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Showing posts from January, 2015

Food is love, or The fundamentals of Long Term Care

Although I usually think with my stomach, I have been particularly preoccupied with how we feed our most vulnerable elders this week. That’s because my Home Based Primary Care team took up the #ThickenedLiquidChallenge in order to raise our awareness of what we put our patients through. The challenge is admittedly biased to make one hate thickened liquids. Participants have to thicken everything they drink with corn starch until it resembles honey in consistency. Those of us who have fed these products to our patients are well aware that “nectar-thick” liquids are much more palatable (i.e. less disgusting).

It has been fascinating to watch a transformation take place as we accept the challenge. Our dietitians are speaking up in team meeting. They are questioning whether or not thickened liquids are consistent with our patients’ goals and wishes. We care for patients at home, so we are well poised to ask this question. HBPC can even bring a provider and the RD out together on a ho…

What is Reminiscence Therapy and does it work?

Ms. HR is an 84 year-old lady with mild to moderate Alzheimer’s disease (Mini Mental State Exam score of 22) and hypothyroidism for about 5 years, with gradual but steady worsening in her memory over past year. She takes levothyroxine and donepezil. Currently, she lives with her daughter and is independent in her ADLs (activities of daily living) and IADLs (instrumental activities of daily living). In light of the memory problems, her family wonders if in addition to her cholinesterase inhibitor (donepezil), using old photos or videos might help preserve some of her memories. One of our social workers brought up the concept of reminiscence therapy.
Reminiscence therapy (RT), which was introduced over 20 years ago, makes use of life events by having participants vocally recall episodic memories from their past. It may take place in a group setting, individually, or in pairs. It may be structured or unstructured. While the primary aim of RT is to strengthen cognitive memory component…

Pallimed-GeriPal Party at the Annual Assembly of AAHPM-HPNA-SWHPN

Time to gather your peers and join fellow readers of Pallimed and GeriPal for our annual party at the Annual Assembly of AAHPM, HPNA, and SWHPN. Since the last two years were such a success with the progressive party we will be doing that again this year. We will begin at McGillin’s at 8pm. After that follow the hashtag #HPMparty or our Facebook event page where we will be posting updates on the next location.

All are welcome, this is no exclusive crowd. There will be many writers from both websites at the party and we always like to meet readers and hear your feedback.

McGillin’s is near the corner of 13th and Chesnut just a few blocks South of the Marriott Hotel and Convention Center.

Date: Thursday, February 26th. Start time 8pm. End time TBD

Where: Depends:
Only way to find out is to keep up with our twitter and Facebook feeds, or type in #hpmparty in twitter to follow the live feed Pallimed Twitter feed / Pallimed Facebook pageGeriPal Twitter feed / GeriPal Facebook page #H…

Working with rather than against speech & swallow therapists #ThickenedLiquidChallenge

By Alex Smith @AlexSmithMD and Sarah Stranberg, Speech Pathologist, University of Pittsburgh Medical Center

Consider the following vignettes, common in both geriatrics and palliative care:

1. A 93 year old woman with advanced dementia is admitted to the hospital for the third time in the past 6 months for an aspiration pneumonia. The admitting team orders a speech and swallow consult.

2. A 68 year old man suffers a massive ischemic stroke. After 15 days in the ICU he has recovered minimal function.  The neurology team requests a speech & swallow consult to justify likely need for PEG (a hole into the stomach for artificial feeding through a tube).

In each of these cases, my initial reaction has always been “Noooooooooooooooooo!!!!! Don’t place the speech and swallow consult!” I worry that the consult will place the patient on an inevitable path toward a PEG tube, without assessment of goals, values, and alternative approaches such as hand feeding.

However, at the annual Fo…

Do thickened liquids benefit people with swallowing problems? #ThickenedLiquidChallenge

There are a lot of people with swallowing difficulty who are currently getting thickened liquids.  For instance, in one study published in 2004 in the Journal of the American Dietetic Association, one out of twelve nursing home residents in the U.S. were getting thickened liquids. Of these individuals getting thickened liquids, 30% were getting honey consistency thickened liquids and 60% were getting nectar thick (which is less viscous than honey thick).

If this many individuals are on thickened liquids, there has to be some evidence to back it up, right?

Evidence for Thickened Liquids

Thickened liquids are most commonly used in individuals with dysphagia to improve the ability to safely swallow liquids with the hopes of preventing aspiration, pneumonia, and death. Most of what we have regarding the benefits of thickened liquids comes from bedside or videofluoroscopic evaluation looking at risk of aspiration during the evaluation.   However, what we really care about is not the …

The Thickened Liquid Challenge - #ThickenedLiquidChallenge

Our hospice and palliative care team decided this weekend to do the "Thickened Liquid Challenge.”  This is a simple challenge that is mainly focused on putting ourselves in the shoes of our patients who are prescribed thickened liquids (or perhaps I should say drink from their cups).

The rules are simple:
12 Hour Challenge: All fluids must be thickened to “honey consistency” using a beverage thickener for a 12 hour contiguous period. Food does not have to be thickened.Mini-challenge: drink an 8 ounce drink thickened to honey consistency (coffee, wine, juice, water, or any drink of your choice)Videotape yourself and include an announcement that you accept the challengeIf you fail the challenge you must donate $20 to a geriatrics or palliative care charity of your choice (see notes below for some suggestions)At the end of your challenge, nominate a minimum of three other people/teams to participate in the challenge. When posting the challenge online, please use the hashtag #thicke…

Institutionalized and Interventionalized: the ways we care for the medically fragile

by: Diane Stonecipher, RN

As a young nurse, some 30 years ago, I worked in a large academic medical center, famous for its cardiovascular surgery. The environment was exciting, scary, cutting edge and steeped in humanity. Anything that could be done was done, yet these physicians were pioneers, not profiteers. They were making discoveries and doing procedures on the cusp of progress. Fearless and skilled, they were not particularly comfortable with death or failure and I was often in the position of tending to the daily needs of patients who no longer saw their surgeon frequently. Uncomfortable in the OR, I was very at home at the bedside. It was here where I learned so much about these patients and here where I could ask what they wanted and they were free to tell me. I never thought twice about getting Mr. B some sushi and Chinese food or Mr. M a small bottle he could hide for his “nightcap.”

I also noticed how much the family members appreciated that once nothing more could “be d…

Geri Tech: It's the little things

There's a lot of interest in using technology to improve the lives of seniors, especially here in the Bay Area. This Christmas my grandmother received as a gift this little gadget which to me so beautifully captured both the promise and pitfalls of such tech.

It's a headlight. For a walker! Brilliant. Maybe.

If you want to help seniors, first you need to identify a problem. Falls are a big problem. Many falls occur at night, when a person gets out of bed to use the bathroom in the dark.

Next you need to conceptualize effective solutions. We have many imperfect tools and strategies to help prevent falls at night, ranging from bedside commodes to reducing nighttime fluid intake to leaving lights on. The solution here is a light that attaches to the walker.

There's a lot to like. It's small, lightweight, and unobtrusive, yet has a strong LED light and long-lasting battery. The soft, stretchable plastic housing wraps simply but securely around the walker's horizontal …

Choosing life: a story of the value of palliative care

by Leanne M. Yanni, MD


It’s a name. It comes across in our Electronic Health Record as a consult is placed to the Palliative Care Team. Mary Tulane; age 67; ovarian cancer. I call her hospital doctor and ask, “How can our team be of support?” He replies, “She is refusing tests and her family is asking a lot of questions about her disease. They seem anxious and confused.” This is often how a consultation begins; a consultation that most often turns into a relationship.

A Palliative Care Team is a team of individuals with specialized training in serious illness.

As the doctor on the team, I assess how patients are feeling physically as well as how they are functioning which tells me a lot about the future trajectory of their illness. I then translate this medical information into an understandable framework that is used by patients and families to make important, often life-impacting decisions.  Understanding the emotional and spiritual response to serious illness (for example, fear, …

Will You Wish With Us?

By: Kim Evanoski (@CareManage4All)

So I am waking up in the dark and, at the end of the day, driving through the dark finishing the work day; it leads to wanting “wishes” granted for some simple life treats like warm sun light through the car window.

 The act of "wishing" is pretty significant in palliative care, if you really think about it fully. It happens weekly, if not daily, where personal struggles require "wishing".

 Do you have "wishing" happening on your watch?

 In my practice, “wishes” are validated for the sheer empowerment of the act.

 "Wishing" is actually a significant activity. It provides a therapeutic and thoughtful process that I would like to encourage. I think "wishing" is important to all matters human. "Wishing" brings a tremendous amount of open thinking towards improving our internal and external worlds. And in that open thinking, "wishing" should be allowed in statement form with no j…

Prognostic Factors for Survival in Multiple System Atrophy

An 88 year-old male with probable multiple system atrophy-parkinsonism (MSA-P) with at least 4 years of gait instability complicated by fall and cervical fracture, sick sinus syndrome status post pacemaker placement, postural hypotension requiring midodrine and fludrocortisone, achalasia status post BOTOX® injection and dilation, urinary retention status post chronic indwelling Foley catheter presented to the Geriatrics outpatient clinic to explore hospice care. In a brief background search of MSA, I found that there are 2 distinct presentations of MSA – cerebellar and parkinsonian. In discussing his prognosis with the patient, I wondered if in patients with MSA, does parkinsonism phenotype predict better survival than the cerebellar phenotype? And are there other disease specific or patient specific features that predict survival in MSA patients? 


I searched the terms “multiple system atrophy, survival” on PubMed Clinical Queries (website url), which I have often found more useful t…

Let's Talk About Prognosis

GeriPal's very own Alex Smith recently gave an absolutely fabulous "Ted-like" talk in which he made the statement that "prognosis needs to be a part of everyday medical care."  Unfortunately, as he so eloquently states in the video (which can be watched here), it isn't always taken into account.



To dive a little deeper into the lack of prognosis in health care decision making, lets just take a look at cancer screening.   Individuals with a limited life expectancy are exposed to all the immediate harms from a screening test, yet may not live long enough to see any of the benefit (the concept of lag-time-to-benefit).   Yet, people with limited life expectancy still get these screening tests as evident by the following studies:
A 75-year-old with severe comorbidities is twice as likely to be screened for colorectal cancer than a 76-year-old no comorbidities (click here for the article).  This is despite that the knowledge that a healthy 76 year old is expected …

Sudden death with trimethoprim-sulfamethoxazole while on ACE-inhibitor or ARBs

What? It’s already 2015. But, I have so many great articles published in 2014 that I need to post about! Well then, for my next series of posts I’m going to do a quick round-up of articles published last year that we haven’t already talked about on GeriPal.   This first on the list shows an association between sudden death in those who were given trimethoprim-sulfamethoxazole (co-trimoxazole) while already on renin-angiotensin system blockers (i.e. angiotensin converting enzyme inhibitors (ACE-inhibitors) and angiotensin receptor blockers (ARBs).

The Study

This was a large nested case-control study published in the BMJ last year.  It included residents of Ontario who were 66 years of age or older and were treated with an ACE-inhibitors or ARBs.   The cases were those who had sudden death and who received an outpatient prescription for either co-trimoxazole, amoxicillin, ciprofloxacin, norfloxacin, or nitrofurantoin within 7 days of death.  Each case was matched with up to four cont…

Back to basics: are we losing sight of what hospice care is all about?

by: Amy Getter, a hospice nurse who blogs regularly at hospicediary.com

In our ever-challenging and changing medical system, the current hospice and palliative care movement has undergone heightened scrutiny, increased regulatory stipulations, and in general has become a part of the federal government’s health care crisis (just review Medicare Conditions of Participation and billing requirements to get a head full of terms and guidelines to be overwhelmed by it all). Yes, hospice has become big business.

I am a hospice nurse. I have seen the changes in the past decade, as Medicare requirements become more stringent and hospice has moved from grassroots to mainstream; and the “evidence-based practice” mantra has precluded use of medications and treatments that have historically been effective but now lack current “research validation”. Or new results from a few cooperate-funded studies who have the most to gain by predetermining that certain treatments are not effective change our…

Does doll therapy reduce agitation in dementia patients?

This post is the first in the #GeriCases series, in which we discuss a clinical case in geriatrics and the attempt to provide patient-centered care with the use of best available evidence.
Mrs. GM, an 84 year old woman with moderate dementia with behavioral disturbances, comes in accompanied by her daughter to the office. Daughter was feeling overwhelmed trying to care for her mother, and very angry and frustrated that she can’t seem to get help. Mrs. GM lives alone and is independent in her ADLs and most IADLs despite having dementia. The problem is that at night she becomes confused and starts shouting and banging on the walls. She wakes up her neighbors who call the police. Her daughter doesn’t know what to do and thinks that her medications (including an anti-psychotic) are not helping. I wondered if there was another way to help her. I remembered that in the nursing home, some residents who were very agitated were given dolls. I wondered if doll therapy was an option instead of …

Welcome to #GeriCases

I want to welcome all GeriPal bloggers and readers to this new series of geriatric patient cases (#GeriCases) under the realm of Evidence-Based Medicine (EBM).
EBM is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.
In fewer words, it can be explained by the model by Haynes, et al.


Even though patients would like to believe that clinicians have all the answers to their medical problems, clinicians often face questions and uncertainty when evaluating patients. EBM urges the clinicians to utilize best available evidence in light of their clinical expertise and patient preferences. This requires skill and time: to identify the question, look for evidence in the literature, evaluate the article for its validity and applicability and finally …