GeriPal - A Geriatrics and Palliative Medicine Podcast

We've talked at length on prior podcasts about the failures of aducnumab, Biogen, and the FDA's decision to approve it. But wait, there's a shiny new anti-amyloid drug, lecanemab! (No it's not just the French version of Aducanumab). In an article in the NEJM (a published article this time, wonder of wonders!) lecanemab was shown to slow the rate of cognitive decline by 0.45 points on an 18 point cognitive scale compared to placebo. Wow! Wow? Wait, what? On today's podcast we talk with Jason Karlawish, who we've had on previously talking about his book The Problem of Alzheimer's and with Aaron Kesselhim, to discuss FDA approval of Aducanumab, as well as frequent guest and host Ken Covinsky. They debate today's central question: is it time for geriatricians to get on board with lecanemab? Along the way we address: Is this degree of slowed cognitive decline meaningful to patients or care partners? What about the burdens, risks, and harms? Every 2 week visits for infusions, regular monitoring for brain swelling and bleeding, case report level risk of death? Did the study do enough to address issues of inclusion and diversity by age, race and ethnicity, and multimorbidity? What does this study say about the amyloid hypothesis? Should the FDA approve, and under what conditions? Their answers may surprise you. As a preview of final thoughts at the end of the episode, Ken and Jason agree that the FDA should approve lecanemab conditional on a post-approval monitoring system and public access to study data, geriatricians should be prepared to have thoughtful conversations with patients about the risks and benefits of lecanemab in view of their values and priorities, and ultimately, that geriatricians should be open to prescribing it. Wow! The times, they are a changin. -@AlexSmithMD

Eric and I weren't sure what to call this podcast - storytelling and medicine? Narrative medicine? We discussed it with today's guests Heather Coats, palliative care NP-scientist, and Thor Ringler, poet. It wasn't until the end that the best term emerged - storycatching. Because that really is what this is about. Clinicians "catching" patient life stories. What's in a story? Well, as we learned, everything. Our patients aren't "the 76 year old with heart failure in room 202," as Heather Coats astutely noted. They're people, and what makes us people if not our life's stories? Our loves, our triumphs, our failures, our work, our families. Thor Ringler helped start the My Life My Story project at the Madison VA in Wisconsin. It's since spread to over 70 VAs. VA "gets" the importance of storytelling in medicine, without the need for reams of research to back it up. As Thor notes, capturing patient stories has face validity as positively impacting the patients who share their stories and have them documented, and for the clinicians who get to truely and deeply know their patients in far greater depth than "what brought you to the hospital?" Heather Coats is hard at work establishing the evidence base for the power of capturing patient stories in healthcare settings, for those health systems that need a little more convincing. Wonderful work. Enjoy! Many links: VA Presents: My Life, My Story: George: A Voice To Be Heard on Apple Podcastshttps://podcasts.apple.com/us/podcast/id1529359511?i=1000489683280 Every Veteran has a story. Our mission is to help them tell it.https://www.va.gov/wholehealth/mylifemystory/ My Life, My Story: VA's healthcare improvements through deliberate storytelling - YouTubehttps://www.youtube.com/watch?v=fpzgVlExS20&ab_channel=VeteransHealthAdministration Storytelling Helps Hospital Staff Discover The Person Within The Patienthttps://www.npr.org/sections/health-shots/2019/06/08/729351842/storytelling-helps-hospital-staff-discover-the-person-within-the-patient A few data based publication links from Person-Centered Narrative Intervention Program of Research: Unpacking characteristics of spirituality through the lens of persons of colour living with serious illness: The need for nurse-based education to increase understanding of the spiritual dimension in healthcarehttps://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.16055 Integration of Person-Centered Narratives Into the Electronic Health Record: Study Protocolhttps://pubmed.ncbi.nlm.nih.gov/32740306/ Bennett, C.R., Shive, N., Coats, H. (2020). What Mattered Then, Now, and Always: Illness Narratives From Persons of Color. Journal of Hospice and Palliative Nursing, 22 (5):392-400/ PMID: 32740304https://pubmed.ncbi.nlm.nih.gov/32740304/ Coats, H., Meek, P., Schilling, L., Akard, T., Doorenbos, A. (2020). Connection -- The Integration of a Person-Centered Narrative Intervention into the Electronic Health Record: An implementation study. Journal of Palliative Medicine, 23 (6) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7249456/ Coats, H., Crist, J., Berger, A., Sternberg, E., & Rosenfeld, A. (2015). African American elders' serious illness experiences: Narratives of "God did," "God will," and "Life is better." Qualitative Health Research. doi:10.1177/1049732315620153. PMID: 26701962https://journals.sagepub.com/doi/abs/10.1177/1049732315620153. Narrative Methods Textbook referenced in podcastNarrative Methods for the Human Sciences A few Dignity Therapy- Harvey Max Chochinov links https://dignityincare.ca/en/about-us.html About us - Dignity in Carehttps://dignityincare.ca/en/about-us.html Research Team - Dignity in Carehttps://dignityincare.ca/en/research-team.html Other links: Curiosity by Faith Fitgeraldhttps://www.acpjournals.org/doi/full/10.7326/0003-4819-130-1-199901050-00015 Eric's blog post on Dignity Therapy from 2011https://geripal.org/study-of-dignity-therapy-on-distress/

What would it take to transform dementia care? While a lot of hope and money is being put into new monoclonal amyloid antibodies like lecanemab, the evidence is that while they are great in reducing amyloid in the brain for those with early Alzheimer's disease, the effects are at best modest in slowing down the decline in cognition and function (more to be said on that in an upcoming podcast). In order to truly transform dementia care we need to think much broader than the amyloid hypothesis. So on today's podcast we invite four brilliant individuals to talk about their perspective on how to change how we as a society and health care system partner with individuals with dementia. These amazing guests include: Susan McFadden, PhD, retired professor emerita (psychology and gerontology) at the University of Wisconsin, Oshkosh, an experienced researcher and practitioner in the field of dementia, and creator of the Fox Valley Memory Project. Her most recent book is Dementia Friendly Communities: why we need them and how we can create them Anne Basting, PhD, a MacArthur Genius Grant awardee and professor (English/Theatre), University of Wisconsin, Milwaukee. She created TimeSlips which we talk about in our podcast. Her most recent book is Creative Care: a revolutionary approach to dementia and elder care Abhilash Desai, MD, geriatric psychiatrist, adjunct associate professor in the department of psychiatry at University of Washington School of Medicine, and poet! He wrote a book titled "Psychiatric consultation in long term care" that has a strengths based approach to staging dementia (how cool is that) Judy Long, MDiv, BCC, palliative care chaplain and educator at UCSF and caregiver. She directs UCSF MERI's patient, family, and clinician support with classes and consultation on resiliency, well-being, and grief. We discuss the importance of viewing individuals with dementia from a lens of resilience, the importance of creative engagement (as noted in Anne and Susan's wonderful article on this subject), the role of collaborative care, and what we can do to improve inclusivity for individuals with dementia in our community and health care systems.

Assisted Living Communities (no longer preferable to call them Assisted Living Facilities, as we learned on the podcast) are…what, exactly? That's the central question on today's podcast. The problem is the tremendous heterogeneity in services offered and quality of care. If you've seen one Assisted Living Community you've seen one Assisted Living Community. To address this question, we talk with Sheryl Zimmerman, author of a recent study in JAMA Network Open that used a Delphi process to ascertain what experts thought were the essential services an Assisted Living Community should offer to residents. The experts settled on a range of key services, from more palliative care focused (e.g. end of life care and advance care planning) to more geriatrics focused (e.g. toenail trimming) to things in between (e.g. staff training in person centered care). The problem, as Kenny Lam and Ken Covinsky, authors of an accompanying editorial, state on the podcast: there is an inherent tension between the motives of the corporations that own most Assisted Living Facilities (profit) and the ideal services offered in Assisted Living Facilities. We additionally firmly establish that the song How to Save a Life by the Fray was a product of the aughts (2005, to be exact), not the 90's ): Enjoy! -@AlexSmithMD (still on Twitter at present)

Health care professionals are human, and as humans we experience loss both in and out of work. You'd imagine though that our professional expertise and experiences in helping patients and families cope with loss and grief would be helpful in managing our own personal losses. Turns out, it's maybe not. That was the lesson I learned from reading a new book edited by Matt Loscalzo along with Marshall Forstein called "Loss and Grief: Personal Stories of Doctors and Other Healthcare Professionals". It's a collection of personal stories of a small number of health professionals, including Craig Blinderman and Susan Block, who have been struck by personal illness and loss. On today's podcast, we've invited Matt Loscalzo and Craig Blinderman to talk about their book and the process they used to create these stories, which all stood out for their openness in talking about things that we as healthcare professionals often keep so very private. We also brought in Vickie Leff to talk about the work she does with Wellness Debriefings. These debriefings create a safe outlet for health care professionals to talk about the feelings resulting from their work. Vickie worked with CAPC to create tools, including a facilitator guide, to encourage clinicians and their organizations to adopt debriefings. So take a listen and check out some of these resources for healthcare provider loss, grief, and wellness: Loss and Grief: Personal Stories of Doctors and Other Healthcare Professionals Dates & registration info about debriefings offered by CAPC The CAPC Debrief Facilitator Training Manual we developed: PDF Download. Jared Rubensteins' "Token of Appreciation" video A great website for dealing with loss and grief: refugeingrief.com SPONSOR: This episode of the GeriPal Podcast is sponsored by UCSF's Division of Palliative Medicine, an amazing group doing world class palliative care. They are looking for physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here: https://palliativemedicine.ucsf.edu/job-openings

Dr. Faith Fitzgerald once quipped that prognostic modeling is the "punctilious quantification of the amorphous." She has a point. Prognosis is inherently uncertain. As Alex Lee says on our podcast today, all prognostic models will be wrong (in some circumstances and for some patients); our job is to make prognostic models that are clinically useful. As Sei Lee notes, the argument for developing prognostic models has won the day, and we increasingly use prognostic scores in clinical decision making. What makes prognostic models for mortality different from models used for anticoagulation or risk of renal injury? James Deardorff replies that there is something inherently different about predicting mortality. Death is different. For some reason clinicians who might be perfectly comfortable using an anticoagulation risk calculator might be skeptical of a mortality risk calculator (see this recent terrific JAMA IM study from Nancy Shoenborn on this issue). And yet, the only thing that may be worse than a prognostic calculator is a clinician relying solely on their clinical intuition. Today our guests Alex Lee, James Deardorff, and Sei Lee, talk to us about the uses, limitations, and clinical use cases for prognostic models. As a springboard for this conversation we discuss new prognostic models developed to predict (simultaneously) mortality, disability, and mobility impairment (Alex Lee first author, JAGS) and mortality for people with dementia residing in the community (James Deardorff first author, JAMA IM). Both new models are now available and free to use on ePrognosis. And Sei and Eric reminisce about slow dancing to "Forever Young" by Alphaville in their teenage years. Enjoy! -AlexSmithMD

The Department of Health and Human Services helps to guide billions of dollars in investment and direction in research, policy, and health care. The Assistant Secretary for Planning and Evaluation (ASPE), within the HHS, is the principal advisor to the Secretary of HHS on health policy, ranging from legislation to strategic planning to research. How does this relate to aging policy and research? How does coordination occur between the federal, state and local level in aging health policies? And, who within ASPE guides aging policy and connects policy to every day health challenges experienced by patients and clinicians? On today today's podcast, we are joined by guest host and UCSF geriatrician Ashwin Kotwal as we welcome Dr. Tisamarie Sherry (Deputy Assistant Secretary for the Office of Behavioral Health, Disability, and Aging Policy (BHDAP), appointed by the Biden administration). This office is tasked with providing aging policy research and recommendations within ASPE, including long term care and the National Alzheimer's Project Act. Dr. Sherry shares her expertise in aging health policy and helps us make sense of the role of her Office and how she coordinates with the multitude of federal agencies aligned around the goal of advancing aging research, policy, and health. For the policy buffs and policy newbies out there, we hope this podcast is an essential primer to government in action. We talk about: The structure of federal agencies and how they coordinate Priorities of the National Alzheimer's Project Act, and the unique role of ASPE and BHDAP in guiding the agenda and long-term goals The recent focus on nursing facilities and long term supportive services during the pandemic, along with key gaps How HHS and ASPE solicit input from clinicians, community leaders, and older adults and how much it impacts policy decisions (spoiler alert: this involvement is CRUCIAL) How to make your voice heard and get involved We also touch briefly on topics discussed in prior podcasts such as loneliness and federal responses to the pandemic in relation to long-term care. Tune to hear Alex's rendition of 'With a Little Help from My Friends'! - Ashwin Kotwal, MD, MS

When I'm on service these days there is inevitably a moment when a resident says "Patient so-and-so is on X" - and I have absolutely no idea what X is. Modern subspecialist practice advances at such a remarkably rapid pace, it can be hard to keep up. In this context, we're excited to hear from infectious disease experts and nephrologists about updates in the care of older adults. Sonali Advani and Lona Mody talk about their recent JAGS article highlighting three recent articles that every clinician caring for older adults should be aware of in the treatment of infectious diseases (hint: I've never finished a course of antibiotics, and maybe your patients don't need that full course either). Devika Nair and Rasheeda Hall talk about their JAGS article highlighting updates from nephrology in the care of older adults, including a link to this new eGFR calculator that does NOT include race. We have a discussion about the decision to remove race, a social construct, from clinical risk calculators (though I'm not 100% sold that race should always be removed - if removal is likely to worsen disparities for example - at least until a superior race-blind calculator can be developed). These articles are part of a new series called Clin-Star Corner, a new series in JAGS that reviews practice changing articles in the care of older adults. And yeah, they made me sing a Miley Cyrus song…(but not this hilarious parody about UTIs). Enjoy! -@AlexSmithMD

Earlier this year palliative care was the correct response to the following clue on the game show Jeopardy: From a Latin word for "to cloak", it's the type of care given to seriously ill patients to provide comfort without curing What struck me most was not that palliative care was a question, nor that it made it seem that palliative care isn't provided alongside care directed at curing, nor was it that hospice was the first buzzed in response, but it was that palliative care was the $2000 question in the Double Jeopardy round! The fact that palliative care was the hardest of questions told me that we have a massive messaging problem in our field. So what do we do about it? Well, on today's podcast we talk with Marian Grant and Tony Back, who with support form the John A Hartford Foundation and the Cambia Health Foundation, have done a deep dive into the research on layperson perceptions of palliative care, hospice, and advance care planning. The result is a new toolkit to help us fix our messaging & engage the public: seriousillnessmessaging.org Questions we talk about include: What do we know about the public's perception of palliative care, hospice, and advance care planning? What's wrong with the "pictures of hands clasping each other" as our palliative care meme? How can we bring in marketing strategies into our public messaging? Don't palliative care clinicians already know how to explain things with empathy? Why is this different from clinical communication skills? If we avoid talking about death, is it just contributing to the public death denial that is rampant in American culture? Related Links Public Perceptions of Advance Care Planning, Palliative Care, and Hospice: A Scoping Review https://www.liebertpub.com/doi/full/10.1089/jpm.2020.0111 Public Messaging for Serious Illness Care in the Age of Coronavirus Disease: Cutting through Misconceptions, Mixed Feelings, and Distrust https://www.liebertpub.com/doi/full/10.1089/jpm.2020.0719 Effective Messaging Strategies: A Review of the Evidence. Communicating to Advance the Public's Health: Workshop Summary https://www.ncbi.nlm.nih.gov/books/NBK338333/

Have you had difficulty managing a particular type of cancer pain? For me it's radiation induced mucositis/esophagitis. Janet Abrahm is one of the world's experts in pain and symptom management for patients with cancer joins us to talk about (among other things): Ketamine for hyperalgesia and allodynia, how to treat dissociative side effects Lidocaine: worth the hype? Strengths and weaknesses of buprenorphine for cancer pain Fentanyl patch: often missed issues Hypnosis: uses and how to get training via the American Society of Clinical Hypnosis Janet is the author of the 4th edition of the book Comprehensive Guide to Supportive and Palliative Care for Patients with Cancer, along with co-authors Molly Collins and BR Daubman. This book is terrific, truly comprehensive, and is a go to resource for when I'm "stuck" taking care of patients with cancer. And yes, this would be a great one for CME. Eric and I are working on it…maybe by 2023? Finally, can you believe this is our 236th podcast and, I believe, the first request for the Grateful Dead?!? Enjoy! -@AlexSmithMD