GeriPal - Geriatrics and Palliative Care Blog

"Never be the first to use a new descriptive term for older people nor the last to give up an old one."  This is the advice given by Laura Morrison and colleagues in the discussion section of a fascinating new study published in JAGS this week.  The authors looked at how "older people" are described in the English-language medical literature from 1950 to 2015. Specifically they looked at the use of the terms “geriatric,” “aged,” “old,” “older,” and “elderly” in Pubmed.

Here is what they found:
We liked using the term “aged” in publications before 1961, but "aged" quickly lost its appeal over the next decade“Geriatric” became more common from 1955 to 1976 but again fell out of favor over the last couple decades “Elderly” peaked around the time of George Michael's release of "Father Figure" (I'm not sure if there was a connection between the two)“Older" hit its low point in 1962 but boomed in use with the boomers, and is now our most…

by: Alex Smith, @AlexSmithMD

In 1976, Balfour Mount published a landmark description of the first palliative care unit, in the Royal Victoria Hospital, Montreal.  He opens with this quote from John Hinton's Dying:
We emerge deserving of little credit; we who are capable of ignoring the conditions which make muted people suffer.  The dissatisfied dead cannot noise abroad the negligence they have experienced.Bal Mount goes on to decry decreases in physicians and nursing visits as death becomes imminent, longer response times to care for dying patients than those expected to recover, and isolation, distrust, and suspicion that arises from lack of communication between patients, family members, nurses, and physicians.

How far has palliative care come as a field in the intervening 40 years?  What can we say about palliative care and how it helps or does not help people?  How well have we advanced care for those seriously ill people whose voices are "muted," and the "dis…

Nursing home residents are often sent to the hospital for care that often offers little hope of improving quality of life or changing the course of illness. Some facilities though seem to do much better in preventing these "potentially burdensome hospitalizations". We discuss with Andrew Cohen, the lead author of a recent JAMA IM paper on this subject, to learn a little about what is in the secret sauce of these exceptional nursing homes.

Listen to the podcast here, see the transcript below.

by: Alex Smith, @alexsmithMD


Links to articles discussed:

Main article:

Cohen, Andrew B., M. Tish Knobf, and Terri R. Fried. "Avoiding Hospitalizations From Nursing Homes for Potentially Burdensome Care: Results of a Qualitative Study." JAMA Internal Medicine (2016).

Other interesting/related articles mentioned:

Sulmasy DP, Snyder L. Substituted Interests and Best JudgmentsAn Integrated Model of Surrogate Decision Making. JAMA. 2010;304(17):1946-1947. doi:10.1001/jama.2010.1…

Clinical formulations, something that few of us outside of mental health providers know about, but can be a critical tool in improving communication skills, especially around serious illness.  Learn about them from our special guest, Dani Chammas, in this weeks GeriPal Podcast.  Dani makes the case in this podcast that the single most valuable thing clinicians can do to improve communication is to get into the practice of asking yourself:
What is the core psychological struggle that has this patient or family stuck?What communication techniques might I use to address that?How did their response to my intervention change my hypothesis?Repeat 1-3.   I love it when people can distill complicated topics into a couple steps that we can all try. I know I will.  (listen to the podcast here)

 Here are links to a couple papers if you want to learn more:
The first article is called "Taking Care of the Hateful Patient" dating all the way back to 1978!  And per Dani, it is “a total clas…

Antipsychotics are often used to treat delirium, although the evidence behind their efficacy is pretty minimal.   That evidence is even worse when it comes to patients with advanced illness or those nearing the end of their lives.    This week’s JAMA IM gives us the first placebo-controlled trial of two antipsychotics, risperidone and haloperidol, in relieving symptoms of delirium associated with distress among patients receiving palliative care.   The results do not look good for antipsychotics.

The Study

This was a randomized controlled, double-blind clinical trial done in eleven Australian inpatient hospice or hospital palliative care services.  Patients all had life-limiting illness, delirium, and symptoms of delirium that are associated with distress (inappropriate behavior, inappropriate communication, and illusions or hallucinations).

The participants received either placebo or pretty conservative age-adjusted doses of oral risperidone or haloperidol every 12 hours for 72 hours,…

This week on the GeriPal podcast, we talk with Angelo Volandes (click here to listen) (see transcript below).  Angelo Volandes is famous for his use of video to improve advance care planning conversations with patients and their families.  In this podcast we ask Angelo "why video?" We hear the story of how he got the idea for video in the first place.  And we push him about the potential for bias in these videos.

If you want to read more about Angelo's work, please check out the following:
ACP Decisions website for access to free video examples Angelo mentions in the podcastAngelo's article in JGIM about use of video advance care planning aids in HawaiiGeriPal review of Angelo's book "The Conversation" by: Eric Widera (@ewidera)
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Transcript of the Podcast

Eric:      Welcome to the GeriPal Podcast. This is Eric Widera.

Alex:      This is Alex Smi…