GeriPal - A Geriatrics and Palliative Medicine Podcast

In today’s podcast we talk with Eric Wong, geriatrician-researcher from Toronto, and Thiago Silva, geriatrician-researcher from Brazil, about the comprehensive geriatrics assessment.  We spend the first 30 minutes (at least) discussing what, exactly is the comprehensive geriatric assessment, including: What domains of assessment are essential/mandatory components of the comprehensive geriatrics assessment? Who performs it? Is a multidisciplinary team required? Can a geriatrician perform it alone? Can non-geriatricians perform it? Who is the comprehensive geriatrics assessment for? Who is most likely to benefit? Eric Widera suggests not as much benefit for very sick and very healthy older adults, more benefit in the vast middle. Why do the comprehensive geriatrics assessment? What are the interventions that it leads to (we cover this more conceptually, rather than naming all possible interventions) How does the comprehensive geriatrics assessment relate to the 4Ms (or 5 Ms)? How long does it take to conduct a comprehensive geriatrics assessment? What’s the evidence (BMJ meta analysis) for the comprehensive geriatrics assessment?  What are the outcomes we hope for from the comprehensive geriatrics assessment?   That final point, about outcomes, bring’s us to Eric Wong’s study, published in JAGS, which evaluates the cost effectiveness of the comprehensive geriatrics assessment performed by a geriatrician across settings (e.g. acute care, rehab, community clinics). As an aside, as the editor at JAGS who managed this manuscript, I will say that we don’t ordinarily publish cost effectiveness studies at JAGS, as the methods are opaque to our clinical audience (e.g. raise your hand if you understand what ‘CGA provided in the combination of acute care and rehab was non-dominated’ means). We published this article because its bottom line is of great interest to geriatricians.  In Eric’s study, geriatricians performing CGA were more cost effective than usual care in Every. Single. Setting. And of course cost effectiveness is only one small piece of the argument for why we do the comprehensive geriatrics assessment in the first place (no patient in the history of the world has ever asked for a test or treatment because it’s cost effective for the health care system). I’ll close with a couple of “mic drop” excerpts from Thiago’s accompanying editorial: Finally, it is instructive to compare the cost-effectiveness of geriatric services and CGAs with other interventions. A recent analysis of lecanemab for early-stage Alzheimer's disease found that gaining one QALY would cost approximately $287,000 (USD). In contrast, Wong et al. estimated that adding community-based CGA would cost about $1203 (CAD) per quality-adjusted life month (QALM) (equating to roughly $10,105 (USD) per QALY, using $1 USD = $0.7 CAD), making geriatrician-led CGA nearly 30 times more cost-effective. Put simply, for each dollar spent to improve quality of life for a year through CGA, one would need to spend almost $30 to achieve the same benefit with lecanemab.  Ultimately, the question is not whether geriatricians represent a worthwhile investment (they are) but how healthcare systems can ensure that every older adult requiring specialized, comprehensive care can access it. Wong et al.'s modeling study provides a valuable contribution by showing that geriatricians placed in acute and rehabilitation settings offer the most cost-effective deployment given current workforce limitations. Despite some caveats, the overarching message remains clear: geriatric expertise not only enhances care quality but can also align with health-economic objectives, especially in high-acuity environments. However, we cannot allow an inadequate geriatric workforce to become a permanent constraint, forcing painful decisions about which older adults and which settings will miss out on optimal geriatric care. Instead, we should continue to strive to increase the number of geriatricians through robust training programs and payment model reform to ensure that cost-effective care can be provided for this large and growing vulnerable population.  -Alex Smith  

On a prior podcast we talked with Todd Semla and Mike Steinman about the update to the AGS Beers Criteria of potentially inappropriate medications in older adults (Todd and Mike co-chair the AGS Beers Criteria Panel).  One of the questions that came up was - well if we should probably think twice or avoid that medication, what should we do instead? Today we talk with Todd and Mike about their new recommendations of alternative treatments to the AGS Beers Criteria, published recently in JAGS, and also presented at the 2025 AGS conference in Chicago (and available on demand online). We had a lot of fun at the start of the podcast talking about the appropriate analogy for how clinicians should use the AGS Beers Criteria.  In our last podcast, the analogy was a stop sign. You should come to a stop before you prescribe or refill a medication on the Beers list, look around at alternatives, and consider how to proceed.  You might in the end decide to proceed, as there are certainly situations in which it does make sense to start or continue a medication on the Beers list. Today’s analogy had somewhat higher stakes, involving a driver, a pothole in the road, and a cyclist on the side who you’d hit if you swerved.  Really upping the anti!!! The podcast is framed around a case Eric crafted of a patient with most of the medications and conditions on the Beers list. We used this as a springboard to discuss the following issues (with links to prior GeriPal podcasts): Insomnia (Doxepin is an alternative, trazodone and melatonin are not?!?) Diabetes management  PPI for GERD Treatments for pain, including NSAIDS, COX2, and gabapentinoids Cannabis Deprescribing,org - terrific Canadian website (no tariff to use) And I hope that the prescribing landscape is indeed getting better (thanks to Kai on guitar)! -Alex Smith  

Health care trainees rotate through a variety of different settings. ICUs, hospital wards, and outpatient clinics. If they're lucky, they might even spend time in a nursing home. But on today’s podcast, we’re adding one more setting to that list: your local art museum. In this thought-provoking episode, we explore how art museum teaching is being integrated into the education of medical professionals—and why it's making a profound difference. Our guests, Amy Klein, Laura Morrison, and Gordon Wood, share their journey of integrating art into medical training, along with practical strategies you can use if you're inspired to do the same. You'll also hear how engaging with museum-based medical education can help health care professionals deepen empathy and emotional awareness, practice the skill of multiple perspective-taking, and grow more comfortable with ambiguity and uncertainty. Resources mentioned in the podcast include: A story about one medical student's experience with a day in the museum using multiple museum-based education exercices A Journal Article published in the Journal of Palliative Medicine titled “Museum-Based Education: A Novel Educational Approach for Hospice and Palliative Medicine Training Programs”  A journal article on “Twelve Tips for Starting a Collaboration with an Art Museum.” A handout from the 2025 AAHPM/HPNA preconference gives examples of museum-based education exercises and resources for further training.  Alex’s summary of some prompts we discussed for the “Personal Responses Tour”, which is a reflective exercise where participants choose artwork based on a personal prompt, then share with a small group. The prompts include: Find a work of art that reminds you of a patient Find a work of art that reflects a challenging clinical situation Find a work that speaks to an experience you have had in your palliative medicine training that taught you about the impact of bias or racism Find a work that connects to the path you took into palliative care or geriatrics Find a piece that makes you think about community Find a piece that reflects your idea of what a “good death” is Lastly, stay on the “look out for” the 2026 Art Museum-Based Education preconferences session at the AAHPM/HPNA annual meeting on March 4, 2026 in San Diego!    

In his book, “Why We Revolt,” Victor Montori decries the industrialization of healthcare.  We’ve become a healthcare factory, beholden to health systems motivated by profit. In particular, he laments the loss of the “care” aspect of healthcare. Clinicians are under the clock to churn through patients.  Patients are tasked with doing work outside of the clinic. Patients are tasked with hours and hours of work to self manage, obtain and manage medications, track weights and fingersticks, not to mention scheduling visits and waiting around for the visit to start. Now we have an app for that. For what, you ask? Well, for everything! Digital burden is real. Think about what we ask patients to do: charge your device, remember your password, 2 factor authentication, each interface is different, wait…where do you enter your fingersticks again? Victor is an endocrinologist who often provides care for older patients with multiple chronic conditions, polypharmacy, and complex social situations.  He’s “one of us.” Some might argue that these circumstances call for incremental change.  Not Victor.  He argues that we need a revolution. In particular, he argues that the revolution must come from patients to be successful. On this podcast we discuss: Why do we need a revolution? What made him get to this point of arguing for a revolt? Why should the revolution be patient led, rather than clinician led? What role do clinicians have to play? What is minimally disruptive medicine (a term Victor coined with Carl May and Francis Mair in 2009)? How does shared decision making fit into the revolution? What’s the matter with guidelines? What’s the role of standardization? We suspect that most geriatrics and palliative care providers feel like they’ve escaped many of the issues Victor describes, trading less glamorous and remunerative work for more satisfying time spent caring for patients; focusing on what matters, goals of care, and attention to emotion and social well-being.  Are we deluding ourselves? If you’d like to join the revolution, please check out Victor’s website, patientrevolution.org And I believe this is the first Peter Gabriel song request! I think Peter Gabriel’s album So was the first cassette tape I purchased.  About time, 350+ podcasts in.  My son Kai turns this very non-guitar friendly song into an acoustic jam for the audio-only podcast version; you get my weaker attempt on YouTube :)  Finally, a quick plug for the Sommer Lecture series in Portland OR.  Victor and I had a terrific time bonding at this year’s lecture series. While not strictly geriatrics and palliative care focused, the lectures seem targeted at a broad audience, with something for everyone.  And yes, I made them sing parody songs :) -Alex Smith  

Most health care providers understand the importance of goals-of-care conversations in aligning treatment plans with patients’ goals, especially for those with serious medical problems. And yet, these discussions often either don't happen or at least don't get documented. How can we do better? In today’s podcast, we sit down with Ira Byock, Chris Dale, and Matthew Gonzales to discuss a multi-year healthcare system-wide goals of care implementation project within the Providence Health Care System. Spanning 51 hospitals, this initiative was recently described in NEJM Catalyst, showing truly impressive results, including an increase from 7% to 85% in goals of care conversation documentation for patients who were in an ICU for 5 or more days. How did they achieve this?  Our guests will share insights into the project’s inception and the strategies that drove its success, including: Organizational Alignment: Integrating GOC documentation into the health system’s mission, vision, and strategic objectives. Clinical Leadership Partnership: Collaborating with clinical leaders to establish robust quality standards and metrics. Ease of Documentation: Upgrading the electronic health record (EHR) system to streamline the documentation and retrieval of GOC conversations. Communication Training: Conducting workshops based on the Serious Illness Conversation Guide to equip clinicians with the skills needed for impactful GOC conversations. Join us as we explore how these strategies were implemented and learn how you can apply similar approaches in your own healthcare setting.  

What is death anxiety?  We spend the first 15 minutes of the podcast addressing this question.  And maybe this was unfair to our guests, the fabulous dynamic duo of palliative psychiatrists Dani Chammas and Keri Brenner (listen to their prior podcasts on therapeutic presence and the angry patient).  After all, we invited them on to our podcast to discuss death anxiety, then Eric and I immediately questioned if death anxiety was the best term for what we want to discuss! Several key points stood out to me from this podcast, your key points may differ: The “anxiety” in “death anxiety” is not a pathological phenomenon or a DSM diagnosis;  it references an existential concern that is fundamental to the human experience .  To me,” awareness of mortality” might be a better term, but in fairness, the idea of “death anxiety” was coined well before the formal establishment of “anxiety disorders.” The ways in which death anxiety manifests in our patient’s choices and behaviors varies tremendously, and our responses as clinicians must be individualized. There is no “one size fits all” approach. In one example Dani discusses, a pain level of 1.5/10 might be overwhelming, because for a patient  in remission from cancer any pain might signal return of cancer.  Some manifestations of death anxiety can be debilitating, others lead to tremendous personal growth, connection to others, and a drive toward finding meaning in their illness experience.   Death anxiety impacts us as clinicians, not only through countertransference, that word that I still can’t define (sorry Dani and Keri!), but also through our own unexamined fears about death. As clinicians who regularly care for people who are dying, we might find ourselves becoming “used to” death. Is this a sign that we are inured to the banality of death, and less able to empathize with the death anxiety experienced by our patients or their families? Or could it reflect our acceptance of the finitude of life, prompting us to live in the present moment? Perhaps it is something else entirely. The key is that looking inwards to understanding our own unique relationship with mortality can deepen our ability to authentically accompany the experiences of our patients. I mean, don’t fear the reaper, right?  Sorry, no cowbell in my version, but you do get my son Kai, home from college, on guitar for the audio only podcast version. Here are some resources for listeners wanting to learn more about this topic: Books: Yalom ID. Existential Psychotherapy. New York, NY: Basic Books; 1980. Yalom ID. Staring at the Sun: Overcoming the Terror of Death. San Francisco, CA: Jossey-Bass; 2008. Solomon S, Greenberg J, Pyszczynski T. The Worm at the Core: On the Role of Death in Life. New York, NY: Random House; 2015. Becker E. The Denial of Death. Free Press; 1973. Articles: Emanuel LL, Solomon S, Chochinov HM, et al. Death Anxiety and Correlates in Cancer Patients Receiving Palliative Care. J Palliat Med. 2023;26(2):235-243. Chochinov HM, McClement SE, Hack TF, et al. Death anxiety and correlates in cancer patients receiving outpatient palliative care. J Palliat Med. 2023;26(12):1404–1410. doi:10.1089/jpm.2022.0052. Clark D. Between hope and acceptance: the medicalisation of dying. BMJ. 2002;324(7342):905–907. doi:10.1136/bmj.324.7342.905. Vess M, Arndt J, Cox CR, Routledge C, Goldenberg JL. The terror management of medical decisions: The effect of mortality salience and religious fundamentalism on support for faith-based medical intervention. J Pers Soc Psychol. 2009;97(2):334–350. Menzies RE, Zuccala M, Sharpe L, Dar-Nimrod I. The effects of psychosocial interventions on death anxiety: A meta-analysis and systematic review of randomized controlled trials. J Anxiety Disord. 2018;59:64–73. doi:10.1016/j.janxdis.2018.09.00 Brown TL, Chown P, Solomon S, Gore G, De Groot JM. Psychosocial correlates of death anxiety in advanced cancer: A scoping review. Psychooncology. 2025;34(1):45–56. doi:10.1002/pon.70068. Tarbi EC, Moore CM, Wallace CL, Beaussant Y, Broden EG, Chammas D, Galchutt P, Gilchrist D, Hayden A, Morgan B, Rosenberg LB, Sager Z, Solomon S, Rosa WE, Chochinov HM. Top Ten Tips Palliative Care Clinicians Should Know About Attending to the Existential Experience. J Palliat Med. 2024 Oct;27(10):1379-1389. doi: 10.1089/jpm.2024.0070. Epub 2024 Mar 28. PMID: 38546453.  

What’s the ideal blood pressure target for older adults with hypertension? Should we aim for a systolic BP of 120 mmHg in all older adults, as suggested by the SPRINT trial? Or should we be more flexible—especially for those who are frail or among the oldest old? This week on the GeriPal Podcast, we explore the nuances of managing blood pressure in older adults with our guests Dr. Mark Supiano, Dr. Mitra Jamshidian, and Dr. Simon Ascher.  Now, some of our astute GeriPal listeners may say, “wait, didn't you already talk about this with Mark Supiano in a 2017 podcast titled How Low Should We Go with Blood Pressure in Older Adults?”  Yes, we sure did, but we decided to revisit this topic as Mitra Jamshidian and Simon Ascher published a new JAGS research study focused on developing a framework to individualize the net benefit of intensive blood pressure control based on the results of the SPRINT trial.  Their key finding: most community-dwelling older adults in the SPRINT trial experienced greater benefits than harms from more aggressive blood pressure targets—even those who were older, frail, or on multiple medications. Join us for an in-depth discussion on balancing risks, benefits, and patient preferences in hypertension management for older adults. Plus, we might just sneak in a little Frank Sinatra for good measure.

In this week’s episode, we dig into two deceptively simple questions: When does someone become a cancer survivor, and should palliative care be in the business of caring for them? Spoiler: It’s more complicated than it seems. We’ve invited two palliative care doctors to talk about survivorship with us: Laura Petrillo, a physician-researcher at Mass General Hospital and Harvard Medical School, and Laura Shoemaker, an outpatient palliative care doctor at the Cleveland Clinic. This episode is a must-listen for those navigating the evolving landscape of cancer care, and asking not just how we treat cancer, but how we support people who are living with it.  If you want some further reading on survivorship, check out some of these articles: A NEJM article titled “Time to Study Metastatic-Cancer Survivorship” A ASCO publication that includes a section on survivorship - Patient-Centered Palliative Care for Patients With Advanced Lung Cancer A webinar on survivorship - Blending Survivorship and Palliative Care (NCI)

June Lunney famously characterized the end of life functional course of people with dementia as a slow dwindle over time. Tom Gill later found that people with dementia do indeed have persistent severe disability throughout the last year of their lives. But from our clinical work, many of us are familiar with people with dementia who experience sudden shocks to their health, think hip fracture, think hospitalization for pneumonia.  Those disruptive events or shocks often portend a major decline in function from which people with dementia never fully recover.  And they’re often a sign of (or cause of?) worsening prognosis. Today we talk about disruptive events, or health and wealth shocks.  We start with Lauren Hunt, who described the incidence and outcomes of hip fracture and hospitalization for pneumonia in a pair of publications in JAGS, comparing people with dementia who experience these events to people without dementia.  We then turn to social events, starting with Rebecca Rodin, who studied the effect of widowhood on mortality and function for people with dementia, cancer, and organ failure, published in JAMA Network Open.  Finally, we turn to Tsai-Chin Cho, who studied the impact of a wealth shock (loss of 75%+ of wealth in a short time period) on cognitive decline in 4 countries.  Tsai-Chin’s article, published in Lancet Healthy Longevity, found a tantalizing hint that countries with stronger safety nets had lower incidence of wealth shocks, and less of a deleterious impact of the wealth shock on cognitive function. Wait, so one key message is that social health is linked to physical and cognitive health?!?  And the government can do something about that?!? Yes indeed, we like to hammer that home regularly, dear listeners. And I enjoyed singing Leonard Cohent’s Who By Fire, about the many ways people might die…you know…typical uplifting GeriPal song lyrics! -Alex Smith   Additional links mentioned by Tsai-Chin Cho: -Wealth shocks and mortality in the US -Change in marital status as a risk for wealth shock  

Happy Pride Month GeriPal listeners! Transgender issues are in the news. Just today (June 17th) as we record this podcast: Ezra Klein released a wonderful interview with Sarah McBride, the first openly transgender member of congress A judge ruled that cuts to NIH grants focused on minority groups, including transgender people, were illegal and ordered the government to restore funding.  It’s Pride month, and our guests remind us of the leadership of two trans women in the Stonewall riots, which started the modern fight for LGBTQI+ rights and liberation. Today’s guests are Noelle Marie Javier, a geriatrician and palliative care doc who tells her story of transitioning as a faculty member at Mt. Sinai in New York, and Jace Flatt, who started their journey as a gerontology researcher at UCSF and is now faculty at UNLV. Jace was in the news recently for having multiple federal grants cancelled because they included transgender participants. We cover many topics, including: Terminology: gender identity, sexual orientation, gender expression, transgender, nonbinary, intersex, what’s in LGBTQI+ Gender affirming care Major health and medical issues associated with aging as a transgender person Allostatic load Accelerated aging What can clinicians do - pointers, pearls, and attitudes Dementia risk  Caregiver issues Hormone replacement therapy at the end of life Sexual orientation and gender identity (SOGI) data, what is it, how to collect it respectfully and safely Mentioned: Harvey Chochinov’s Dignity Therapy question, and our prior podcast on LGBT Care for older adults and serious illness with Carey Candrian and Angela Primbas So pleased to sing True Colors by Cyndi Lauper, with Kai on guitar for those of you listening to the podcast. -Alex Smith Many links! -Rainbows of Aging: Jace Flatt’s research site. -LGBTQcaregivers -Callen-Lorde gender affirming trans health services -GLMA: organization for health professional advancing LGBTQ+ equality -Center of Excellence for Transgender Health at UCSF -World Professional Association for Transgender Health -Sage advocacy services for LGBTQ+ Elders: focus on impact of Medicaid cuts -Trans bodies, Trans selves: resource guide