Stay ConnectedA geriatrics and palliative medicine podcast for every health care professional.
Two UCSF doctors, Eric Widera and Alex Smith, invite the brightest minds in geriatrics, hospice, and palliative care to talk about the topics that you care most about, ranging from recently published research in the field to controversies that keep us up at night. You’ll laugh, learn, and maybe sing along.
CME and MOC credit available (AMA PRA Category 1 credits) at www.geripal.org
Copyright: © 2020 GeriPal. All rights reserved.
The US Preventive Services Task Force (USPSTF) concluded back in 2000 that there is insufficient evidence to recommend for or against routine screening for dementia in older adults. Are there, though, populations that it may be helpful in, or should that change with the advent of the new amyloid antibodies? Should it? If so, how do we screen and who do we screen?
On this week's podcast we talk with three experts in the field about screening for dementia. Anna Chodos is a geriatrician at UCSF and the Principal Investigator of Dementia Care Aware, a California-wide program to improve the detection of dementia in older adults who have Medi-Cal benefits. Joseph Gaugler is the Director of the Center for Healthy Aging and Innovation at the University of Minnesota, director of the BOLD Public Health Center of Excellence on Dementia Caregiving, and Editor-in-Chief of the Gerontologist. Lastly, Soo Borson is a self-described primary care leaning geriatric psychiatrist, developer of the Mini-Cog, and co-leads the CDC-funded BOLD Center on Early Detection of Dementia.
In addition to the questions asked above, we also cover the following topics with our guests:
What is dementia screening?
Who should get it if anyone?
What should we use to screen individuals?
What happens after they test positive?
And if you are interested in learning more about the Guiding an Improved Dementia Experience (GUIDE) Model for dementia, check out this podcast.
Emergency podcast! We've been asked by many people, mostly junior/mid career faculty, to quickly record a podcast on ageism and the elections. People are feeling conflicted. On the one hand, they have concerns about cognitive fitness of candidates for office. On the other hand, they worry about ageism. There's something happening here, and what it is ain't exactly clear. We need clear eyed thinking about this issue.
In today's podcast, Louise Aronson, author of Elderhood, validates that this conflict between being concerned about both fitness for the job and alarmed about ageism is exactly the right place to be. We both cannot ignore that with advancing age the prevalence of cognitive impairment, frailty, and disability increase. At the same time, we can and should be alarmed at the rise in ageist language that equates aging with infirmity, and images of politicians racing walkers or a walker with the presidential seal. Ken Covinsky reminds us that we should not be making a diagnosis based on what we see on TV, and that if a patient's daughter expressed a concern that their parent "wasn't right," we would conduct an in depth evaluation that might last an hour. Eric Widera reminds us of the history of the Goldwater Act created by the American Psychological Association in the 1960s which states that psychiatrists should refrain from diagnosing public figures, and the American Medical Association code of ethics which likewise discourages armchair diagnosis (rule established in 2017).
We frame today's discussion around questions our listeners proposed in response to our Tweets, and are grateful for questions from Anand Iyer, Sandra Shi, Mike Wasserman, Ariela Orkaby, Karen Knops, Jeanette Leardi, Sarah McKiddy, Cecilia Poon, Colleen Christmas, and Kai Smith. We talk about positive aspects of aging, cognitive screening, the line between legitimate concerns and ageism, ableism, advice for a geriatrician asked to comment on TV, frailty and physical disability, images in the press, historical situations including , and an upper age limit for the Presidency, among other issues.
Of note, we talk about candidates from all parties today. We acknowledge concerns and speculation that others have raised about candidates across the political spectrum, current and former. We do not endorse or disclose our personal attitudes toward any particular candidate. Fitness for public office is a non-partisan issue that applies to all candidates for office, regardless of political party.
There's something happening here, and what it is ain't exactly clear.
Strong recommendation to also listen to this terrific podcast with another geriatrician all star, Jim Pacala, on MPR!
In May we did a podcast on KidneyPal (the integration of palliative care in renal disease), which made us think, hmmm… one organ right next door is the liver. Maybe we should do a podcast on LiverPal? (or should we call it HepatoPal?)
On today's podcast, we do that by inviting four palliative care leaders who are integrating palliative care into the care of those with liver disease: Kirsten Engel, Sarah Gillespie-Heyman, Brittany Waterman, and Amy Johnson.
It's a jampacked 50 minutes, filled with pearls on taking care of patients with liver disease. We cover:
How each of their LiverPal teams are structured
Why and how LiverPal differ from general palliative care or other palliative care specialty areas (KidneyPal, PalliPulm, etc)
How to prognosticate in liver disease and how they communicate this with patients
How to think about expectations of transplants and limitations of it
How to manage complications and symptoms ranging from ascites, hepatic encephalopathy, pain, itching, cramps, and depression
Also, if you want to take an ever deeper dive, check out our 2022 podcast on End Stage Liver Disease with Jen Lai, Ricky Shinall, Nneka Ufere, and Arpan Patel
"Anxiety is a lot like a toddler. It never stops talking, tells you you're wrong about everything, and wakes you up at 3 a.m." I'm not sure who wrote this quote, but it feels right to me. We've all had anxiety, and probably all recognize that anxiety can be a force of action or growth but can also spiral to quickly take over our lives and our sleep. How, though, do we navigate anxiety and help our patients who may end up in the anxiety spiral that becomes so hard to get out of?
On today's podcast, we've invited Alex Gamble and Brianna Williamson to talk to us about anxiety. Alex is a triple-boarded (palliative care, internal medicine, and psychiatry) assistant professor of medicine at Stanford. Brianna is one of UCSF's palliative care fellows who just completed her psychiatry residency.
We start by defining anxiety (harder said than done), move on to talking about when it becomes maladaptive or pathologic, and how DSM5 fits into all of this. We then walk through how we should screen for anxiety and how we should think about a differential. Lastly, we talk about both non-pharmacologic and pharmacologic treatments.
It's a lot to cover in 45 minutes, so for those who like to take a deeper dive, here are some of the references we talked about:
Two books that Alex Gamble often recommends to patients can help build up your capacities to sit with anxiety (per Alex, both are from an Acceptance and Commitment Therapy framework)
I have to start with the song. On our last podcast about urinary incontinence the song request was, "Let it go." This time around several suggestions were raised. Eric suggested, "Even Flow," by Pearl Jam. Someone else suggested, "Under Pressure," but we've done it already. We settled on, "Oops…I did it again," by Britney Spears.
In some ways the song title captures part of the issue with urinary incontinence. If only we lived in a world in which much of urinary incontinence was viewed as a natural part of aging, the normal response wasn't embarrassment and shame, but rather an ordinary, "Oops…I did it again." And if only we lived in a world in which this issue, which affects half of older women and a third of older men, received the research and attention it deserves. We shouldn't have therapeutic nihilism about those who seek treatment, yet urinary incontinence is woefully understudied relative to its frequency and impact, and as we talk about on the podcast, basic questions about urinary incontinence have yet to be addressed. I don't see those perspectives as incompatible.
Today we talk with George Kuchel and Alison Huang about:
Urinary incontinence as a geriatric syndrome and relationship to frailty, disability, and cognitive decline
Assessment of incontinence: the importance of a 48 hour voiding diary, when to send a UA (only for acute changes)
How the assessment leads naturally to therapeutic approaches
Non-pharmacologic approaches including distraction, scheduled voiding, and pelvic floor therapy
"Last ditch" pharmacologic treatments.
Landmark studies by Neil Resnick and Joe Ouslander.
Enjoy!
I always find cachexia in serious illness puzzling. I feel like I recognize it when I see it, but I struggle to give a clear definition or provide effective ways to address it.
In today's podcast, we had the opportunity to learn from a renowned expert in palliative care, Eduardo Bruera, about cachexia and anorexia in serious illness. Eduardo established one of the first palliative care programs in 1984, created the Edmonton Symptom Assessment Scale (ESAS), and significantly contributed to the evidence base for palliative care symptoms that many of us rely on daily.
During our discussion with Eduardo, we delved into how we can define cachexia and anorexia, why they occur in conditions like cancer, how to assess for them, and explored the interventions that are helpful and those that are not in the treatment of these conditions.
As Eric notes at the end of today's podcast, we talk about many difficult issues with our patients. How long they might have to live. Their declining cognitive abilities. What makes their lives meaningful, brings them joy, a sense of purpose. But one issue we're not as good at discussing with our patients is sexual health.
On today's podcast Areej El-Jawahri, oncologist specializing in blood cancers at MGH, says that sexual health is one of the top if not the top issue among cancer survivors. Clearly this issue is important to patients. Sharon Bober, clinical psychologist at DFCI, notes that clinicians can get caught in an anxiety cycle, in which they are afraid to ask, don't ask, then have increased anxiety about not asking. Like any other conversation, you have to start, and through experience learn what language is comfortable for you. Don Dizon, oncologist specializing in pelvic malignancies at Brown, suggests speaking in plain language, starting by normalizing sexual health issues, to paraphrase, "Many of my patients experience issues with intimacy and sexual health. Is that an issue for you? I'm happy to talk about it at any time." All guests agree that clinicians feel they need to have something they can do if they open Pandora's box. To that end, we talk about practical advice, including:
The importance of intimacy over and above physical sexual function for many patients
Common causes and differential diagnoses of sexual concerns in patients with cancer and survivors
Treatments for erectile dysfunction - first time the words "cock ring" have been uttered on the GeriPal Podcast - and discuss daily phosphodiesterase 5 inhibitor therapy vs prn
The importance of a pelvic exam for women experiencing pain
What is "pelvic physical therapy?"
Treatments for vaginal dryness and atrophy
ACS links, NCCN links, Cancersexnetwork, and a great handout that Areej created
And I get to sing Lady Gaga, also a first for GeriPal! And let me tell you, there's nothing like the first time (sorry, I couldn't help it!).
The landscape of options for treating people with kidney failure is shifting. It used to be that the "only" robust option in the US was dialysis. You can listen to our prior podcast with Keren Ladin talking about patients who viewed dialysis as their only option, and structural issues that led to this point (including this takedown of for profit dialysis companies by John Oliver). One of the problems was a lack of an alternative robust option to offer patients. As one of our guests says, you have to offer them something viable as an alternative to dialysis.
Today we interviewed Sam Gelfand, dually trained in nephrology and palliative care, Kate Sciacca, a nurse practitioner (fellowship trained in palliative care), and Josh Lakin, palliative care doc, who together with a social worker and other team members started KidneyPal at DFCI/BWH, a palliative care consult service for people with advanced kidney disease. As a team, they provide a robust alternative to dialysis for patients with kidney failure: conservative kidney management.
And "conservative," as they note, can mean not only a "conservative approach," as in non-invasive/less aggressive, but also an effort to "conserve" what kidney function remains.
We get right down to the nitty gritty of kidney supportive care techniques they incorporate in clinic, including:
Communication about the choice between dialysis and conservative kidney management: what are the tradeoffs? Function often declines after initiating dialysis, at least among nursing home residents. Dialysis may extend life, but those "additional" days are often spent in the hospital or dialysis, away from home. Symptoms are common in both options, though more anxiety and cramping in dialysis, more pruritus and nausea in conservative kidney management..
Introducing the idea of hospice early, at the time of diagnosis with kidney failure. Listen also to our prior podcast with Melissa Wachterman on hospice and dialysis.
Approaches to treating fatigue
Approaches to treating pain - the second most common symptom (!) - and the answer isn't tramadol (or tramadon't) - rather think buprenorphine patch or methadone, and how to dose gabapentin and pregabalin. Also, don't count out the NSAIDS!
Approaches to treating itching/pruritus
Approaches to treating nausea
Our guests were deeply grateful to their colleagues Dr. Frank Brennan, Dr. Mark Brown, and clinical nurse consultant Elizabeth Josland of the renal supportive care team at St. George Hospital in Sydney, Australia (down under) for teaching them the ropes of palliative care in kidney failure. And we got to learn some new vocabulary, including the meaning of "chunder."
Enjoy!
Who gets to decide on what it means to have a disease? I posed this question a while back in reference to Alzheimer's disease. I'll save you from reading the article, but the main headline is that corporations are very much the "who" in who gets to define the nature of disease. They do this either through the invention of disease states or, more often, by redrawing the boundaries of what is considered a disease (think pre-diabetes).
On today's podcast, we invite Adriane Fugh-Berman to discuss the influence of industry, whether it be pharma or device manufacturers, on healthcare. Adriane founded PharmedOut, a Georgetown University Medical Center project that "advances evidence-based prescribing and educates health care professionals and students about pharmaceutical and medical device marketing practices."
I've listened to a lot of Adriane's talks. It is clear to me that she is not anti-medicine or even anti-pharma but is very much against both the visible and hidden influences that pharma and device manufacturers use to sell their products. This could be through overt marketing like advertisements or drug rep visits, or more covert measures like unrestricted grants to advocacy organizations, funding of CME, paying "key opinion leaders," or the development of "disease awareness campaigns."
So take a listen and dont worry, while GeriPal podcasts offer CME, we never take money from industry.
By: Eric Widera
On today's podcast, we've invited four hospice and palliative care social media influencers (yes, that's a thing!), all of whom focus their efforts on educating the general public about living and dying with a serious illness. Their work is pretty impressive in both reach (some of their posts are seen by millions of viewers) and breadth of work. We've invited:
Julie McFadden (aka Hospice Nurse Julie): Julie is a social media superstar, with 1.5 million subscribers on TikTok, another 400,000 subscribers on her YouTube channel, and another 350k followers on Instagram. She covers topics on death, dying, and hospice from a hospice nurse perspective, and she also has a book coming out called "Nothing to Fear: Demystifying Death to Live More Fully," which is now available for pre-order.
Matt Tyler (aka Pallidad for those on Twitter): Matt is the Hospice and Palliative care doctor who created How To Train Your Doctor, which helps patients living with serious illness find tips on "owning" their healthcare plan on his Instagram and YouTube pages. He was also the one who we have to thank for suggesting this podcast!
Hsien Seow & Samantha ("Sammy") Winemaker: Hsein and Sammy's goal was to start a revolution with their podcast "The Waiting Room Revolution," which is now in its 7th season! The hope was by going directly to those living with a life-changing illness, we could directly tackle the question that comes up so many times - "Why didn't anyone tell me that sooner…" They also just published a book," Hope for the Best, Plan for the Rest," and Sammy is a TikTok star in her own right, with some posts having over a million views.
We covered a lot of topics in the podcast from::
What motivated them to create public-facing social media channels?
Why focus on the public rather than other health care providers?
How do they deal with professional barriers and the barrage of comments?
Advice for others who might want to dabble in social media outreach
So, take a listen and check out their social media sites to get inspired. Just don't let Alex make me do another TikTok dance…
Eric Widera
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