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Showing posts from May, 2015

The house calls imperative and what you can do about it - right now.

A timely study came out in JAMA IM this week that highlights the need and potential demand for home-based delivery of health care in the US. The study, led by Katherine Ornstein, gave us the most reliable estimate to date of the homebound population in the United States.

The Study

The authors of this study used data from the National Health and Aging Trends Study (NHATS), a population-based survey of individuals 65 years and older living in the US and enrolled in Medicare. For this study, they included 7,603 community dwelling adults ages 65 years and older.

The problem with NHATS is there was no predefined measure of homebound status. So the authors created measures that accounted for the fact the homebound status is more than just disability and more than just receiving skilled home health care service benefits. These measures included data on (1) the frequency with which individuals leave home, (2) whether the individual had difficulty leaving the home, and (3) whether hel…

New guidelines address conflicts over "potentially inappropriate" treatment in the ICU

By: Laura Petrillo, @lpetrillz

Summary

Decisions about life-sustaining treatment in the intensive care unit are among the most ethically fraught decisions in medicine, and disagreements between clinicians and families are not uncommon. To provide guidance to clinicians, the American Thoracic Society (ATS) collaborated with the American Association of Critical Care Nurses and other critical care societies to create a policy statement on "Responding to Requests for Potentially Inappropriate Treatment in the Intensive Care Unit," to be published on June 1st in the American Journal of Respiratory and Critical Care Medicine.

Proponents of palliative care will be glad to see that the guidelines recommend an emphasis on good communication in the ICU and early, expert consultation from palliative care or ethics services to prevent conflict. There has been increasing appreciation of the value of palliative care in intensive care, and efforts like IPAL-ICU are making strides to facili…

Decision aids in serious illness: dissemination strategy, anyone?

by: Alex Smith, @AlexSmithMD

I was fortunate to be part of a really nice systematic review of decision aids for patients with serious illness by Adrian Austin (senior author Laura Hanson).  This manuscript was published online ahead of print in JAMA: Internal Medicine last week.

For this study, Austin reviewed nearly 10,000 titles to identify 38 rigorous studies that meet inclusion criteria.  Seventeen were randomized controlled trials.

I'm not going to summarize the article here - suffice it to say there are a number of very promising decision aids to help people with serious illness.  The article is self explanatory, and I highly recommend that people at a minimum look at the tables to see if there are decision aids you might like to incorporate into your practice. Note, you have to be a JAMA: Internal Medicine subscriber to read the article.

I'd like to pose a question, raised in part by James Tulsky in his terrific accompanying editorial.  James says:
Hospitals and health…

Insights into Geriatrics by Cartoonist Roz Chast

Roz Chast, a beloved and well known cartoonist for the New Yorker, has written a brilliant book that should be required reading for the geriatric curriculum. It is entitled “Can't we talk about something more PLEASANT,” and the title comes from her parents’ refusal to discuss their advancing years and the prospect of death. As I read it I literally saw my entire field flashing before my eyes. 
Known for her nervous looking pen and hilarious observations of urban life, she presents a starkly realistic portrayal of the last years in her parents’ lives and their progressive physical and mental deterioration. An only child, she takes on the responsibility of caring for them in their 90's as they face a trajectory of decline that is the bread-and-butter of any geriatrician. Through the artist's words and images, elder care is depicted in a way that is heartbreaking, funny, and quite accurate.

We observe Ms. Chast’s ailing parents through simple pen and ink and watercolor as th…

Outcomes of In-Hospital CPR in Patients Receiving Dialysis

We’ve talked a lot about the prognosis after receiving in-hospital CPR in this blog (here, here, and here to name a few). In a recent issue of JAMA Internal Medicine, Susan Wong and colleagues looked at what happens to individuals on maintenance dialysis when they receive in-hospital cardiopulmonary resuscitation (CPR).  The results are summarized in the infographic above, and discussed in a little more detail below.

The Study

The authors used data from the US Renal Data System (USRDS) registry that enrolls patients after the onset of end stage renal disease, identifying all patients 18 years or older without a prior kidney transplant who initiated maintenance dialysis from January 1, 2000, through December 31, 2010. Importantly, to be included in this study, these patients needed to be on dialysis for at least 90 days (thereby exluding the sickest of the sick). By linking Medicare claims, they determined who in this registry was hospitalized and who got in-hospital CPR (althou…

Yes, There is a Medical App for That

At this years AGS Annual Meeting, Manuel Eskildsen, Alice Pomidor, Amit Shah, Niharika Suchak, and I led a session aimed teaching how to integrate mobile applications and other emerging technologies into clinical education and patient care.

As part of this session, we created a brief handout for attendees describing some of the apps and resources we use in our own teaching and clinical practice.  We thought it may also be helpful to share this with our GeriPal audience.  We also would love to hear from you on what apps you use in your teaching or clinical practice (please add to the comment section below the handout):
Yes, There’s an App for That: How to Integrate Mobile Applications and Other Emerging Technologies into Clinical Education and Patient Care Apps and Resources List American Geriatrics Society 2015 Annual Meeting  Manuel A. Eskildsen, MD, MPH; Alice Pomidor, MD; Amit Shah, MD; Niharika Suchak, MD; Eric Widera, MD 
Apps/Resources Mentioned by Dr. Eric Widera (Clinical Tea…

Finding the Workforce to Care for an Aging Population

Returning from the American Geriatrics Society Annual Scientific Meeting, I am struck by the thought that the United States’ health care policy is functioning without a compass. We are at the beginning of a tremendous demographic change in this country, but are we adequately preparing US physicians to care for an aging population?

Most residency education in the US is funded through Medicare. Given Medicare’s charge is primarily to care for adults over 65, you would think that Medicare would emphasize training physicians to meet the needs of an aging population. Yet the statement that sticks with me from AGS is this: “10,000 new beneficiaries enroll in Medicare every day, yet we lose 5 geriatricians every week.” Astounding!

Moreover, the additional trends in geriatric education actually point to less support for training physicians to care for older adults. The Reynolds Foundation, which has been a tremendous supporter, is a foundation designed to spend down its assets and will…

The AGS Annual Meeting Program Cover

I am thrilled that the AGS is using my images on the cover of their Annual Meeting program. The collection of photos is the result of years of travel across America photographing aging. The message in this design is that our country's aging population is vast and diverse. In my images I try to portray the inner strength of my subjects that has enabled a long life, and explore spiritual connectedness with the world and society. I also like to show the commonalities of growing old and how the elderly fit within our culture, and present a realistic and positive view of the human journey that most of us will experience.  
Aging is not a popular topic to look at, as most people would rather see flowers, dogs, parakeets, or cute kids. Few people embrace images that tweak insecurities about wrinkled skin and thoughts of mortality. Ageism permeates the mass media's imagery of growing old, which contributes to stereotypes and negativity. In my view, the lack of images of aging in mass…

Celebrate nurses week by stopping the customer satisfaction nonsense

by: Alex Smith, @AlexSmithMD

Happy nurses week!  A special double happiness to the nurses who are also mothers today.

This year, as we celebrate the awesome nurses in our lives, let's take a moment to consider what makes a terrific nurse.

First, by way of gathering information, let's consider the healthcare industry's present views on excellence in nursing.  Let's think about how this conception of excellence in nursing aligns with our own perspectives.

In a recent Atlantic article, titled "The Problem with Satisfied Patients,"Alexandra Robbins writes about the economic incentive hospitals face to improve patient satisfaction scores.  This is a high stakes issue for hospitals, as their bottom line in terms of Medicare dollars is now tied to patient satisfaction scores.  Most of these scores, derived from a patient survey called HCAPS, rely on ratings of nurses.  For example:
“During this hospital stay, after you pressed the call button, how often did you ge…

#ThickenedLiquidChallenge on Making Sense of Alzheimers

by: Alex Smith, @AlexSmithMD

Check it out folks, the #ThickenedLiquidChallenge is now a featured video on MakingSenseofAlzheimers.org, a new site out of U Penn run by Jason Karlawish.  The purpose of the site, as they describe it:
Making sense of Alzheimer's is a creative space for people to understand the past, present, and future of Alzheimer's disease.  It is an evolving forum, a gallery of ideas, a museum without walls. This a brilliant site.  It features personal stories, like that of Dougald MacArthur, a writer, director, and former head of the MFA program in Acting at Temple.  The story is told by his wife Christine MacArthur who marvels at his ability to laugh and enjoy life in spite the Alzheimer's that generally renders him completely unintelligible.

It features poetry, like Twitch, by Deborah Fries.about the complicated feelings a person might feel upon being asked to donate part of a body, like a brain, for scientific research.

It features thoughtful videos, l…

Fatal Falls Rising in Older Adults

The Centers for Disease Control released a sobering report on mortality due to falls and other unintentional injuries in older adults.   The good news:  death from motor vehicle accidents has fallen since 2000, and death from other unintentional injuries such as suffocation, fire, and poisoning remain relatively rare.  The bad news:  between 2000 and 2013, the age-adjusted rate of death from falls in older adults nearly doubled, from 30 deaths per 100,000 adults to 57 deaths per 100,000 adults.  Among adults at the upper reaches of age, the death toll from falls is even more striking.  In 2012-13, there were 226 deaths due to falls per 100,000 adults.


Figure 2. Age-adjusted death rates, by cause of death among adults aged 65 and over: United States, 2000–2013
While concerning, these numbers only scratch the surface of the total burden of falls in older adults. According to the CDC, in any given year, one in three older adults will have a fall, and 20-30% of adults who fall will suffe…

Anticoagulation in Elders who Fall

If you had suggested to me only a short time ago that older people who fall should be taken off of anticoagulation, I would not have hesitated to agree. After all, first, do no harm, right? And isn’t the adage “less is more” absolute in geriatric medicine? But if there is one message I have learned through my internal medicine and geriatrics training, it is to always question “absolutes.”

Case
Mr. A was 91 years old when I first met him and when I took him off warfarin, which he was taking for atrial fibrillation.  He had many falls, lived alone, and required a walker to walk steadily but often did not use it in his very cluttered home. One week later, he fell right in front of our office sustaining a broken nose and I patted myself on the back. One month later, he awoke with aphasia and was admitted to the hospital for suspicion of stroke.  Thankfully, his event cleared within 24 hours, but the message it conveyed cued me to look further into the data we have on anticoagulation and fal…