to return back to the hospital within one month of discharge.

To address this problem, a number of interventions have been developed to smooth the transition to home. A central component of these interventions is intensive patient education and training before they go home. This sure seems like a great idea.

But, an innovative study from Geriatrician Lee Lindquist of Northwestern University suggests there may be an Elephant In The Room. What if the patient is …

Hip Fracture: "A Quintessential Geriatric Illness"

I'd like to briefly turn readers attention to two terrific papers published recently in the Annals of Internal Medicine on the timing and outcomes of surgical hip fracture repair.

The first, an empirical study by Vidan and colleagues from Spain of 2250 patients with hip fracture, investigating the relationship between timing of hip fracture repair and the outcomes mortality and in-hospital complications (delirium, pneumonia, UTI, pressure sores).  Poorer outcomes have been observed for patients with delayed time to hip fracture repair compared to those with immediate hip fracture repair.  Surgeries are often delayed for patients who are very ill, such as patients with advanced heart failure, so that their physiology can be optimized prior to the stress of surgery.  The question is - are the worse outcomes due to the delay in surgery or the reason for the delay?

This study illustrates an interesting research principle called "selection bias."  In the raw unadjusted ana…

A Study of Dignity Therapy on Distress and the End-of-Life Experience

Dignity Therapy is a brief form of psychotherapy developed by Harvey Chochinov, MD with a goal of conserving a dying individuals sense of dignity. It attempts to address sources of psychosocial and existential distress, all the while giving individuals a chance to record the meaningful aspects of their lives in a written document they can pass down to their survivors.

Dignity therapy is administered by trained health care professionals (you too can get trained - just go to the Dignity in Care website to learn more). Sessions last between 30 to 60 minutes and revolve around a series of open-ended questions that encourage patients to talk about important aspects of their lives, hopes, wishes for loved ones, lessons learned, and things they wanted remembered by those they were about to leave behind. The questions used in Dignity Therapy include:


Tell me a little about your life history, particularly the parts that you either remember most or think are the most important? When did you …

Now I Trust My Heart to Lipitor OTC

The New York Times just published an excellent piece by Paula Span on a plan by Pfizer to make its cholesterol blockbuster drug Lipitor an over-the-counter (OTC) medication. A couple things caught my eye when reading this piece, not the least of which was the story was picked up by the Times after this tweet by our very own Ken Covinsky (FYI, in the twitterverse, Ken goes the name @geri_doc):
Pfizer wants to make Lipitor OTC. Just happens to be coming off patent. Message to FDA: no No NO NO! NO!! NO!!!
Well it looks like Ken’s excellent use of exclamation marks worked, as it did get attention. But what’s the big deal? It’s just Lipitor.

As Paula Span reports in the Times, a statin going over the counter is a big deal, both from a financial perspective for Pfizer, and from a patient safety perspective. Lipitor’s patent protection expires this November when at least one generic comes to the US market, so Pfizer is desperately looking for a way to continue milking this cash cow. O…