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Showing posts from 2013

Avoiding too high of a threshold for elder safety and self-neglect

My five-year old sons favorite show on TV is called Railroad Alaska.  Just in case you haven't figured out why by the title alone, may I just ask what self-respecting five-year old wouldn’t love a show whose protagonist is a train and whose antagonist is snowpack in various forms, including avalanches. I though despise the show, mainly because nothing really ever happens during any of the 60 minute long episodes (aside from the aforementioned avalanches). However, I do find it interesting that most of the semi-staged plots focus on older couples who are living off-the-grid, miles away from anything except a railroad line. There are often clips of their children talking about how their weekly/monthly visits are really the only help the older adults get in their rural homes. The children also talk about how far away their parents are from any medical care, and if she/he had “another” stroke, they would likely find him/her dead a week later. But they all seem comfortable with t…

What to give Uncle Ernie, Grandma Mabel and Great Aunt Rose?

I’m literally running out the door for last minute shopping. I wanted to make time, though, to share with GeriPal good gifts for older adults that my colleagues have been sharing with me in case you're still in gift buying mode.

These suggestions are a mix of practical, helpful and more traditionally gifty. And it's meant to make you feel generous because giving makes your and your recipient's brains actually grow, sort of like this! (Thanks for the tip, Don Berwick, who summarized the wonderful benefits of being social and giving during a recent speech).

Links are embedded in each description.

Have a Very Geri Holiday!

Need a hand?There are lots of products that help maintain independence at home by making little things easier.
Jar Opener: There are jar openers that help a hungry jar owner open the lid by releasing the suction first. Ideal for people with reduced grip strength or wrist arthritis. Jar opener 1 or jar opener 2. (Credit: Lousie Aronson and Dandan Liu) Oth…

How Your Name Can Influence Your Health

"We find ourselves in something of a quandary when it comes to making up our minds about the phenomenon which Stekel calls the 'compulsion of the name'. What he means by this is the sometimes quite gross coincidence between a man's name and his peculiarities or profession. For instance ... Herr Feist (Mr Stout) is the food minister, Herr Rosstäuscher (Mr Horsetrader) is a lawyer, Herr Kalberer (Mr Calver) is an obstetrician ... Are these the whimsicalities of chance, or the suggestive effects of the name, as Stekel seems to suggest, or are they 'meaningful coincidences'?Carl Jung
What's in a name? Apparently a lot if you believe a paper published in a truly merry edition of the British Medical Journal (see here and here for previous very merry article Christmas Edition articles). As Carl Jung noted, there has been a longstanding belief that one's name may affect one's chosen profession and character (the theory of this is called nominative determ…

The Dementia Caregiver: Improving their Mental Health and Quality of Life

There are few harder things than being a caregiver for a family member with dementia.   These caregivers are the unsung heroes of the US health system.   Because of family caregivers, 2/3 of persons with dementia are able to continue living at home, often avoiding nursing home care until dementia is very advanced. 
Nursing home care is hugely expensive, and much of the cost in the US is paid by Medicaid.  Next time you hear about how Medicaid nursing home costs are big contributors to federal and state budget crises, remember that without caregivers these costs would at least double. 
But while caregivers of dementia patients are unsung heroes, they are also forgotten heroes.   The US medical system does little to help them.  And they need help.  Dementia caregiving is very stressful and numerous studies have shown negative health consequences in caregivers.  Most prominent is depression.  Caregivers of dementia patients often meet clinical criteria for a diagnosis of major depress…

Communication training: is simulation enough?

 by: Alex Smith, @AlexSmithMD

Major paper in JAMA about palliative care communication.  I think we all believe there are better and worse ways to communicate with seriously ill patients.  Tony Back, Bob Arnold, and James Tulsky have really led the way in creating a curriculum for training doctors how to have these conversations - first with OncoTalk for oncologists, followed later by the spinoffsIntensiveTalk for intensivists and GeriTalk for geriatricians.  The OncoTalk program has been shown to improve communication skills with simulated patients.  But no real world studies had examined the impact of communication skills training on real world (not simulated) patient reported outcomes.

Until now.

The well-known physician-researcher Randy Curtis teamed up with others from the University of Washington (including Tony Back) and the Medical University of South Carolina to investigate the impact of communication skills training on patient reported outcomes.  Over 400 internal medic…

Celebrating in Stillness

by: Brad Stuart MD

Thanksgiving dinner at our place was loud, as only 3 generations of people can make it. Now, a couple of days later, only stillness remains. The celebration continues, but more quietly.

I spent the weekend before last, November 16 and 17, with an old friend on the East Coast. We joked, told stories and drank wine like we had for over 40 years. At 3 AM on Friday, November 22 he woke up with chest pain. Not the relentless, sqeezing ache of coronary disease, but much worse: aortic dissection ripped through his chest and belly. Paramedics rushed him to a nearby academic center. He was awake and aware the whole way, without pain medication because his blood pressure was near zero. 3 teams of surgeons were waiting. It took them 10 hours to replace his entire aorta.

Yesterday, one week later, the day after Thankgiving, he walked back into his house with a couple of minor visual field cuts and no other problems. Over the phone we marveled at his good fortune. He’s not a me…

Aging 2.0: Why We Should Engage the Innovators, & 11 Start-ups To Consider

If you are interested in the intersection between aging and innovation, these certainly are intriguing times.

Last Thursday I attended the kickoff event for Aging 2.0's brand new GENerator program. This is "a new founders program that supports the most promising entrepreneurs working to enhance the lives of older adults and improve long-term care." (Which I think means this is a business accelerator, but after only a year blogging about digital health innovations, I can't promise to have mastered all the business lingo.) 
Despite the whopping size of the boomer market (see this terrific Bloomberg article on how business has so far struggled to tap it), this seems to be the first accelerator focused on serving the 50+ demographic.
I found myself impressed both by the growth of Aging 2.0 -- an organization co-founded by a gerontologist only 18 months ago -- and by the offerings of the eleven companies chosen. It's encouraging to see the power of innovation and tec…

10 Serious Illnesses & the Number of Times "Palliative Care" Was Mentioned In Wikipedia #HPM

Every time I listen or talk to Diane Meier I get inspired.  Today was no different.  She inspired me to do a quick search looking for how closely wikipedia articles on serious illnesses align with the current CAPC definition of palliative care.  I thought this may be tough, as I was trying to figure out how to judge different definitions of palliative care.    I was wrong.  Dead wrong.  It was shockingly easy as most articles on the ten life threatening illness that I looked up NEVER even mentioned palliative care.  The ones that did were mostly talking about palliative chemotherapy or radiation therapy.

10 Serious Illnesses and the Number of Times "Palliative" or "Palliative Care" Was Mentioned in Wikipedia

1. Breast Cancer: No mention of the word palliative (really, zero.  Check for yourself)

2. Prostate Cancer: the word palliative used twice, both times talking about how treatments would be "palliative and not curative”. No other mention of palliative care…

Oral Ketamine for Depression and Anxiety in Hospice

by: Alex Smith, @alexsmithMD

Journal of Palliative Medicine recently published a nice exploratory open label study of daily oral ketamine for depression and anxiety in hospice patients.  We discussed this paper in our last palliative care fellow's journal club, with the esteemed fellow Dr. Virginia Dzul-Church presiding.

I won't regurgitate the whole article - although Eric Widera just pointed out that one of the take home points of discussing this article is the importance of actually reading the article.  In brief, the wonderful Dr. Scott Irwin recruited 14 hospice patients with depression and anxiety and treated them with 0.5mg/kg of ketamine by mouth daily.  He found a significant reduction in both anxiety (starting at day 3) and depressive symptoms (starting at day 14) with few adverse side effects.

Sounds great, right?

Some points to consider:

No placebo.  Without a placebo we can't tell how well this drug would have performed above and beyond the placebo effect.  S…

Should My Patient Get an Amyloid PET Scan for the Diagnosis of Alzheimers?

In April, the Food and Drug Administration (FDA) approved florbetapir F-18 (Amyvid) PET scans to identify areas of accumulation of amyloid plaques.  Centers for Medicare and Medicaid Services (CMS) though has yet to allow reimbursement for amyloid PET scans for the evaluation of dementia outside of clinical studies, citing insufficient evidence that it improves health outcomes for Medicare beneficiaries.

The CMS decision is strongly opposed by Eli Lilly and its subsidiary Avid Radiopharmaceuticals, the makers of Amyvid. The Alzheimer's Association also was "disappointed" by the CMS decision, stating that there was “clear, scientific consensus recommendations by the Association and the Society for Nuclear Medicine and Molecular Imaging (SNMMI) regarding appropriate, limited coverage, only in specific populations."

So who is right? CMS? The Alzheimers Association? The Association and the Society for Nuclear Medicine and Molecular Imaging (SNMMI)?  Eli Lilly? …

A Better Health System for Frail and Disabled Elders

"The current 'care system' provides disjointed specialty services, ignores the challenges of living with disabilities, tolerates routine errors in medications and transitions, disdains individual preferences, and provides little support for paid or volunteer caregivers."

This quote is from an amazing and brilliant viewpoint by Dr. Joanne Lynn on how the US health system and Medicare are failing to meet the needs of frail and disabled elders.  As Dr.  Lynn notes, this is an issue that that is virtually ignored in the media, political discourse, and professional education.  The vast majority of persons who live into their 80's and 90's will live with a prolonged period of disability in which they will need help because of physical and cognitive problems.

Older people and their families facing the problems of late life disabilty are faced with a Medicare system that offers unlimited resources to spend on disjointed disease-focused medical care.  But older pers…

The Quality of Palliative Care: It Can and Must Be Measured

Is it important to provide high quality palliative and supportive care in patients with serious illness?  Does it matter if we treat pain in patients with metastatic cancer?  Does it matter if we listen to patients and provide care consistent with their goals?

I'm sure most health system leaders would answer an emphatic yes! to these questions.  But do they really mean it?  Will their actions match their words?  Unfortunately, the answer to that question will usually be no.  If you are serious about improving a care process, you need to measure that process, and use those measurements to improve.   Performance measurement has led to many process improvements in health care such as increasing the use of Beta Blockers after MI and the use of screening eye exams to prevent vision loss from diabetic retinopathy.  Shouldn't we also be using performance measurement to improve the quality of palliative and supportive care in the seriously ill?

This is what makes a study recently pub…

Using Tech to Engage Patients in Advance Care Planning

Advance care planning is a process; a seemingly hard to do, hard to document process that we just aren’t very good at doing. No wonder, as to do it right involves multiple different steps like choosing a surrogate decision maker, identifying what is most important in life, and communicating these wishes to loved ones and other clinicians. Making it harder is the finding from Terri Fried and others that older individuals are in different phases of readiness to engage in these different aspects of advance care planning.

So how do we get individuals to engage in the advance care planning process? A new and potentially game changing way is to use technology to move individuals along the different stages of behavior change (i.e. from pre-contemplation to higher stages such as contemplation, preparation, and action) for each component of advance care planning. A new publication in the Journal of Pain and Symptom Management suggests that the PREPARE website, designed by Dr. Rebecca Su…

On Cooks and Cookbooks: Failure of a Palliative Care Pathway

by: Alex Smith @AlexSmithMD

Wouldn’t it be great if we came up with a standardized approach to caring for hospitalized patients in the last two days of life? Think of it. Experts in hospice and palliative care could come to consensus on the best palliative care pathway for hospitalized patients nearing the end of life. Standardized assessment of distressing symptoms, the use of opioids, and other common medications used near the end of life. We could incentivize use of pathway, and improve care across the board. We should do it, right?

Well in the UK, they did it. It was widely adopted in the UK and throughout Europe. And now they’re retracting it.

The Liverpool Care Pathway was just that – an intervention designed to export the best of hospice and palliative medicine to non-palliative care clinicians caring for hospitalized patients in the UK.  And now the government is scrapping it.

How did this happen? First, two critical must reads for more details. Stories in the med…

Literature Potpourri

by: Alex Smith, @AlexSmithMD

Some great paper GeriPal readers should be award of published recently:
In the Journal of Pain and Symptom Managment, Harvey Chochinov calls for action on dignity conserving care.  He argues for just 20 minutes of dedicated time four times a year to reflect on the subject of caring, using brief videos as prompts (a very GeriPal concept).  Here is an excerpt, "Formal education for healthcare providers lacks a continued focus on achieving a culture of caring. If caring really matters, healthcare systems can insist on certain behaviors and impose certain obligations to improve care tenor, empathy, and effective communication....Healthcare professionals must set aside some time, supported by their institutions, to advance a culture of caring—now is the time to take action."Opioid prescribing for chronic pain is a hot topic - see this New York Times article about the forthcoming FDA restrictions on Vicoden prescribing, restrictions opposed by the Ameri…

Doing the Right Thing and Making It Pay

Advanced care and palliative care can reduce healthcare costs for people with serious chronic illness. It’s hard to dispute that this is a good thing. But some dispute it anyway, using graphic language to frighten people into believing that something wonderful will be taken away from them in a heartless attempt to cut costs.

Yes, these are scare tactics, but they are more than that. They reflect a deep cultural anxiety that the mistakes that led to the downfall of managed care will be resurrected by health care reformers. “Death panel” rhetoric may give voice to justifiable fears that access to services wanted by patients and their physicians will be denied by agents of payers and of providers who are increasingly assuming financial risk.

These fears must be confronted head-on. Advanced care and palliative care take no test, procedure or intervention off the table. They take nothing away. In fact they provide new services and a new kind of support to seriously ill people and their lo…

Specialized Care for Older Hospitalized Adults as a Palliative Care Intervention

Hospitals are dangerous places for older adults.   Nearly a third of hospitalized older adults are discharged with a new major functional disability they didn't have before becoming to the hospital. They are also at greater risk for being unable to return home, to require nursing home placement, and to be rehospitalized within 6 months.  Moreover, having delirium in the hospital is even worse, as it is associated with an even greater risk of long term cognitive impairment, institutionalization, and death compared with those who don't develop delirium.

Thanks to our geriatrics colleagues, a number of interventions, including acute care of elders (ACE) units and the Hospital Elder Life Program (HELP), have been developed around the idea that a redesigning the hospital care system can improve these outcomes.  What though are we to make of a new negative study published in BMJ by Sarah Goldberg, Rowan Harwood and colleagues on specialized care units for older adults with deliriu…