GeriPal

by: Jeffrey M. Levine MD, AGSF   Benares, also known as Varanasi, is the holiest city in India and one of the oldest living cities of the world.  It is built on the banks of the sacred river Ganges – a place of pilgrimage and home to Shiva, the volatile and compassionate god who is known as the destroyer of worlds.  It is in Benares where one can obtain “moksha,” when the soul is freed from the cycle of reincarnation through birth and death.   Hindus bring their dead to this city for cremation on the banks, and spread the ashes into the river.  There are even hostels where the elderly can come to die.  As a geriatrician I became interested in these customs, and traveled to Benares to learn and observe.  On the banks of the Ganges I unexpectedly found a celebration of old age.     To get to the river you need to wind through ancient alleys only a few feet wide, lined with beggars and shared with sacred cows that wander freely.  Along the banks are Ghats, or large sets

by: Alex Smith, @AlexSmithMD We've talked previously on GeriPal about Dumb Medicine: continuing preventative treatments near the end of life. In one study of patients diagnosed with advanced incurable cancer and an average life expectancy of less than 2 years, up to 15% were being screened for another cancer that had no chance of harming them in their lifetime. In another study of women with dementia and an average life expectancy of less than 3 years, 18% were being screened with mammograms for a breast cancer that if detected, would not harm them in their lifetime.   Key features of both of these studies: Preventive treatments have a lag time to benefit.  Cancer screening is designed to detect slow growing cancers that will not cause symptoms or harms for about 10 years. The harms of testing are real.  False positives are no joke.  Detecting a clinically insignificant cancer can lead to tests and treatments (think biopsy, surgery, chemotherapy, radiation) for a

by: Alex Smith @AlexSmithMD An article was published yesterday that provides supporting evidence that a treatment* for advanced cancer improves survival by up to 6 months (18 vs 12 months).  This study was conducted in a population of patients with advanced cancer who had a prognosis of less than 2 years.  The first, earlier study of this treatment* to examine survival demonstrated a survival benefit of about 3 months in advanced lung cancer. This is big news folks.  A major question for our society - can we afford this treatment*?  By way of comparison, Avastin (bevacizumab) increases survival by about 4 months, about the same as the average survival benefit of this treatment*. Avastin had sales of about $2-3 billion per year at the time it was released.  The average cost for Avastin per patient is between $40,000-100,000 per course of treatment . How much as a society are we willing to invest in a treatment* that improves survival by 4 months in advanced cancer? *

Photo by Joan Teno Blog by: Amy Getter, a hospice nurse who blogs at hospicediary.com I had been drained with frustration and immersed in the medical disaster we call home care this past week. Perhaps if I had never known the simplicity of visiting hospice nurses, before the medical giants of organizations and corporations had grabbed such a firm hold to significantly alter just a home visit by a nurse to a dying person, I would not have recognized what was startling. Okay, I have agreed that it is imperative to standardize what we do, what we say, ensuring that our care is cloaked in the vestiges of the acceptable and researched and validated hospice and palliative care approach. Last week we learned of a new shortage and increased cost of a medication (atropine) used for years for an end of life symptom: to reduce the gurgling sounds present at the last hours of many dying people, what hospice nurses term “respiratory congestion” and what the untrained average person stil

by: Stephanie E. Rogers, MD @SERogersMD For the first time in human history, adults older than age 65 will outnumber children younger than age 5.(1) In medical school, we receive training in treating young patients during the pediatrics lecture series and later in an extended clinical rotation, yet the training we receive for treating geriatric patients is significantly lacking. It was not until I entered my fellowship in geriatrics - after completing four years of medical school and three years of internal medicine residency - that I received any formal training in the care for older adults. Pediatric units are common at most hospitals, where multidisciplinary teams including nurses and pharmacists are specialized in treating children and most children have access to an outpatient pediatrician. In contrast, few health systems have adopted the specialized models that exist to provide cost-effective care for older adults in hospitals, clinics, and at home. Furthermore, plen

by: Jeffrey M. Levine MD, AGSF (jlevinemd@shcny.com), www.jmlevinemd.com Successful aging is hard to define. The concept took root in 1987 when Rowe and Kahn published an article distinguishing “successful aging” from “usual aging.” Since then, scholars have been grappling for a definition but with little consensus. As discussed in a recent special issue of The Gerontologist (V 55 #1, February 2015) there are numerous directions from which the successful aging concept can be approached ( see also this previous GeriPal post ). As a geriatrician who spent much of my career in nursing homes with the sickest sick I grapple with the concept of successful aging. Early on I noticed that two persons of the same advanced age can have vastly different states of health, functional status, family structure, economic status, and social standing. Lifestyle, personal choices, attitude, and coping mechanisms often had an influence on how people lived in their advanced years. The Geront

by: Colin Scibetta, MD ( @colinscibetta ) Malignant bowel obstructions are a known complication of advanced cancer, especially in ovarian and gastrointestinal, and a frequent reason for admission to the hospital. Somatostatin analogues (such as octreotide) reduce gastric secretions and intestinal activity and there is some evidence for their use in improving symptoms of malignant bowel obstructions. A randomized control trial published last year out of Australia [1] sought to understand the benefit, if any, of adding IV octreotide to a standardized regimen of steroids and histamine blockers. A little about the Study This was a double blind, placebo controlled randomized trial of patients with nausea and vomiting from a confirmed malignant bowel obstruction. Patients were enrolled at multiple sites by providers from different specialties (ER, general medicine, oncology and palliative care) after the diagnosis was confirmed and assuming they did not meet criteria for immedi

by: Kelley Babcock, MS, CCC-SLP, BCS-S, @kelleybabcock The #thickenedliquidchallenge has certainly raised awareness of how difficult it can be for patients to enjoy honey-thickened liquids. Many physicians and speech pathologists have never tried the liquids they so frequently prescribe to patients, so this increased awareness may help initiate important conversations with patients, clinicians and family members about quality of life and patientʼs rights to decline recommended interventions. Unfortunately, this challenge has been named the “thickened liquid challenge,” which could be confusing for patients who find these videos on YouTube. A more accurate name would be the “honey-thick liquid challenge.” While I almost never recommend honey-thickened liquids ( see my blog here for rationale ), I do recommend nectar-thickened liquids with appropriate patients. I do this judiciously and using the following decision-making process: Does the patient show consistent aspiration on an i