GeriPal - A Geriatrics and Palliative Medicine Podcast

On June 7th, 2021 FDA approved the amyloid beta-directed antibody aducanumab (Aduhelm) for the Treatment of Alzheimers. This approval of aducanumab was not without controversy.   Actually, let me restate that.  The approval of aducanumab was a hot mess, inside a dumpster fire, inside a train wreck.  After the approval, three members of the FDA advisory panel, which unanimously was not in favor of the approval of aduhelm, quit.  One of them, Aaron Kesselheim (who we have on our podcast today) described it as “the worst drug approval decision in recent U.S. history" in his resignation letter. Then the FDA had to revise the label one month after publishing it because the original didn't even come close to looking like the population in which treatment was initiated in clinical trials.  Then, wait for it, after a firestorm of criticism the FDA’s commissioner had to ask for an independent investigation to look into the interactions between Biogen representatives and FDA members.  And now CMS is deciding if and how to cover Aduhelm, a drug that will cost at least $56,000 a year per patient not incluiding the doctor’s visits, amyloid PET scans, and frequent MRIs that will be necessary to monitor for side effects. On today's podcast we talk all about aducanumab with Aaron Kesselheim, Professor of Medicine at Harvard Medical School and previous member of that now famous FDA advisory committee, as well as Jason Karlawish, Professor of medicine, medical ethics and health policy, and neurology at the University of Pennsylvania Perelman School of Medicine. I’d love to point you to the journal articles for the two phase III trials on aducanumab, but as of yet, they are unpublished (this should tell you a little about the faith Biogen has on its drug data), so I’ll leave you with these resources instead: Our podcast with Gil Rabinovici on “All things Amyloid, including Aducanumab and Amyloid PET scans” AGS’s preliminary advice on prescribing Aducanumab -  Jason Karlawish’s book, The Problem of Alzheimer's, and the previous podcast that we did on it  FDA’s document dump on Aduhelm  Biogen’s open letter to the Alzheimer’s disease community complaining about the “turn outside the boundaries of legitimate scientific deliberation” that has occurred with aduhelm (while ignoring the fact that the trials have not been published yet). CMS’s request for public comment for their National Coverage Determination analysis to determine whether Medicare should cover the drug and any other monoclonal antibodies directed at amyloid The last one is particularly important as whether you are for or against the coverage of aducanumab, your voice matters. There is a letter being circulated by physicians who care for people with Alzheimer's Disease urging CMS not to cover aducanumab given the limited clinical evidence for benefit, known harms, and exorbitant cost. You can find the letter here.  If you would like to sign the letter, you can add your name by clicking this link.  

Cannabis use by older adults has increased substantially over the last decade, a trend that has paralleled the legalization of its use for medical and recreational purposes. In that same time, there has been a decreased perceived risk associated with cannabis use in older adults as noted in a recent study published in JAGS. On today’s podcast we talk with Drs. Bree Johnston and Ben Han about what the health care providers role is in cannabinoid prescribing and advising when caring for older adults.  We try to cover a lot in this podcast, including some of these topics: Epidemiology of cannabis used by older adults (including aspects of the JAGS study) The basic pharmacology and dosing of cannabinoids The latest evidence for the efficacy of cannabis Specific risks and side effects that providers should be aware about, and how we should monitor patients using cannabinoid products Drug interactions we should be aware about

In a new study in JAGS, Matthew Growdon found that the average number of medications people with dementia took in the outpatient setting was eight, compared to 3 for people without dementia.   In another study in JAGS, Anna Parks found that among older adults with atrial fibrillation, less than 10% of disability could be explained by stroke over an almost 8 year time period.  She also talked about the need for a new framework for anti-coagulation decisions for patients in the last 6 months of life, based on an article she authored in JAMA Internal Medicine with Ken Covinsky. In today’s podcast we talk with Matthew and Anna, joined by co-author Mike Steinman, to talk about polypharmacy, deprescribing, where we are and what we need to do to stop this freight train of ever more medications for older adults and those living with serious illness. We start by addressing the root cause of the problem.  Clinicians want to “do something” to help their patients.  And one thing we know how to do is prescribe.  It’s much harder psychologically for clinicians to view deprescribing a medication as “doing something.”  This attitude needs to change.  It will take teamwork to get there, with robust involvement of pharmacists, and likely activating patients to advocate for themselves. And Eric might have mentioned aducanumab a time or two… -AlexSmithMD

Older adults often turn to institutional settings like nursing homes when they need more help than they can get at home.  However, since the 1970s, there has been a program that allows older adults to receive nursing home-level care outside of nursing homes.  That model of care is known as the Program of All-inclusive Care for the Elderly, or PACE.  On today’s podcast, we discuss PACE with two leaders in the PACE community, Dan Drake and Jay Luxenberg. Dan is the President and CEO of Trinity Health PACE, the second largest provider of PACE in the country, and Jay is the Chief Medical Officer of On Lok, the very first PACE demonstration site in the nation. We talk with Dan and Jay about all things PACE, including: What is PACE and what is included in it that makes it able to care for nursing home level care in peoples homes? How is PACE paid for, what does it need to cover, and who is eligible? How did PACE start and what’s the evidence that it works? What are the challenges to PACE implementation and what do they think the future has in store for PACE? Why should you work at a PACE program?

We have made remarkable progress in reducing the use of feeding tubes for patients with advanced dementia.  This has been due to the leadership of people like Susan Mitchell and Joan Teno, among others.  One might hope that this reduction in use of feeding tubes has been in part due to advance care planning discussions that helped align care and treatment with patients goals.   How then, do we explain the concerning findings in a pair of recent papers demonstrating high rates of mechanical ventilation among patients with dementia?  In today’s podcast, we talk with Rashmi Sharma, who in JAGS found that rates of mechanical ventilation rose from 4% to 12% among whites with advanced dementia and 9% to 22% among blacks between 2001 and 2014.  One in five blacks with advanced dementia admitted from a nursing home received mechanical ventilation.  That’s startling.   And Zhi Jia found in a Medicare sample that Asians were more likely to receive mechanical ventilation than whites, and disparities were higher for older Asians with dementia compared to cancer.   We have made progress, due to the leadership of GeriPal superstars.  But even as we make progress in feeding tubes, it doesn’t seem to have translated across the board to mechanical ventilation, a burdensome and potentially non-beneficial treatment for patients with dementia.  The fact that rates are highest among older blacks and Asians is particularly concerning. Though the reasons behind this are complex, it’s likely that structural racism plays a major role in these growing inequalities.   We have more work to do. -@AlexSmithMD  

While palliative care most traditionally grew up with a strong association with cancer care and end-of-life care, more and more evidence is coming out about how to integrate palliative care into a variety of serious illnesses from heart failure to chronic lung conditions.  Another emerging field is the integration of neurology and palliative care, something that has been coined as “neuropalliative care.”  We had Benzi on a previous GeriPal podcast to talk about palliative care in Parkinson's disease.  On this week’s podcast we go much deeper into the field of neuropalliative care by inviting leaders of the new field and in the International Neuropalliative Care Society (INPCS),  Benzi Kluger, Edward Richfield, and Christine Ritchie.  INPCS connects clinicians, researchers, interdisciplinary team members, people living with neurological illness, family members, and advocates at the intersection of neurology and palliative care.  In addition to talking about why INPCS was developed, we talk with these leaders about: What are the unique palliative care needs of patients with neurological conditions and their family members?  Do we really need a society focused on a subspecialty in palliative care and do we need it for every subspecialty in palliative care? How can palliative care be integrated into neurology practice? What are the gaps in the field of palliative care when addressing the needs of patients with neurological diseases? What are some key lessons learned doing neuropalliative care on how to care for patients with neurological diseases? One other big shout out too for INPCS is for their inaugural Annual Meeting on November 4-6, 2021. The online conference will offer attendees the opportunity to learn from experts, hear updates in practice patterns, review the state of the science in neuropalliative care, and network with others interested in this growing field.  Best part, it’s free!   So sign up.

What if there was a tool that could break down a neighborhood’s socioeconomic measures, like income, education, employment and housing quality, to give us a sense of how those factors influence overall health, and maybe even inform where to target health resources and social interventions.   On today’s podcast we talk with Dr. Amy Kind from the University of Wisconsin School of Medicine and Public Health, who developed that tool, the Neighborhood Atlas.  The Neighborhood Atlas uses the “Area Deprivation Index,” which includes 17 measures of education, housing quality and poverty, and can be used free by anyone by going to the Neighborhood Atlas website (https://www.neighborhoodatlas.medicine.wisc.edu/). In addition to talking with Amy about the Atlas, we discuss some of the following questions: What is neighborhood disadvantage and what health outcomes is it linked to? How should providers use neighborhood disadvantage when caring for patients? How should health care systems use neighborhood disadvantage? How does the Atlas also identify areas of resilience in communities? So take a listen and if you want to read more about it, check out Amy’s NEJM article on the topic - https://www.nejm.org/doi/full/10.1056/NEJMp1802313

Harm reduction, as so clearly described by our guest Monica Gandhi on this podcast, began as a public health approach that guided management of HIV.  Harm reduction represented an alternative to an abstinence-only approach, which clearly did not work.  In the harm reduction model, you acknowledge that people will take some risks, and that the goal is to decrease risk, not eliminate it.    And yet, here we are with a fear-not-facts approach to the COVID-19 pandemic. Some are advocating for the use of masks in schools, hospitals, and nursing homes in perpetuity.  As in, forever.  Sounds eerily like an abstinence-only approach, right?  Science would dictate that now that we have vaccines, which Monica describes as “the solution,” we don’t need to engage in masking (with a few exceptions). Monica Gandhi, an infectious disease doctor at UCSF, has advocated strongly for a fact-based approach to school opening, early masking and now dropping masking, and global access to vaccinations (and temporarily dropping vaccine patents), among other things. You can and should follow her: @MonicaGandhi9 And from Ashwin Kotwal, geriatrician and palliative care doc-researcher, we hear about experiences caring for patients who are afraid to return to normal after a year of masking and forced isolation, despite the toll these experiences have taken on them (documented in his recent paper in the Journal of the American Geriatrics Society).   It’s time to get back where we once belonged. (song choice hint) -@AlexSmithMD

In your clinical experience, you may have cared for patients receiving palliative chemotherapy and wondered, hmmm, why is that called “palliative” chemotherapy? We’ve written about this issue previously here at GeriPal (“a term that should be laid to rest”) as has Pallimed (“an oxymoron”). Well, now we have “palliative” inotropes for people with heart failure.  And we have to ask, is this a fitting term?  And the answer is...complex...more so than you might think.  Recall that in one of our earliest podcasts, we talked with Nate Goldstein who memorably proclaimed “the best palliative care for heart failure is treatment for heart failure.”   To unpack the issue of palliative inotropes, we welcome back Haider Warraich, a cardiologist with a strong interest in palliative care.  We are joined again by Anne Rohlfing, palliative care fellow at UCSF who spent last year as a hospitalist on the heart failure service.  Please tune in to hear more about the role of palliative care in inotrope therapy, inotropes in hospice, Haider’s study on palliative needs of patients with heart failure, and a bit about Left Ventricular Assist Devices (including a shout out to Dan Matlock’s decision aids) and Haider’s Journal of Palliative Medicine paper on top 10 tips for palliative care clinicians on caring for patients with LVADs. -@AlexSmithMD

What is a care manager?  In this week’s podcast we talk with Chanee Fabius, who after a personal experience caring for a family member with dementia, became a care manager.  Chanee explains in clear terms what a care manager is, what training is required, and what training is required.  In essence, a care manager is a “glue person” who hold things together. After observing major race/ethnic disparities in caregiving, Chanee was inspired to obtain a doctoral degree in gerontology, and her research is now directed toward reducing disparities in caregiving, particularly for patients with dementia.  See for example, her recent paper in the Gerontologist describing Black and White differences in caregiving. We are also joined by Halima Amjad, a geriatrician-researcher, who, like Halima, is at Hopkins.  Halima is very interested in improving care for people with dementia.  As she notes, when we talk about outcomes for older adults, we often talk about the characteristics of the patient as predictors, but rarely do we consider how caregiver factors might influence important outcomes for older adults.  In a paper published in JAGS, Halima found that caregiver factors predict hospitalization.  For example, caregivers who are new to the caregiving role are more likely to care for someone who is subsequently hospitalized than someone who has been caregiving for longer. We talk about all things caregivers, including research issues around the need to assess the needs of caregivers, health policy issues such as how to provide more support for caregivers, and clinical issues, such as the fact that the identity and contact information for caregivers are not routinely captured in the EHR. -@AlexSmithMD