GeriPal - A Geriatrics and Palliative Medicine Podcast

On today's podcast we welcome back Haider Warraich to talk about pain. Now this may surprise our frequent listeners as we have had Haider on before to talk about heart failure as well as palliative inotropes, so why are we having him come on to talk about pain? . Well, Haider has an intimate relationship with pain, having experienced chronic pain himself and now having dove deep into the latest research on pain for his new book The Song of Our Scars: The Untold Story of Pain. We discussed the nature of pain, what makes chronic pain different from acute pain, what's the difference between proprioception, pain, and suffering, and so much more. So take a listen and if you are up for it, check out some of Haider's other books including Modern Death: How Medicine Changed the End of Life and State of the Heart: Exploring the History, Science, and Future of Cardiac Disease.

You have a patient with dementia severe enough that she cannot recognize relatives. She falls and breaks her hip. Should she have an operation, and risk the pain, potential complications, and attendant delirium associated with the operation? Should she be treated non-operatively, with aggressive symptom management? A huge part of this decision rests on (1) her previously stated wishes, values, and goals (prior to the onset of dementia); and (2) the outcomes of surgery for patients with dementia. In today's podcast we talk with surgeon Samir Shah and Health Services Researcher Joel Weissman about a pair of JAGS articles they published on the outcomes of high risk surgery and advance care planning among persons with dementia. Toward the end we get to hear from Samir about how he would approach decision making for a patient such as the above patient, and from Joel Weissman about what's to be done about the pressure and incentives our health system exerts to operate, operate, operate. -@AlexSmithMD

Cancer screening is designed to detect slow growing cancers that on average take 10 years to cause harm. The benefits of mammography breast cancer screening rise with age, peak when women are in their 60s, and decline thereafter. That is why the American College of Physicians recommendation regarding mammography for women over age 75 is: In average-risk women aged 75 years or older or in women with a life expectancy of 10 years or less, clinicians should discontinue screening for breast cancer. Today we talk with Mara Schonberg, who has been tackling this issue from a variety of angles: building an index to estimate prognosis for older adults, writing about how to talk with older adults about stopping screening, a randomized trial of her decision aid, and how to talk to older adults about their long term prognosis. In the podcast she gives very practical advice with language to use, and references her decision aid, which is available on ePrognosis here. Mara keeps working at it, and the more she works, the closer we are to fine. -@AlexSmithMD

There are a lot of old myths out there about managing urinary tract symptoms and UTI's in older adults. For example, we once thought that the lower urinary tract was sterile, but we now know it has its own microbiome, which may even provide protection against infections. So giving antibiotics for a positive urine culture or unclear symptoms may actually cause more harm than good. On today's podcast, we are gonna bust some of those myths. We've invited some very special guests to talk about the lower urinary tract - Christine Kistler and Scott Bauer. First, we talk with Christine, a researcher and geriatrician from the University of North Carolina, who recently published a JAGS article titled Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline. We discuss with her how we should work-up and manage "urinary tract infections" (I've added air quotes to "UTI" in honor of Tom Finucane's JAGS article titled "Urinary Tract Infection"—Requiem for a Heavyweight in which he advocated to put air quotes around the term UTI due to the ambiguity of the diagnosis.) Then we chat with Scott Bauer, internist and researcher at UCSF, about how to assess and manage lower urinary tract symptoms in men. We also discuss Scott's recently published paper in JAGS that showed that older men with lower urinary tract symptoms have increased risk of developing mobility and activities of daily living (ADL) limitations, perhaps due to greater frailty phenotype.

In the US, geriatrics "grew up" as an academic profession with a heavy research base. This was in part due to the tremendous support of the National Institute on Aging. Clinical growth of geriatrics programs has lagged academic research, despite the rapid aging of the population. Palliative care, in contrast, saw explosive growth in US hospitals. In contrast to geriatrics, the evidence base for palliative care lagged clinical growth, in part because palliative care has no centralized "home" at the National Institutes of Health. The National Palliative Care Research Center (NPCRC)and Palliative Care Research Cooperative (PCRC)were founded in part to meet this need. Today we interview Kate Courtright, a critical care and palliative care physician-researcher who conducts trials of palliative care. Kate's journey is in a way emblematic of the lack of centralized funding for palliative care: she's received funding from three separate NIH institutes, the NPCRC, and been involved in the PCRC. We talk with Kate about how despite how far we've come in palliative care research, we still don't have answers to some fundamental questions, such as: Who should get specialized palliative care? Should eligibility and access be determined by clinician referral? By diagnosis? By prognosis? By need? If we move away from clinician referrals as the means by which people get access, how do we keep the clinicians engaged, and not enraged? Can nudges help? (see our prior podcast on Nudges with Jenny Blumenthal-Barby and Scott Halpern) When should people get palliative care? What does "early" really mean? We can't possibly meet the needs of all people with newly diagnosed serious illness How do we move from efficacy (works in highly controlled settings) from effectiveness (works in real world settings? What's the role of implementation science? What is a pragmatic trial? What outcomes should we measure? We cover a lot of ground! Working on a mystery. Going wherever it leads. Runnin down a dream… -@AlexSmithMD

We are two and a half years into the COVID pandemic. We've lived through lockdowns, toilet paper shortages, mask mandates, hospital surges where ICU's overflowed, a million COVID deaths, prolonged school closures, development and roll out of novel vaccines, an explosion of social isolation and loneliness, and the invention of the "zoom meeting." But what have we really learned over this seemingly endless pandemic other than how to make a quarantini? Well, on today's podcast we invite Monica Gandhi to sum up the evidence to date about how best to prevent getting COVID (or at least the severe outcomes of the disease) and how to treat it, including the role of Paxlovid in symptomatic disease. Monica Gandhi is a professor of medicine and associate division chief of HIV, Infectious Diseases, and Global Medicine at UCSF & San Francisco General Hospital. In addition to her research publications, she is a prolific writer both on social media and on media outlets like the Atlantic and the Washington Post. Some call her an optimist or maybe a pragmatist, but I'd call her someone who inherently understands the value in harm reduction when it's clear harm elimination just ain't gonna happen. So take a listen and if you want a deeper dive into some of the references we discuss on the podcast, here is a list: Medscape article on how "COVID-19 Vaccines Work Better and for Longer Than Expected Across Populations, Including Immunocompromised Individuals" Stat news article about variants/COVID becoming more predictable A good twitter criticism of the CDC 1 in 5 COVID survivors have long COVID study NIH study about long COVID published the day before in Annals of Internal Medicine Evusheld and how it works against BA4 and BA5 Our World in Data COVID graphs

It's been a while since we've done a Covid/bioethics podcast (see prior ethics podcasts here, here, here, and here). But Covid is not over and this pandemic keeps raising challenging issues that force us to consider competing ethical considerations. This week, we discuss an article by bioethicists Govind Persad and Emily Largent arguing that the NIH guidance for allocation of Paxlovid during conditions of scarcity. They argue that the current guidelines, which prioritize immunocompromised people and unvaccinated older people on the same level, should be re-done to prioritize the immunocompromised first, and additionally move up older vaccinated individuals or vaccinated persons with comorbidities. The basis of their argument is the ethical notion of "reciprocity" - people who are vaccinated have done something to protect the public health, and we owe them something for taking that action. Eric and I attempt to poke holes in their arguments, resulting in a spirited discussion. To be sure, Paxlovid is no longer as scarce as it was a few months back. But the argument is important because, as we've seen, new treatments are almost always scarce at the start. Evusheld is the latest case in point. Sometimes, you can't always get what you want… -@AlexSmithMD

A patient is on morphine and you want to convert it to another opioid like hydromorphone (dilaudid). How do you do that? Do you do what I do, pull out a handy-dandy opioid equianalgesic table to give you a guide on how much to convert to? Well on today's podcast we invited Drew Rosielle on our podcast who published this Pallimed post about why opioid equianalgesic tables are broken and why we shouldn't use them, as well as what we need to move to instead. But wait, before you throw out that equianalgesic table, we also invited Dr. Mary Lynn McPherson, PharmD extraordinaire who published this amazing book, Demystifying Opioid Conversions, 2nd Ed., which advocates for an updated, wait for it… equianalgesic table! Oh boy, what should we do? Should we throw out the equianalgesic table like some are advocating we do with advance directives (see here), or should we just modernize it for the times with updated data? Listen to this spicy podcast with these wonderful guests to make up your own minds (I'm sticking with the equianalgesic table for now). If you want to take a deeper dive into some of the references, here you go: Pallmed Post on why "Opioid Equianalgesic Tables are Broken" Pallimed post on "Simplifying Opioid Conversions" Dr. Akhila Reddy and colleagues study looking at converting hospitalized cancer patients from IV hydromorphone to PO morphine, PO hydromorphone, or PO oxycodone. Our previous podcast with Mary Lynn titled "All the Questions You Had About Opioids But Were Afraid To Ask"

In today's podcast we talk with Dr. Rajagopal (goes by "Raj"), one of the pioneers of palliative care in India. Raj is an anesthesiologist turned palliative care doctor. He is also author of the book, "Walk with the Weary: Lessons in Humanity in Health Care," and was featured in this Atlantic article. Raj is the founder of Pallium, an organization dedicated to improving palliative care throughout India. We are joined by guest-host Tom McNally, a rehab and pediatric palliative care doc at UCSF. In this podcast, we cover a great deal of ground, including: Early challenges Dr. Raj faced in pain management: access to opioids, corruption, a system that doesn't see addressing suffering as a priority Prognosis communication and the subtle ways we may communicate it without intention Social pain and loneliness Community-based palliative care networks Raj's reflections on the state of palliative care in the US How definitions bind us, for example the division between chronic pain and palliative pain in much of the US Ways listeners can learn more and contribute (see this link in the US) Because the song request was the short theme-song for Pallium, I recorded it two ways. The intro is the upbeat guitar driven version. The outro is the synthesizer (new toy!) slowed down version. Enjoy! -@AlexSmithMD

Think about the last time you attended a talk on communication skills or goals of care discussions. Was there any mention about the impact that hearing loss has in communication or what we should do about it in clinical practice? I'm guessing not. Now square that with the fact that age-related hearing loss affects about 2/3rd of adults over age 70 years and that self-reported hearing loss increases during the last years of life. Screening for addressing hearing loss should be an integral part of what we do in geriatrics and palliative care, but it often is either a passing thought or completely ignored. On today's podcast, we talk to Nick Reed and Meg Wallhagen about hearing loss in geriatrics and palliative care. Nick is an audiologist, researcher, and Assistant Professor in the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health. Meg is a researcher and professor of Gerontological Nursing and a Geriatric Nurse Practitioner in the School of Nursing at UCSF. We talk with Nick and Meg about: Why hearing loss is important not just in geriatrics but also for those caring for seriously ill individuals How to screen for hearing loss Communication techniques we can use when talking to individuals with hearing loss The use of assistive listening devices like pocket talkers and hearing aids Their thoughts on the approval and use of over the counter hearing aids If you want to take a deeper dive into this subject and read some of the articles we discussed in the podcast, check out the following: Hearing Loss: Effect on Hospice and Palliative Care Through the Eyes of Practitioners COVID-19, masks, and hearing difficulty: Perspectives of healthcare providers Association of Sensory and Cognitive Impairment With Healthcare Utilization and Cost in Older Adults Over-the-counter hearing aids: What will it mean for older Americans? Addressing Hearing Loss to Improve Communication During the COVID-19 Pandemic