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
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We know from study after study that most older adults would prefer to age in place, in their homes, with their families and embedded in their communities. But our health system is in many ways not particularly well set up to help people age in place. Medicare does not routinely require measurement or tracking of disability that leads many people to move out of their homes, and many interventions that support people to age in place are unfunded, underfunded, or funded by philanthropy rather than the government.
Today we talk with Sarah Szanton, who created the CAPABLE multi-disciplinary model to help older adults stay at home, and Kenny Lam, who used a national study to examine the need for home-modification devices. And we preview another of the AGS songs for the literature update - this one to the tune of "My Get up and Go" by Pete Seeger.
Enjoy!
-@AlexSmithMD
There are no currently approved disease modifying drugs for Alzheimer's disease, but in a couple months that may change. In July of 2021, the FDA will consider approval of a human monoclonal antibody called Aducanumab for the treatment of Alzheimer's disease. If approved, it will not only make this drug the defacto standard of care for Alzheimer's disease, but will create a monumental shift in the usage of other currently limited diagnostic tests, including Amyloid PET scans and other biomarkers.
On today's podcast, we talk about all things Amyloid, including Aducanumab and Amyloid PET scans with Gil Rabinovici. Dr. Rabinovici is the Edward Fein and Pearl Landrith Endowed Professor in Memory & Aging at UCSF.
I could talk to Gil all day long, but we try to fit all of these topics in this jam-packed podcast:
One of our earliest COVID podcasts with Jim Wright and David Grabowski a year ago addressed the early devastating impact of COVID on nursing homes.
One year ago Mike Wasserman, geriatrician and immediate past president of the California Long Term Care Association, said we'd have a quarter million deaths in long term care. A quarter of a million deaths. No one would publish that quote - it seemed inconceivable to many at the time. And now, here we are, and the numbers are going to be close.
In this podcast we look back on where we've been over the last year, where we are now, and what's ahead.
One theme that runs through the podcast is that if this level of death, confinement, and fear occured to any other population, change would have been swift. But nursing home residents, for the most part, don't have a voice, they're not able to speak up, they lack power to move politicians and policy.
Mike Wasserman is a provocateur. He is a needed voice for the nursing home residents and the nursing home staff who often are not able to speak for themselves. He is regularly quoted in major news outlets, and was in the Washington Post about opening up nursing homes to visitation the day of our podcast. If you don't follow him on Twitter @Wassdoc you should!
-Link to Wassmerm and Grabowski's article in the Health Affairs blog on the need for financial transparency in nursing homes.
-Link to webinar about what to do about COVID in long term care from April 2020
-@AlexSmithMD
COVID has taken a devastated toll in nursing homes. Despite representing fewer than 5% of the total US events, at least 40% of COVID‐19–related deaths occurred in older individuals living in nursing homes. The good news is that with the introduction of COVID vaccines in nursing homes, numbers of infections and outbreaks have plummeted. However, only about 2/3rds of nursing home patients and only about ½ of nursing home staff have been vaccinated, largely due to hesitancy about taking the vaccine.
On today's podcast we talk about vaccine hesitancy with Sarah Berry, Kimberly Johnson, and David Gifford and the lessons learned from their "town hall" intervention they did that was just published in the Journal of the American Geriatrics Society.
A couple of take-home messages for me in this study was that vaccine misinformation was rampant, many nursing staff had lingering questions they wanted answered before getting the shot, and that sharing stories and personal experiences is an important way to overcome hesitancy.
In addition to listening to the podcast, we really encourage everyone to take a look at the JAGS article as it has two great tables for anyone willing to do similar town halls. The first is a summary of the concerns of healthcare staff. The second is sample responses to address some of these concerns.
Hospice may not be a great match for all of the care needs of people with dementia, but it sure does help. And, as often happens, when patients with dementia do not decline as expected, they are too frequently discharged from hospice, an experience that Lauren Hunt and Krista Harrison refer to in an editorial in the Journal of the American Geriatrics Society (JAGS) as feeling like being "expelled."
We talk on this week's podcast with Elizabeth Luth, author of a study in JAGS about her study of patients in a large New York Hospice with dementia who either are discharged from hospice or live longer than 6 months. Turns out this happens - brace yourselves - nearly 40% of the time!
And we talk with Elizabeth and Lauren Hunt, who helps us contextualize these findings in the setting of larger issues around the fit of hospice for persons with dementia and hospice Medicare policy.
(We will add the link to the editorial when it's uploaded to the JAGS website).
-@AlexSmithMD
The COVID pandemic brought to light many things, including how society views older adults. Louise Aronson wrote a piece in the NY Times titled "'Covid-19 Kills Only Old People.' Only? Why are we OK with old people dying?". The ageist viewpoint she was rallying against was also brought to light in a study of ageism in social media. When looking at those tweets that were related to older adults and covid, more than 1 in 10 tweets implied that either the life of older adults was less valuable or that it downplayed the pandemic because it mostly harms older adults.
So on today's podcast we are going to talk about the initiative to "Reframe Aging" with Patricia D'Antonio. Patricia is a geriatric pharmacist, and the Vice President of Professional Affairs at the Gerontological Society of America (GSA).
The Reframing Aging initiative is a national effort, led by GSA and supported by Archstone Foundation, uses an evidence-based approach to communicating more effectively about older adults. There are a variety of resources available, including research reports, an online toolkit, and free instructional videos, to help us talk about our work in geriatrics and aging.
For information about the Reframing Aging Initiative, please check out their webpage www.reframingaging.org. In particular, check out these two helpful resources on their website:
So what exactly does a hospice medical director do? Why do some choose to become hospice physicians? What additional training is needed, if any, beyond Hospice and Palliative Medicine fellowship and boards? Who should take the new Hospice Medical Director Certification Board Examination? A recent study in JAGS found high rates of hospice disenrollment ("live discharge") for people with dementia - is that a good thing or a bad thing? Hmmm…
We address these and other questions in this week's podcast with Tommie Farrell, hospice physician in West Texas and Chair of the Hospice Medical Director Certification Board, and Kai Romero, Chief Medical Officer for Hospice By the Bay (that's San Francisco Bay).
And I get a re-do attempt at REM's "Everybody Hurts!". Apologies for the first attempt!
-@AlexSmithMD
Where are we with Alzheimers? Are we about to see a revolution in how we diagnose and treat it with Amyloid PET scans and the amyloid antibody aducanumab (which is currently on FDA's desk for approval)? Or are we still in the same place where there is no meaningfully effective treatment? Or is it somewhere in between, given the data that we have on comprehensive dementia care?
We talk today with Jason Karlawish, a professor of medicine, medical ethics and health policy, and neurology at the University of Pennsylvania Perelman School of Medicine. In addition to being a geriatrician extraordinaire, he is the author of the new book "The Problem of Alzheimer's: How Science, Culture, and Politics Turned a Rare Disease into a Crisis and What We Can Do About It."
In addition to talking about PET scans and new drugs like aducanumab, we discuss with Jason about the history of Alzheimers, the history of how we care for a fund caregivers, and where we go from here.
So take a listen and check out Jason's book!
Nursing home residents have been devastated by COVID. Somewhere around 40% of deaths from COVID have been among nursing home residents, though they make up just a sliver of the US population.
Prognostication among nursing home residents who have COVID is important for a host of reasons - for counseling patients and families about what to expect, for making clinical decisions, and potentially for allocation of scarce resources such as treatments.
In today's podcast, we talk with Orestis Panagiotou and Elizabeth White, the authors of a JAMA IM study that finds that physical and cognitive function are key predictors of mortality prediction for nursing home residents with COVID. We also talk with Marlon Aliberti, who authored a commentary.
Physical and cognitive function are easy to assess measures that should be routinely captured for older adults, in nursing homes and elsewhere. Study after study document the importance of function to risk prediction.
We also have a brief debate about how vaccinations should be allocated - according to a "one size fits all" age criteria, or a prognostic model that individualizes risk. Though I'm an advocate for prognostic models (see eprognosis.org) I'm actually on the age criteria alone side of the debate, with generous distribution among hardest hit minority communities.
And sing along to This Little Light of Mine!
-@AlexSmithMD
Lesbian, gay, bisexual and transgender (LGBT) older adults have lived through a lifetime of discrimination, social stigma, prejudice, and marginalization. Is the care that we are giving them in later life changing any of that or are we pushing them back into the closet?
This is what we talk about in this week's podcast with Carey Candrian from the University of Colorado School of Medicine, and Angela Primbas from Stanford University (and future geriatrics fellow at UCSF!).
Carey has published a wonderful article in the Gerontologist titled "She's Dying and I Can't Say We're Married?": End-of-Life Care for LGBT Older Adults, in which she describes how older LGBT adults may be at higher risk for having their health care wishes ignored or disregarded, their families of choice are less likely to be included in their decision making, and they may experience increased isolation, bullying, mistreatment, or abuse, which ultimately contribute to receipt of poor-quality health care.
We talk about the scripts that we use in medicine that may hamper open discussions about sexual orientation and gender identity (SOGI) including the term "family meeting", the need to revise our intake forms to incorporate SOGI questions, and the need for education. We also get a chance to hear Alex Sing "The Story" whose lyrics very much speak to the subject at hand:
"All of these lines across my faceTell you the story of who I amSo many stories of where I've beenAnd how I got to where I amBut these stories don't mean anythingWhen you've got no one to tell them to…"
If you want to learn more, please check out these wonderful resources:
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