GeriPal - A Geriatrics and Palliative Medicine Podcast

Artificial Intelligence, or AI, has tremendous potential. We talk on this podcast about potential uses of AI in geriatrics and palliative care with natural language processing guru Charlotta Lindvall from DFCI, bioethicists and internist Matt DeCamp from University of Colorado, and prognosis wizard Sei Lee from UCSF. Social companions to address the epidemic of loneliness among older adults Augmenting ability of clinicians by taking notes Searching the electronic health record for data Predicting mortality and other outcomes We talk also about the pitfalls of AI, including: Recapitulation bias by race and ethnicity, and other factors, exacerbating disparities Confidentiality concerns: do those social companions also monitor older adults for falls? 24/7? Hallucinations, or when the AI lies or bullshits, then denies it When the AI approaches sentience, is it ethical to unplug it? I'm sure this is a subject we will return to, given the rapid progress on AI. Enjoy! -@AlexSmithMD Links: Papers on AI and palliative care and concerns about bias: https://www.healthaffairs.org/do/10.1377/forefront.20200911.401376/ https://academic.oup.com/jamia/article/27/12/2020/5859726 Comparison of machine learning vs traditional prognostic methods based on regression: https://www.ingentaconnect.com/content/wk/mcar/2022/00000060/00000006/art00011 Other links on the issue of AI and racial or ethnic bias: Are Robots Racist? Greenwall Foundation Bill Stubbing lecture Are Robots Racist? Rethinking Automation and Inequity in Healthcare https://www.nber.org/papers/w30700 https://www.science.org/doi/10.1126/sciadv.add2704 https://theconversation.com/including-race-in-clinical-algorithms-can-both-reduce-and-increase-health-inequities-it-depends-on-what-doctors-use-them-for-206168 MD Calc approach to inclusion of race https://www.mdcalc.com/race

Diabetes is common. When I'm on nursing home call, the most common page I receive is for a blood sugar value. When I'm on palliative care consults and attending in our hospice unit we have to counsel patients about deprescribing and de-intensifying diabetes medications. Given how frequent monitoring and prescribing issues arise in the care of patients with diabetes in late life, including the end of life, Eric and I were excited when Tamryn Gray emailed us requesting a follow up podcast on this issue. Our last podcast was with Laura Petrillo in 2018 - 5 years ago seems ancient history - though many of the points still apply today (e.g. Goldilocks zone). And yet we're also in a different place in diabetes monitoring and management. To answer our questions, we invited Nadine Carter, a current hospice and palliative care fellow at Dartmouth who previously worked as an NP in outpatient endocrinology, and Alex Lee, an epidemiologist at UCSF interested in diabetes monitoring and management in the nursing home. And we invited Tamryn Gray from the Dana Farber joins us to ask insightful questions, including: What blood sugar range should we target for patients in the nursing home or hospice? How high is too high? Should considerations differ for people with dementia? What are the risks and rewards of new classes of medications? How do caregivers fit into this? Continuous glucose monitoring (CGM) is commonplace in Type 1 and gaining traction in Type 2. We debate the merits of use of CGM in the nursing home and other late life settings (Eric and I argue against CGM and lose). Ozempic is a new fancy med that, by the way, leads to weight loss among celebrities, resulting in shortages of the drug from people using it off-label for that purpose. Should we use Ozempic (if we can find it) in patients with serious illness, which often results in undesirable and profound weight loss? Listen in to learn more! -@AlexSmithMD Additional Links: -Fingerstick monitoring in VA nursing homes (too common!) -Improving diabetes management in hospice -Continuous Glucose Monitoring complicating end of life care

Our guests today present an important rejoinder to the argument that we should refocus away from advance care planning (ACP). Sarah Nouri, Hillary Lum, and LJ Van Scoy argue that diverse communities are asking for ACP. Sarah Nouri gives an example from her work in the LGBTQ+ community of a trans woman who was buried as a man because existing laws/rules did not protect her wishes. Others cited the call from communities to meet them where they are - be they senior centers, Black-owned businesses, or churches (we have a podcast planned in the fall with Fayron Epps and Karen Moss on the church setting). It does seem that if communities, particularly historically marginalized communities, are interested in ACP, that fact should carry some weight in how resources are allocated to research and health care financing. We additionally have a debate/discussion about which outcomes of ACP matter most, including Terri Fried's commentary in JAGS that caregiver outcomes matter more than goal concordant care (the "holy grail"), completion of advance directives, or changes in health care services use. Did the caregiver feel heard and understood? Did they have PTSD? Complicated grief? Depression? Group visits are one way of reaching diverse communities to which advance care planning has not traditionally been targeted. In a group visit there is a social norming effect - "if my neighbor is doing it, perhaps I should be doing it to?" Please tune in to hear more, and listen to the whistle of the "Friendship train!" -@AlexSmithMD Links: Community Based Participatory Research and ACP in Latinx communities: https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.18236 Community based ACP in the Black Community: https://link.springer.com/article/10.1007/s11606-023-08134-2 ACP in the Chinese American Community: https://www.sciencedirect.com/science/article/pii/S0885392423000982 Group ACP in primary care: https://www.annfammed.org/content/14/2/125.short and https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16694 Project Talk Website: www.ProjectTalkTrial.org Project Talk Trial Protocol Paper: https://journals.sagepub.com/doi/pdf/10.1177/1049909116656353 Hello Article (including Black churches): https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2765685 Communication Quality Analysis: https://www.tandfonline.com/doi/abs/10.1080/19312458.2022.2099819 Conceptualizing Surrogate Decision Making: https://www.tandfonline.com/doi/abs/10.1080/19312458.2022.2099819 What counts as a surrogate decision: https://journals.sagepub.com/doi/abs/10.1177/10499091231168976 For e-training modules on ACP group visits: https://cuelearning.org Click on the Register link (upper right corner). A pop-up box will appear and enter your email address and set up your password. For Registration Code, enter: ENACT (not case sensitive). The ACP Group visit implementation guide is available here: www.coloradocareplanning.org. Scroll down to "Innovations in ACP page"

Hot off the press is a brand spanking new updated 2023 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The Beers Criteria is one of the most frequently cited reference tools in geriatrics, detailing potentially inappropriate medications to prescribe to older people. We've invited two members who helped update the criteria including Todd Semla and Mike Steinman. We discuss a little history of the Beers criteria, including the original Beers Criteria that was published by the late Dr. Mark Beers, and how it has evolved over the last three decades. We also discuss specifics about how to use and not use the Beers Criteria, how medications are selected for inclusion in the criteria, and specifics about certain medications. And of course, take a deep dive by downloading the JAGS paper on the updated Beers Criteria or any of the great links from AGS including the: 2023 AGS Beers Criteria App Beers pocket card

We've had multiple GeriPal episodes about treatments for dementia, including aducanumab (here, here, and here) and lecanemab (here). As today's guest, Kristine Yaffe notes, part of the reason for that emphasis is that in the US we prioritize treatment, whereas other countries are ahead of us in prioritizing prevention. Deb Barnes and Kristine Yaffe published a landmark paper in Lancet Neurology finding that up to half of dementia risk is due to modifiable factors. If we focused on prevention, from a public health standpoint, we would achieve far more than spending millions billions on treatment. Today we talk about steps we can and should take to reduce the risk of dementia, including: Education and cognitive games (I reveal my embarrassingly poor average time on the NYT mini cross word) Physical activity Sleep Depression Smoking Social isolation Blood pressure control (listen also to our podcast on Sprint Mind with Jeff Williamson) We also delve into an exciting new trial Kristine led with others on the impact of risk factor reduction on cognition - here's a link to press about the trial from a fall meeting presentation - article forthcoming. And because we can't resist, we dip into aducanumab and lecanemab at the end. -@AlexSmithMD

I haven't worked with many adolescents and young adults (AYA, roughly teens to twenties). But when I have, I find that they're often some of the hardest patients to care for. Why? We talk about why it's so hard with Abby Rosenberg (chief of PC at DFCI and Boston Childrens), Nick Purol (clinical social worker at DFCI and Boston Childrens), Daniel Eison (pediatric PC doc and co-host of PediPal). We are grateful to Andrea Thach (PC doc at Sutter East Bay) for bringing this topic to our attention and for asking questions as a guest host. Here are just a few of the explanations for why it's so hard: They are closer in age to some of us (younger clinicians). Countertransference hits hard. There's an in-between space between adolescence and adulthood - and there's something that we identify with in that in-between space, tugging at our heart strings Everyone has been a teenager. Everyone has lived through their early 20s. Every member of the interdisciplinary team. Adolescence and young adulthood is a romanticized time of life in our culture. We remember bucking the rules, figuring out who you are, hair on fire, feeling invulnerable, trying to figure out who you are - and now those adolescents are stuck in the hospital, with doctors and parents telling them what to do, having their autonomy crushed by the medical institution, realizing they're not invulnerable. We talk about these issues and more - what resources to leverage, how to cope as a team. We in geriatrics and adult palliative care clinicians have so much to learn from our colleagues in pediatrics - and though many of these lessons are specific to adolescents and young adults - many of the lessons are valuable for the care of patients in older life stages. Links to resources for working with AYA, from Nick Purol): The Courageous Parents Network has a wealth of information/resources/videos/articles on many overlapping issues and topics related to caring for children/adolescents/young adults with serious illness (from both the provider and clinician perspective): https://courageousparentsnetwork.org Courageous Parents Network Empowering parents caring for children with serious illness through video, shared community, professional guidance, and palliative care. You are Not Alone. courageousparentsnetwork.org Voicing My Choices is a wonderful tool for discussing goals/wishes and introducing advance directives in the context of serious illness. It's based off 5 Wishes and validated for AYA through direct feedback from the population: https://store.fivewishes.org/ShopLocal/en/p/VC-MASTER-000/voicing-my-choices The Oxford Textbook of Palliative Social Work has several chapters relating to working with AYA (either due to family illness or their own), with many psychosocial clinicians in our field contributing: https://www.amazon.com/Oxford-Textbook-Palliative-Social-Work/dp/0197537855 Same is true for the Interdisciplinary Pediatric Palliative Care Textbook: https://www.amazon.com/Interdisciplinary-Pediatric-Palliative-Joanne-Wolfe/dp/0190090014/ref=sr_1_1?crid=33YG2UAKDZ8DO&keywords=interdisciplinary+pediatric+palliative+care&qid=1682288312&s=books&sprefix=interdisciplinary+pediatric+palliative+car%2Cstripbooks%2C101&sr=1-1&asin=0190090014&revisionId=&format=4&depth=1 -@AlexSmithMD

We have a special extra podcast this week. During the last AAHPM - HPNA meeting in Montréal, we went around asking attendees what one thing that they are most worried about and one thing they are most hopeful for when thinking about the future of our field. We couldn't fit everyone's responses in but came up with the big themes for questions and edited them into this weeks podcast / YouTube video. Eric and Alex DISCLAIMER While we filmed in Montreal during the Annual Assembly, all opinions expressed in this podcast are independent of AAHPM and HPNA, or the Annual Assembly. Furthermore, direction to external websites is not an endorsement from AAHPM or HPNA, or the Annual Assembly. Palliative Care the Next Generation: How the Service May Grow and Evolve https://hospicenews.com/2023/04/14/palliative-care-the-next-generation-how-the-service-may-grow-and-evolve/ AccentCare, a portfolio company of private equity firm Advent International, is another example. The company has expanded its palliative care services through partnerships with hospitals and other managed care providers, according to AccentCare CEO Stephan Rodgers. "We've got a very large palliative care practice," Rodgers told PCN. "What we've seen to make it really work is you either have to be in the hospital, where we've taken over palliative care in the hospital, or you have to be contracted with managed care and get it at some kind of risk, because community-based palliative care is very difficult to make operate right now from a profitable [perspective]."

In 1990 11% of homeless persons were older than 50. Today half are over age 50. Today we talk with Margot Kushel about how we got here, including: That sense of powerlessness as a clinician when you "fix up" a patient in the hospital, only to discharge them to the street knowing things will fall apart. Chronic vs acute homelessness What is the major driver of homelessness in general? What is the major driver of the increase in older homeless persons? Why do we say "over 50" is "older" for homeless persons, why not 65? To what extent is the rise of tech in San Francisco to blame for our local rise in homelessness? What are the structural factors and individual factors that contribute to homelessness? How has the history of redlining and the federal tax subsidy of wealthy (mostly white) people in the form of a mortgage interest deduction contributed to racial inequalities in homelessness? What can we do about it? What are the highest yield interventions and policy changes? What should we call it - homeless or unhoused? We were fortunate to make it to the end of this podcast before Margot lost power. It's storming again in the Bay Area at the time we record this. So much harder than for the older homeless people on the streets with no power to lose. A mad world out there (song hint). Key references: -Margot Kushel's UCSF Grand Rounds -JAMA IM paper on mortality among older homeless persons -NEJM perspective arguing that interventions to address homelessness shouldn't be evaluated on cost savings. -@AlexSmithMD

Social connections impact our health in profound ways, whether it is the support we receive from family and friends in navigating serious illness, the joy from shared social activities, or connecting with our community. Experiencing social isolation, the objective lack of contact with friends, family, or the community, or loneliness, the subjective feeling of lacking companionship or feeling left out, may be signs that our overall social life is struggling. But, should we as clinicians care about the social lives of our patients? Are there meaningful ways of assessing loneliness and social isolation in clinical settings and connecting patients with interventions? How can public health and policy experts address these needs, particularly in light of the COVID-19 pandemic which turned our social lives upside down? On today today's podcast, we are joined by guest host and UCSF geriatrician Ashwin Kotwal as we welcome three renowned scholars in the field: 1) Dr. Julianne Holt-Lunstad, Professor of Psychology and Neuroscience at Brigham Young University, an international expert on loneliness, social isolation, and social interventions, who has served on the National Academy of Sciences committee on social isolation and loneliness and advised the UK Loneliness Campaign, 2) Dr. Thomas Cudjoe, Assistant Professor of Medicine at Johns Hopkins University, who has conducted groundbreaking work on the measurement of social isolation and mechanisms of impact on health, and 3) Dr. Carla Perissinotto, Professor of Medicine at UCSF, who has pioneered the clinical and policy approach to addressing loneliness and social isolation. We talk about: Their personal and clinical inspiration for studying loneliness and social isolation, and hurdles encountered in bringing these needs to the clinical world. The Listening "EAR" approach that simplifies assessment of loneliness and social isolation in clinical settings, and other practical pointers. Check out some of their recent work, including: Dr. Holt-Lunstad's and Dr. Perissinotto's powerful perspective piece in the New England Journal of Medicine which provides a clinical framework for addressing loneliness and social isolation. Dr. Cudjoe's recent work demonstrating the impact of social isolation on dementia risk, populations at risk, and how our social lives "getting under our skin." Dr. Kotwal's work showing how social isolation impacts end-of-life health care use, including hospice and acute care. We touch briefly on (and build on) topics discussed in prior podcasts such as loneliness during the pandemic. Tune in to hear Alex's acoustic rendition of Outkast's Hey Y'All! -Ashwin Kotwal

Do we need an RCT to establish the worth of chaplaincy? Einstein once said, "Everything that can be counted does not necessarily count; everything that counts cannot necessarily be counted." A friend of GeriPal, and prior guest, Guy Micco commented today that we need an RCT for chaplaincy is like the idea that the humanities need to justify their value in medical training: "It's like being told to measure the taste of orange juice with a ruler." On the other hand, all of our guests agree that chaplains are often the most vulnerable to being cut from hospital and health system budgets. These studies are important. Today we have a star-studded lineup, including Lexy Torke of Indiana University, who discusses her RCT of a chaplaincy intervention for surrogates of patients in the ICU, published in JPSM and plenary presentation at AAHPM/HPNA. To provide context, we are joined by Karen Steinhauser, a social scientist at Duke who has been studying spirituality for years (and published one of the most cited papers in palliative care on factors considered important at the end of life, as well as one of my favorite qualitative papers to give to research trainees). We are also joined by LaVera Crawly, a physician turned chaplain, now VP of Spiritual Care at Common Spirit Health (and author of another of my favorite and most cited papers on palliative care in the African American Community). We dive into the issues of measuring spirituality, chaplaincy, the need for an expanded vocabulary around spirituality, spiritual assessments, spiritual history, LaVera's journey from physician to chaplain (listen to her compelling answer to the magic wand question at the end). For further context, please check out our prior podcast on spirituality, and this discussion of the RCT by Lexy that I helped moderate for Transforming Chaplaincy. Thanks to my son Kai for playing the guitar part in 5/4 with strange chords on Riverman by Nick Drake! -Alex