We’ve talked about Brain Death before with Robert (Bob) Troug and guest-host Liz Dzeng, and in many ways today’s podcast is a follow up to that episode (apologies Bob for mispronouncing your last name on today’s podcast!). Why does this issue keep coming up?  Why is it unresolved?  Today we put these questions to Winston Chiong, a neurologist and bioethicist, and Sean Aas, a philosopher and bioethicist.  We talk about many reasons and ways forward on this podcast, including: The ways in which advancing technology continually forces us to re-evaluate what it means to be dead - from the ability of cells/organs to revive, to a future in which organs can be grown, to uploading our consciousness to an AI.  (I briefly mention the Bobiverse series by Denise Taylor - a science fiction series about an uploaded consciousness that confronts the reader with a  re-evaluation of what it means to be human, or deserving of moral standing). The moral questions at stake vs the biologic questions (and links between them) The pressures the organ donation placers on this issue, and questioning if this is the dominant consideration (as Winston notes, organ donation was not central to the Jahi McMath story) What we argue about when we argue about death - the title of a great recent paper from Sean - which argues that “we must define death in moralized terms, as the loss of a significant sort of moral standing,” - noting that those why are “dead” have something to gain - the ability to donate their organs to others. Winston’s paper on the “fuzziness” around all definitions of brain death, titled, Brain Death without Definitions. As we joke about at the start - talking with philosophers and bioethicists, you almost always get a response along the lines of, “well that’s a good question, but let’s examine a deeper more fundamental question.”  Today is no different. And the process of identifying the right questions to ask is absolutely the best place to start.   Eventually, of course, everything must cease.   -@AlexSmithMD

Anti-Asian hate incidents rose dramatically during COVID, likely fueled by prominent statements about the “Chinese virus.”  VIewed through the wider lens of history, this was just the latest in a long experience of Anti-Asian hate, including the murder of Vincent Chin, the Chinese Exclusion Act, and the internment of Japanese Americans during WWII.  For those who think that anti-Asian hate has receded as the COVID has “ended,” just two days prior to recording this episode a Filipino woman was pushed to her death on BART in San Francisco. These incidents are broadcast widely, particularly in Asian News outlets. Today we talk about the impact of anti-Asian hate on the health and well being of older adults with Russell Jeung, sociologist, Professor of Asian Studies at San Francisco State, and co-founder of Stop AAPI-Hate, Lingsheng Li, geriatrician/palliative care doc and T32 fellow at UCSF, and Jessica Eng, medical director of On Lok, a PACE, and Associate Professor in the UCSF Division of Geriatrics.  We discuss: What is considered a hate incident, how is it tracked, what do we know about changes over time The wider impact of Anti-Asian hate on older Asians, who are afraid to go out, leading to anxiety, social isolation, loneliness, decreased exercise, missed appointments and medications. Lingsheng (and I) recently published studies on this in JAMA Internal Medicine, and JAGS. Ongoing reports from patients about anti-Asian hate experiences  Should clinicians screen for Anti-Asian hate? Why? Why not? Proposing the clinicians ask a simple follow up question to the usual “do you feel safe at home?” question used to screen for domestic violence.  Add to this, “do you feel safe outside the home?” This question, while providing an opportunity to talk about direct and indirect experiences, can be asked of all patients, and opens the door to conversations about anti-semitism, islamophobia, or anti-Black racism. See also guides for how to confront and discuss anti-Asian hate in these articles in the NEJM and JGIM. And to balance the somber subject, Lingsheng requested the BTS song Dynamite, which was the group’s first English language song, and was released at the height of the COVID pandemic.  I had fun trying to make a danceable version with electronic drums for the audio-only podcast.  Maybe we’ll get some BTS followers to subscribe to GeriPal?!?   -@AlexSmithMD  

(We couldn’t resist when Miguel Paniagua proposed this podcast idea and title. And no, you’ll be relieved to hear Eric and I did not imitate the interview style of Zach Galifiniakis). We’ve talked a good deal on this podcast about what happens before death, today we talk about what happens after.  Our guest today is Thomas Lynch, a poet and undertaker who practiced for years in a small town in Michigan.  I first met Thomas when he visited UC Berkeley in the late 90’s after publishing his book, “The Undertaking: Stories from the Dismal Trade.” We cover a wide range on this topic, weaving in our own stories of loss with Thomas’s experiences, stories, and poems from years of caring for families after their loved one’s have died. We cover: The cultural shift from grieving to celebration, the “disappearance” of the body and death from funerals The power of viewing the body and participating in preparing the body, including cremation The costs of funerals  The story of why Thomas became an undertaker A strong response to Jessica Mitford’s scathing critique of the American Funeral Industry published in “The American Way of Death” Our own experiences with funerals and burial arrangements for our loved ones Shifting practices, with a majority of people being cremated after death, a dramatic increase This podcast was like therapy for us.  And I got to sing Tom Waits’ Time, one of my favorites.   

What is a healthy diet and how much does it really matter that we try to eat one as we age?  That’s the topic of this week's podcast with three amazing guests: Anna Pleet, Elizabeth Eckstrom, and Emily Johnston. Emily Johnston is a registered dietitian, nutrition researcher, and Assistant professor at NYU.  Anna Pleet is an internal medicine resident at Allegheny Health Network who has a collection of amazing YouTube videos on aging and the Mediterranean diet. Elizabeth Eckstrom is a geriatrician, professor of medicine at OHSU, and author of a new book, the Gift of Aging. I love this podcast as while we talk about the usual topics in a medical podcast, like the role of screening, energy balance, and evidence-based for specific diets, we also talk about what a Mediterranean diet actually looks like on a plate and pepper our guests with questions about their favorite meals to convince Alex and me to eat more like a Sardinian. Eric PS.  NEJM just published a great summary of diets summing up adherence to the Mediterranean diet and the following improved health outcomes: death from any cause, cardiovascular diseases, coronary heart disease, myocardial infarction, cancer, neurodegenerative diseases, and diabetes    

We are dusting off our crystal balls today with three amazing guests who have all recently published an article on prognosis over the last couple months: Kara Bischoff, James Deardorff, and Elizabeth Lilley. To start us off we talk with Kara Bischoff about the article she just published in JAMA Network on a re-validation of the Palliative Performance Scale (PPS) in a modern day palliative care setting.  Why do this?  The PPS  is one of the most widely used prognostic tools for seriously ill patients, but the prognostic estimates given by the PPS are based on data that is well over a decade old. ePrognosis now includes the modern validation of the PPS. Next, we talk with James Deardorff about whether we can accurately predict nursing home level of care in community-dwelling older adults with dementia.  Spoiler alert, he published a study in JAMA IM on a prognostic index that does exactly that (which is also on eprognosis.org) Lastly, we invite Liz Lilley to talk about her paper in Annals of Surgery about prognostic allignment, including why as palliative care and geriatrics teams we need to take time to ensure that all disciplines and specialities are prognostically aligned before a family meeting.  

The US Preventive Services Task Force (USPSTF) concluded back in 2000 that there is insufficient evidence to recommend for or against routine screening for dementia in older adults. Are there, though, populations that it may be helpful in, or should that change with the advent of the new amyloid antibodies?  Should it?  If so, how do we screen and who do we screen? On this week’s podcast we talk with three experts in the field about screening for dementia. Anna Chodos is a geriatrician at UCSF and the Principal Investigator of Dementia Care Aware, a California-wide program to improve the detection of dementia in older adults who have Medi-Cal benefits. Joseph Gaugler is the Director of the Center for Healthy Aging and Innovation at the University of Minnesota, director of the BOLD Public Health Center of Excellence on Dementia Caregiving, and Editor-in-Chief of the Gerontologist.  Lastly, Soo Borson is a self-described primary care leaning geriatric psychiatrist, developer of the Mini-Cog, and co-leads the CDC-funded BOLD Center on Early Detection of Dementia. In addition to the questions asked above, we also cover the following topics with our guests: What is dementia screening?  Who should get it if anyone? What should we use to screen individuals? What happens after they test positive? And if you are interested in learning more about the Guiding an Improved Dementia Experience (GUIDE) Model for dementia, check out this podcast.  

Emergency podcast! We’ve been asked by many people, mostly junior/mid career faculty, to quickly record a podcast on ageism and the elections.  People are feeling conflicted.  On the one hand, they have concerns about cognitive fitness of candidates for office.  On the other hand, they worry about ageism.  There’s something happening here, and what it is ain’t exactly clear. We need clear eyed thinking about this issue. In today’s podcast, Louise Aronson, author of Elderhood, validates that this conflict between being concerned about both fitness for the job and alarmed about ageism is exactly the right place to be.  We both cannot ignore that with advancing age the prevalence of cognitive impairment, frailty, and disability increase.  At the same time, we can and should be alarmed at the rise in ageist language that equates aging with infirmity, and images of politicians racing walkers or a walker with the presidential seal.  Ken Covinsky reminds us that we should not be making a diagnosis based on what we see on TV, and that if a patient’s daughter expressed a concern that their parent “wasn’t right,” we would conduct an in depth evaluation that might last an hour.  Eric Widera reminds us of the history of the Goldwater Act created by the American Psychological Association in the 1960s which states that psychiatrists should refrain from diagnosing public figures, and the American Medical Association code of ethics which likewise discourages armchair diagnosis (rule established in 2017). We frame today’s discussion around questions our listeners proposed in response to our Tweets, and are grateful for questions from Anand Iyer, Sandra Shi, Mike Wasserman, Ariela Orkaby, Karen Knops, Jeanette Leardi, Sarah McKiddy, Cecilia Poon, Colleen Christmas, and Kai Smith. We talk about positive aspects of aging, cognitive screening, the line between legitimate concerns and ageism, ableism, advice for a geriatrician asked to comment on TV, frailty and physical disability, images in the press, historical situations including , and an upper age limit for the Presidency, among other issues. Of note, we talk about candidates from all parties today.  We acknowledge concerns and speculation that others have raised about candidates across the political spectrum, current and former.  We do not endorse or disclose our personal attitudes toward any particular candidate.  Fitness for public office is a non-partisan issue that applies to all candidates for office, regardless of political party. There’s something happening here, and what it is ain’t exactly clear. Strong recommendation to also listen to this terrific podcast with another geriatrician all star, Jim Pacala, on MPR! -@AlexSmithMD  

In May we did a podcast on KidneyPal (the integration of palliative care in renal disease), which made us think, hmmm… one organ right next door is the liver. Maybe we should do a podcast on LiverPal? (or should we call it HepatoPal?) On today’s podcast, we do that by inviting four palliative care leaders who are integrating palliative care into the care of those with liver disease: Kirsten Engel, Sarah Gillespie-Heyman, Brittany Waterman, and Amy Johnson. It’s a jampacked 50 minutes, filled with pearls on taking care of patients with liver disease.  We cover: How each of their LiverPal teams are structured Why and how LiverPal differ from general palliative care or other palliative care specialty areas (KidneyPal, PalliPulm, etc) How to prognosticate in liver disease and how they communicate this with patients How to think about expectations of transplants and limitations of it How to manage complications and symptoms ranging from ascites, hepatic encephalopathy, pain, itching, cramps, and depression Also, if you want to take an ever deeper dive, check out our 2022 podcast on End Stage Liver Disease with Jen Lai, Ricky Shinall, Nneka Ufere, and Arpan Patel

Join experts Alex Gamble, a triple-boarded palliative care specialist, and Brianna Williamson, a UCSF palliative care fellow, as they dive into the complex world of anxiety in late life and serious illness. They dissect the nature of anxiety, exploring how it can both motivate and overwhelm. Listeners will learn about the importance of personalized support, the empathy-boosting BATHE technique, and practical strategies like mindfulness for coping with anxiety. Their insights offer a fresh take on navigating emotional distress in healthcare.

I have to start with the song.  On our last podcast about urinary incontinence the song request was, “Let it go.”  This time around several suggestions were raised.  Eric suggested, “Even Flow,” by Pearl Jam.  Someone else suggested, “Under Pressure,” but we’ve done it already.  We settled on, “Oops…I did it again,” by Britney Spears. In some ways the song title captures part of the issue with urinary incontinence.  If only we lived in a world in which much of urinary incontinence was viewed as a natural part of aging, the normal response wasn’t embarrassment and shame, but rather an ordinary, “Oops…I did it again.”  And if only we lived in a world in which this issue, which affects half of older women and a third of older men, received the research and attention it deserves. We shouldn’t have therapeutic nihilism about those who seek treatment, yet urinary incontinence is woefully understudied relative to its frequency and impact, and as we talk about on the podcast, basic questions about urinary incontinence have yet to be addressed. I don’t see those perspectives as incompatible. Today we talk with George Kuchel and Alison Huang about: Urinary incontinence as a geriatric syndrome and relationship to frailty, disability, and cognitive decline Assessment of incontinence: the importance of a 48 hour voiding diary, when to send a UA (only for acute changes) How the assessment leads naturally to therapeutic approaches Non-pharmacologic approaches including distraction, scheduled voiding, and pelvic floor therapy “Last ditch” pharmacologic treatments.  Landmark studies by Neil Resnick and Joe Ouslander.   Enjoy! -@AlexSmithMD