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Showing posts from June, 2012

Xanax Schmanax

As geriatricians and providers who work with older adults, many of whom are frail, we carry amongst our mantras the avoidance of benzodiazepines (xanax, halcion, ativan, valium to name a handful). Since the inception of the Beers Criteria on Potentially Inappropriate Medications for older adults, benzodiazepines have maintained their steady presence. (see post: http://www.geripal.org/2012/03/beers-criteria-contest-submit-craziest.html) Sadly, I see in my geriatrics practice that benzodiazepines also remain a common prescription for older adults in the community to treat everything from anxiety to insomnia, muscle aches and pain to fear of flying. The patient alluded to in the previous geripal post above who was on valium, halcion, ativan, and doxepin was only one of the MANY patients I encounter in my primary care and consult practice. While her combination of prescriptions was horrifying, I often feel equally depressed and frustrated when I see new patients who come to me with …

What is Meaningful Interaction?

I recently cared for a 96 year old woman who was rehospitalized for a recurrent infection (identifying details altered to protect confidentiality).  Her family struggled mightily with how to balance the goals of prolonging her life, improving her functional ability, and focusing on comfort.

The patient had a history of dementia (not advanced dementia), several chronic conditions, and had been in and out of the hospital 3 times in the last 6 months for infections, each time returning to her nursing home more physically disabled and cognitively impaired than before.  She developed delirium during each hospitalization and never seemed to fully recover.

At the time of admission to the hospital, she was not arousable, and her daughters considered a primarily comfort oriented approach.  After some antibiotics and gentle fluids, she became more responsive.  Although she didn't recall her daughters' names, she seemed to recognize them, and could answer simple yes/no questions.  She …

GeriPal Turns 3: The Training Wheels Come off

Today is GeriPal's third birthday.  This news may bring welcome relief to some of our readers as we have finally moved beyond the Terrible Twos.  However, be forewarned, the training wheels are coming off this year.   So, expect a lot more of the same content that has made this last year so fun to recap in this post.

Highlights from the Last Year

There was a lot of memorable moments this last year, however the following are the ones that really stand out for me:
We launched our sister site ePrognosis and received a huge response from the press with articles in the NY Times, MSNBC, the Daily Beast, Fox News, USA today, and NPR to name a fewDan Matlock's post on being accused of murder went viral with the story being picked up by Colorado Public Radio and the NY TimesJim Cleary used a GeriPal post as a reason why Palliative Medicine should embrace social media in the journal Palliative MedicineGeriPal and Pallimed had another successful year at AAHPM, with Blogs to Boards sess…

Choosing Wisely: AGS's List Open for Recommendations

AGS and AAHPM are teaming up with over a dozen other medical specialty societies to participate in the second wave of ABIM Foundation's Choosing Wisely Campaign.  So far, nine medical specialty organizations, along with Consumer Reports, have identified five tests or procedures commonly used in their field, whose necessity should be questioned and discussed.

AGS is now accepting submissions for its list of five tests or procedures commonly used in their geriatrics, whose necessity should be questioned and discussed.  The Choosing Wisely list should provide specific, evidence-based recommendations to physicians and patients in order to make wise decisions about the most appropriate care based on their individual situation.

Please click on this link here to submit the top three tests and/or procedures that you feel should be included in AGS’ list. Submissions will be accepted until July 6th.

To help spark some ideas, I'll include some comments from our previous post that sugge…

Blogs to Boards: Question 17

We realize that we have been a little slow to post the Blogs 2 Boards questions up on GeriPal and Pallimed (thanks for the nudges GeriPal readers!) So, we will give you this weeks blogs to boards question and, in honor of Pallimed's Birthday, the handouts for the entire block of questions and answers!  (click here for the handout links).

Question 17

Mr G is a 74-year-old nursing home resident with coronary artery disease and end-stage renal failure (eGFR of 12). He is considering starting treatment with dialysis but would like to know more about what life will be like after starting dialysis.

What would be the most accurate statement in regards to his prognosis?

a) His functional status is likely to improve with renal replacement therapy 
b) His functional status is likely to be maintained at his pre-dialysis level 
c) He is unlikely to have significant symptom burden if he elects not to initiate dialysis 
d) The majority of nursing home residents die within one year of starting dialys…

The Role for Acupuncture in COPD Management

About one in 10 adults older than 40 years of age have COPD. For these individuals dyspnea is the primary disabling symptom that limits independence and quality of life. We try to treat it with bronchodilators and inhaled glucocorticoids, but eventually the dyspnea worsens as the disease advances. We add oxygen, we try opioids, and we search for other potential causes and other potential treatments that may relieve this distressing symptom. The good news this week is that there may be one more intervention in our bag of tricks – acupuncture.

Yes, the Archives of Internal Medicine just published a study from Japan that adds some evidence that acupuncture is an effective treatment for dyspnea. Now for all you skeptics out there: I realize I live in San Francisco but I swear I’m generally a skeptic as well. Complimentary and Alternative Medicine (CAM) studies are often fraught with methodological issues. This study done by a group of Japanese researchers unfroze my heart to…

Emergency Departments as a Place for End-of-Life Transitions

I have always been struck by the question of where individuals would prefer to die. You know, the one where most Americans say they prefer to die at home despite the stark reality that the minority actually end up doing so. It just doesn’t seem like this is really the right question. For me, I don't really care where I die - I'll be dead. What matters is how and where I live for the time that I have left.

This is why I am particularly fascinated by a recent article discussed in the NY Times today and published in Health Affairs by our fellow GeriPal bloggers Alex Smith and Ken Covinsky, as well several other researchers from UCSF and Harvard. The study adds to a growing amount of evidence revealing how and where older American live before death.

There is a lot of interesting findings in this paper that uses data from the Health and Retirement Study, a nationally representative data set, and links it to Medicare claims data. The take home point though is summarized best in t…