GeriPal - Geriatrics and Palliative Care Blog

This years' American Geriatrics Society (AGS) meeting in Grapevine, Texas, is fast approaching. The schedule is jam packed with great talks to attend.  I'd like to mention one special event not listed on the final program.

The Palliative Care Special Interest Group (SIG) is schedule for Saturday, May 04, 2013 from 7:00 pm - 8:30 pm. To spice things up this year we have decided to go a little off the general SIG format. What we have in mind is combining the Palliative Care SIG with the International SIG for the first hour (7-8pm) in order to fit in the following presentation:

Difficult Conversations at End of Life (EOL): Opportunities & Techniques to Avoid Cross-cultural Landmines: Views from Four Continents

This special SIG session will be led by Maura Brennan and will feature:

Maria del Carmen Castillo Gallego, MDReham Shaaban DOAriba Khan, MBBS MPHMichael Lerch, MD. MBAShobhana Chaudhari MD Each of the speakers will will discuss Geriatrics and Palliative Care issues fro…

It seems like such a good idea.  Before a patient takes a new drug, they would like to know that it is going to improve a health outcome they really care about.  Will it make me live longer? Will it lower my risk of becoming disabled?

But the problem is that it often takes a long time for a study of a new drug to show that it has meaningful impacts on patient outcomes.  Enter the brilliant idea of surrogate outcomes.  A surrogate outcome is an outcome that is associated with the health outcome a patient may really care about.  For example, a patient may want to take a drug to reduce their risk of getting dementia or Alzheimer's Disease.  They may care so much about preventing dementia that they will even take a drug that gives them side effects.  But, it may take a pharmaceutical company years to conduct a trial to determine if a drug prevents dementia.

Surrogate endpoints seem like a brilliant solution to this problem.  We know that biomarkers such as amyloid, that is found on…

The British Medical Journal (BMJ) has published a couple of interesting pieces this week that might interest you (controversy alert ahead at the end!). Get a copy of this weeks version and read it! (subscription may be needed for links)

First, there is a wonderful piece about an outstanding example of hospital care for patients with dementia by Kate Sartain - a celebration of good care delivery!

Next up, there is a Pair of articles discussing Prognosis Research: A framework for researching clinical outcomes and Stratified medicine research . (I wonder if Eric or Alex know any good bloggers about prognosis who could comment?)

For education of the "competent novice" there is an article on Caring for the dying patient in the hospital that is going into my teaching file (Do people still have those?) along with a thoughtful editorial by Fiona Godlee, the editor of BMJ entitled Helping patients to die well

Do Patients Need to Know They Are Terminally Ill?

Finally, there is a f…

I'm at the annual SGIM meeting and the following topics came up in conversations w/various folks, so I thought I should write about it.

First, I was struck by a recent news article about Google and how the expectation is that each one of their new products should be 10 times better than the competition.  In an interview, Larry Page talked about how setting the bar that high forces everyone to think "outside the box" and come up with new, transformational ideas, rather than tinkering around the edges to make something marginally better.

Second, I was struck by a recent scholarly article by Mittra entitled, "Why Modern Medicine is in a rut" (PMID 19855121) (Props to Dave Aron who suggested the article to me).  In it Mittra argues that the first 30 years after WW2 was characterized by transformational change:  Dialysis, Ventilators, CABG, etc.  However, the last 30 years have been characterized by incremental change despite a huge increase in research funding.  H…

Do you have any good ideas on how to get more people to complete advance directives early, re-visit them periodically, and for people with serious illness document their end-of-life wishes via forms like POLST? Well, it’s time to turn those ideas into something more.

The California HealthCare Foundation (CHCF) Design Challenge is now in full swing.  The goal of the challenge is to "raise awareness of end-of-life care issues and to generate a variety of ideas for compelling experiences that could lead to greater activation and conversation about end-of-life preferences".  Anyone in the US is welcome to enter this design challenge, which will award $10,000 in prizes for inspirational solutions.

You can submit pretty much anything you think will get people talking about end-of-life preferences. Your proposed solutions can be something on a website or mobile app, it can be some type of product or object, it can be a marketing campaign, or even an art installation.

It also …

Richard Besdine, MD medical officer for the American Federation for Aging Research, has a terrific piece in the Huffington Post about palliative care and misconceptions about the field.  This is GeriPal to the core.  Please follow this link to read the full version.

As a tantalizing preview, here are the 5 misconceptions in brief:
If you accept palliative care, you must stop treatment.Palliative care is the same as hospice.Electing palliative care means you are giving up.Palliative care shortens life expectancy.There isn't need for palliative care because my doctor will address pain anyway. Sound familiar?

by: Alex Smith @alexsmithMD

Evidence is mounting that regular exercise may prevent dementia and reduce the decline in physical function associated with dementia. Dr. Covinsky recently decried the lack of a market for exercise interventions to prevent physical decline for patients with dementia, saying there are no "special interests with the resources needed to fight for their availability."
Our answer is home grown!  During a recent Geriatrics Journal Club about the NEJM study on costs of dementia, Dr. Sei Lee realized that what is one man's trash is another man's treasure.  
Presenting Dr. Lee's Miracle Dementia Regimen! 
The first component is regular exercise, at least 3 times a week.  Included in Dr. Lee's regimen are several outstanding DVDs.  Here is a free preview: 


The second really important part of the program is a miracle tonic (see photo).  This tonic should only be taken after regular exercise.  The tonic is called obecalp (caution, do not read backwards). 

This program will …

Today is National Healthcare Decisions Day. The day was created as “an initiative to encourage patients to express their wishes regarding healthcare and for providers and facilities to respect those wishes, whatever they may be.” Much of what will be going on today at various outreach programs will be focused on the first part of this initiative: educating the public on the importance of advance care planning.  I'd like to take a second though and pose the following question to our audience:
Should the failure to follow end-of-life preferences be considered a medical error?
This question is derived from a recent JAMA Internal Medicine editorial by GeriPal contributors Theresa Allison and Rebecca Sudore.  In it they make a persuasive argument that the disregard of patients' preferences is indeed a medical error.  Here is an excerpt:
"Discussions about goals of care and code status constitute a medical procedure every bit as important to patient safety as a central line pl…

Alzheimer’s Disease and other dementias have impacts far beyond cognitive function. Alzheimer’s patients also experience steady declines in physical function. Over time, these patients lose the ability to do basic activities of daily living such as getting dressed or bathing, becoming dependent on family caregivers. Walking ability also steadily declines. For this reason, patients with Alzheimer’s disease fall frequently.

A landmark study published today in JAMA Internal Medicine demonstrates that a patient-centered exercise intervention administered by trained physical therapists can slow the physical deterioration of Alzheimer’s Disease.

The investigators randomized 210 patients (average age= 78) with moderate to severe Alzheimer’s Disease to either usual care or one of two exercise intervention groups as follows:

Home Exercise: A physical therapist visited the patient’s home for one hour twice a week for one year. The treatments were goal oriented and tailored to the patien…

It has been over three decades since the first cases of AIDS were observed in the United States, and in one month we will be marking the 30th anniversary of dual publications in Science attributing a novel retrovirus as the potential cause of AIDS.

Since this time, and in large part due to the development of antiretroviral therapy, mortality due to HIV & AIDS has significantly decreased, so much so that it is now considered a chronic rather than an acutely fatal disease.  With these changes, HIV is also now becoming a disease of the elderly.  By 2015, half of HIV positive individuals will be older than 50 years of age.

This is the background to what I consider one of the most important review articles in JAMA this year. Starting off with a case of a 74 year old who was diagnosed with HIV in 1984 (when AIDS was almost a uniformly fatal disease) the authors, Meredith Greene, Amy Justice, Harry W. Lampiris, and Victor Valcour, walk us through the prevention and management of HIV …