GeriPal

by: Eric Widera (@ewidera)

The word "palliative" is popping up in a lot of unexpected places of late.  

Sometimes its used in combination with the word "care" but not in the traditional way we think of usual palliative care practice.  One just has to go back to Alex Smith’s post of a recent JAMA study on “palliative care” meetings in the ICU or Elizabeth Lindenberger's wonderful post in Pallimed about the same study.    Let’s just say that the term palliative care is used loosely in the discussion section of the manuscript and newspaper articles written about this study.

Another great example is brought to us by Drew Rosielle’s post in Pallimed on the term “Palliative Sedation”:
“Besides the ridiculously confusing nature of the phrase 'palliative sedation,' it's another example of the myriad ways in which 'palliative' is used: care-which-is-palliative, care-which-is-given-by-a-palliative-care-team, palliative pediatric cardiac surgeries, pa…

by: Eric Widera (@ewidera)

So yesterday I wrote about the rapid uptake of using antipsychotics for insomnia in the hospital setting and wondered “when did this become a thing?”   Today, I’ll like to talk about antipsychotics for nausea by first asking that same question.

When did antipsychotics for nausea become a thing?  A long time ago.  Haloperidol and other anti-dopaminergic agents like metaclopromide have a long history of use both in the hospice, palliative care, and oncology setting.  Now we have a little more evidence that at least one of these drugs, olanzapine, may help with the prevention of chemotherapy induced nausea and vomiting.

The Study

A double-blind, randomized control study published in the NEJM last week compared 10mg olanzapine with placebo for 4 days, in addition to usual care with dexamethasone, aprepitant or fosaprepitant, and a 5-HT3 receptor antagonist, in 380 patients with no previous chemotherapy who were receiving cisplatin or cyclophosphamide–doxorubicin…

by: Eric Widera (@ewidera)
Sleep.   It’s sometimes hard enough to get enough at home with all the distractions of daily life.   It’s only made more difficult in the hospital setting.

We’ve seen a lot of interventions to help with this that generally consist of pills, because as compared to changing the environment or culture of the hospital, as it’s an easy intervention.  However, most of these have little to no evidence that they work.

The latest one that I just saw in the hospital was prescriptions for quetiapine, an antipsychotic, for sleep.   I thought to myself, well that’s odd.   Hopefully this won’t become a thing.   I’m sad to say, just like Pokémon Go, it has.

A study came out last week in JAMA IM titled “Off-label Use of Quetiapine in Medical Inpatients and Postdischarge.”   The authors prospectively enrolled all inpatients 60 years or older between December of 2013 and April of 2015 from a teaching hospital in Quebec, Canada.

One of the authors then looked at all of the …

by: Alex Smith, @AlexSmithMD

There's been some terrific discussion about the ICU trial published in JAMA.  I'd like to share some of those reactions here for those who missed them.  For those of you who missed the original GeriPal perspective about the trial, click here.

The first is from the comments on the original post.  Sean Morrison, MD, director of the palliative care service at Mt. Sinai (one of the hospitals participating in the trial) gives his insider understanding of the intent and purpose of the trail: "this was not a palliative care intervention."




As the director of one of the palliative care programs that participated in this study, I thought it might be useful to add a few more comments to the discussion above.

I think it is important to understand the background to this study as we understood it at Mount Sinai. The purpose in conducting this study was to see whether a structured compassionate sharing of prognosis and likely outcomes to ICU families wo…

by: Ken Covinsky @geri_doc

A colleague of mine, who is chief of the Geriatrics Division at a major medical school, recently relayed to me the following story about a conversation with with a leader at their University  when discussing plans to promote the University’s work to potential donors.  I found the report kind of discouraging.  The interaction went something like this:
University Leader:  We are having a wine and cheese reception to show some of our donors the great work that is being done at the University.  We thought it would be great to give them a talk about successful aging.  Would you be willing to talk to them?
Geriatrics Chief:  Gosh.  Thanks for inviting me.  I would love to tell them about all the great work we are doing!  We have some really innovative clinical programs to help seniors who are becoming disabled.  We also have a new initiative to help stressed out caregivers.  I bet your donors will be really excited to hear bout a new program we are developing to help…

by: Alex Smith, MD.  Alex Smith was formerly a palliative care attending at UCSF.  Now that his work has been shown to be ineffective and possibly harmful, he is seeking new employment.  If you know of a job for a former palliative care physician, please tweet Alex @AlexSmithMD.

Groundbreaking new study published in JAMA yesterday.  Wait, is "groundbreaking" the right word?  Perhaps "retrenchment" is a better word, as in "the act of cutting down or cutting off." As in the take home message of the first author: we don't need palliative care, cut them out; ICU docs are doing just as well or better without them.

You may have heard some of the buzz about this paper, as in JAMA's tweet:
No need for routine #palliativecare meetings for families of pts w chronic #criticalillnesshttps://t.co/X1vaF0Ynl5 — JAMA (@JAMA_current) July 5, 2016
My reply to this was:
Re-phrase: No need for routine "fast food style" #palliativecare meetings for families …

Case: Ms. P is a 76 year old lady with a past medical history of GERD, osteoporosis status post right hip fracture, C. diff infection in 2011, uterine fibroids status post TAH-BSO, who comes in for a follow-up visit. Her medications include omeprazole 40 mg daily, vitamin D 800 IU daily, alendronate 70 mg weekly. Physical exam is unremarkable, except for BMI of 18. During medication reconciliation, she asks, “I heard that my omeprazole can cause dementia…”

I recalled the recent NY Times article about heartburn drugs related to increased risk of dementia and wondered if that could be possible. I told Ms. P, “I will look into that and let you know if you need to be concerned about that.”

The question was: In older patients, is the exposure to proton pump inhibitor (PPI) medications as compared to no exposure associated with increased risk of dementia? In order to answer this question, I performed a search for “PPI and dementia risk” in PubMed. I found two recent studies to review.


In…