GeriPal - A Geriatrics and Palliative Medicine Podcast

Much has been written in geriatrics and palliative care about anticipatory grief, about the grief of caregivers, and even the grief clinicians experience following the deaths of their patients. Krista Harrison, in a Piece of My Mind essay in JAMA, writes about something different. She writes about coping, as an academic hospice and palliative care researcher, with personal grief from the deaths of her dad and step-dad within 5 months of each other. There are many reasons this essay likely touched so many people (it seemed to be all over Twitter). One is that there's a silence around this experience of death. Krista's essay opens up a space to talk about it. Another is that the experience of grief is in fact universal, whether it's the loss of a loved one, the loss of a colleague or mentor to illness or a move, the loss of "a return to normal" following COVID. Krista wanted to add a couple of things not mentioned in the podcast that she found helpful. First, she treasures videos she has of her loved ones recorded before death. Second, she made fingerprint imprints of her two dads and keeps the fingerprint impressions in a locket around her neck. We talk with Krista about these and many other things on this week's podcast. Let's keep the conversation going. Links: Making Space for Grief in Academia, JAMA The Hidden Curriculum of Hospice: Die Fast, Not Slow, Health Affairs Live Discharge from Hospice Isn't Graduating - It's Getting Expelled, JAGS Griefcast podcast RadioLab: The Queen of Dying Podcast The Dougy Center Grief Out Loud Podcast On Being Podcast The Five Invitations by Frank Ostaseski Resilient Grieving by Lucy Hone The Art of Losing (poems) When Things Fall Apart by Pema Chodron -@AlexSmithMD

Today's podcast is on academic life hacks, those tips and tricks we have seen and developed over the years to succeed in academic medicine in fields that are somewhat generalist in nature. While the podcast is meant for fellows and junior faculty, we hope some of it applies to the work that all of our listeners do, even in non-academic settings. Why are we doing a podcast on #academiclifehacks? You will notice that at the start of the podcast, we spent a couple minutes to recognize my co-host, Alex Smith, for a particularly important award he received at the 2021 AGS meeting – the Thomas and Catherine Yoshikawa Award for Outstanding Scientific Achievement in Clinical Investigation. As part of this award he presented a talk titled "Confessions of an Unfocused Researcher." We (and when I say we, everyone on this podcast except for Alex who we kept in the dark) thought it would be a good idea both to celebrate Alex's award and talk about some of the topics he brought up in his talk, as well as other tips and tricks. So we asked Lynn Flint and Ken Covinsky from UCSF, and Christopher Langston from Archstone foundation to join Alex and me to talk about our shared tips and tricks to succeed in academic medicine. In particular we focused on several key issues that new faculty need to address as they start their careers including: Academic focus and goals Mentorship (and mentoring up) Academic scholarship & writing Collaboration & Networking Work / Life Balance We would also love to see your own academic life hacks by sharing them on twitter and adding the hashtag #academiclifehacks to the tweet.

"Loneliness is different than isolation and solitude. Loneliness is a subjective feeling where the connections we need are greater than the connections we have. In the gap, we experience loneliness. It's distinct from the objective state of isolation, which is determined by the number of people around you." - Vivek Murthy, two time (and current) Surgeon General. We have heard a lot about loneliness and social isolation, particularly during the pandemic with enforced social distancing and near imprisonment of older adults in nursing homes. In this context, we bring in two experts on these topics, Carla Perissinotto and Ashwin Kotwal, to explain: How loneliness and social isolation overlap and are distinct How common these measures of social well being are in geriatrics and palliative care Why we should care as clinicians How we can ask about them How we should respond to care for patients who are lonely or isolated Some key references from among the many we discuss on the podcast: Loneliness in older adults predicts functional decline and death (JAMA IM 2012) The epidemiology of loneliness and social isolation during the last years of life (JAGS 2021) Use of high risk medications among lonely older adults (JAMA IM 2021) Integrating social care into healthcare: GeriPal podcast with Kirsten Bibbens-Domingo Coalition to end social isolation and loneliness -@AlexSmithMD

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