GeriPal - A Geriatrics and Palliative Medicine Podcast

COVID has taken a devastated toll in nursing homes. Despite representing fewer than 5% of the total US events, at least 40% of COVID‐19–related deaths occurred in older individuals living in nursing homes. The good news is that with the introduction of COVID vaccines in nursing homes, numbers of infections and outbreaks have plummeted. However, only about 2/3rds of nursing home patients and only about ½ of nursing home staff have been vaccinated, largely due to hesitancy about taking the vaccine. On today's podcast we talk about vaccine hesitancy with Sarah Berry, Kimberly Johnson, and David Gifford and the lessons learned from their "town hall" intervention they did that was just published in the Journal of the American Geriatrics Society. A couple of take-home messages for me in this study was that vaccine misinformation was rampant, many nursing staff had lingering questions they wanted answered before getting the shot, and that sharing stories and personal experiences is an important way to overcome hesitancy. In addition to listening to the podcast, we really encourage everyone to take a look at the JAGS article as it has two great tables for anyone willing to do similar town halls. The first is a summary of the concerns of healthcare staff. The second is sample responses to address some of these concerns.

Hospice may not be a great match for all of the care needs of people with dementia, but it sure does help. And, as often happens, when patients with dementia do not decline as expected, they are too frequently discharged from hospice, an experience that Lauren Hunt and Krista Harrison refer to in an editorial in the Journal of the American Geriatrics Society (JAGS) as feeling like being "expelled." We talk on this week's podcast with Elizabeth Luth, author of a study in JAGS about her study of patients in a large New York Hospice with dementia who either are discharged from hospice or live longer than 6 months. Turns out this happens - brace yourselves - nearly 40% of the time! And we talk with Elizabeth and Lauren Hunt, who helps us contextualize these findings in the setting of larger issues around the fit of hospice for persons with dementia and hospice Medicare policy. (We will add the link to the editorial when it's uploaded to the JAGS website). -@AlexSmithMD

The COVID pandemic brought to light many things, including how society views older adults. Louise Aronson wrote a piece in the NY Times titled "'Covid-19 Kills Only Old People.' Only? Why are we OK with old people dying?". The ageist viewpoint she was rallying against was also brought to light in a study of ageism in social media. When looking at those tweets that were related to older adults and covid, more than 1 in 10 tweets implied that either the life of older adults was less valuable or that it downplayed the pandemic because it mostly harms older adults. So on today's podcast we are going to talk about the initiative to "Reframe Aging" with Patricia D'Antonio. Patricia is a geriatric pharmacist, and the Vice President of Professional Affairs at the Gerontological Society of America (GSA). The Reframing Aging initiative is a national effort, led by GSA and supported by Archstone Foundation, uses an evidence-based approach to communicating more effectively about older adults. There are a variety of resources available, including research reports, an online toolkit, and free instructional videos, to help us talk about our work in geriatrics and aging. For information about the Reframing Aging Initiative, please check out their webpage www.reframingaging.org. In particular, check out these two helpful resources on their website: Finding the Frame: An Empirical Approach to Reframing Aging and Ageism (2017): This report explains the process and research behind the development of the evidence-based reframing aging narratives shown to improve attitudes toward aging and to boost understanding of the structural and systemic changes needed to capture the longevity dividend. Reframing Aging: Effect of a Short-Term Framing Intervention on Implicit Measures of Age Bias (2019) This article appearing in The Journals of Gerontology: Series B describes the effect of a reframing aging intervention on implicit age bias.

So what exactly does a hospice medical director do? Why do some choose to become hospice physicians? What additional training is needed, if any, beyond Hospice and Palliative Medicine fellowship and boards? Who should take the new Hospice Medical Director Certification Board Examination? A recent study in JAGS found high rates of hospice disenrollment ("live discharge") for people with dementia - is that a good thing or a bad thing? Hmmm… We address these and other questions in this week's podcast with Tommie Farrell, hospice physician in West Texas and Chair of the Hospice Medical Director Certification Board, and Kai Romero, Chief Medical Officer for Hospice By the Bay (that's San Francisco Bay). And I get a re-do attempt at REM's "Everybody Hurts!". Apologies for the first attempt! -@AlexSmithMD

Where are we with Alzheimers? Are we about to see a revolution in how we diagnose and treat it with Amyloid PET scans and the amyloid antibody aducanumab (which is currently on FDA's desk for approval)? Or are we still in the same place where there is no meaningfully effective treatment? Or is it somewhere in between, given the data that we have on comprehensive dementia care? We talk today with Jason Karlawish, a professor of medicine, medical ethics and health policy, and neurology at the University of Pennsylvania Perelman School of Medicine. In addition to being a geriatrician extraordinaire, he is the author of the new book "The Problem of Alzheimer's: How Science, Culture, and Politics Turned a Rare Disease into a Crisis and What We Can Do About It." In addition to talking about PET scans and new drugs like aducanumab, we discuss with Jason about the history of Alzheimers, the history of how we care for a fund caregivers, and where we go from here. So take a listen and check out Jason's book!

Nursing home residents have been devastated by COVID. Somewhere around 40% of deaths from COVID have been among nursing home residents, though they make up just a sliver of the US population. Prognostication among nursing home residents who have COVID is important for a host of reasons - for counseling patients and families about what to expect, for making clinical decisions, and potentially for allocation of scarce resources such as treatments. In today's podcast, we talk with Orestis Panagiotou and Elizabeth White, the authors of a JAMA IM study that finds that physical and cognitive function are key predictors of mortality prediction for nursing home residents with COVID. We also talk with Marlon Aliberti, who authored a commentary. Physical and cognitive function are easy to assess measures that should be routinely captured for older adults, in nursing homes and elsewhere. Study after study document the importance of function to risk prediction. We also have a brief debate about how vaccinations should be allocated - according to a "one size fits all" age criteria, or a prognostic model that individualizes risk. Though I'm an advocate for prognostic models (see eprognosis.org) I'm actually on the age criteria alone side of the debate, with generous distribution among hardest hit minority communities. And sing along to This Little Light of Mine! -@AlexSmithMD

Lesbian, gay, bisexual and transgender (LGBT) older adults have lived through a lifetime of discrimination, social stigma, prejudice, and marginalization. Is the care that we are giving them in later life changing any of that or are we pushing them back into the closet? This is what we talk about in this week's podcast with Carey Candrian from the University of Colorado School of Medicine, and Angela Primbas from Stanford University (and future geriatrics fellow at UCSF!). Carey has published a wonderful article in the Gerontologist titled "She's Dying and I Can't Say We're Married?": End-of-Life Care for LGBT Older Adults, in which she describes how older LGBT adults may be at higher risk for having their health care wishes ignored or disregarded, their families of choice are less likely to be included in their decision making, and they may experience increased isolation, bullying, mistreatment, or abuse, which ultimately contribute to receipt of poor-quality health care. We talk about the scripts that we use in medicine that may hamper open discussions about sexual orientation and gender identity (SOGI) including the term "family meeting", the need to revise our intake forms to incorporate SOGI questions, and the need for education. We also get a chance to hear Alex Sing "The Story" whose lyrics very much speak to the subject at hand: "All of these lines across my faceTell you the story of who I amSo many stories of where I've beenAnd how I got to where I amBut these stories don't mean anythingWhen you've got no one to tell them to…" If you want to learn more, please check out these wonderful resources: LGBT Resource Center https://www.lgbtagingcenter.org LGBTQ Resource List from GLAAD: https://www.glaad.org/resourcelist National Resource Center on LGBT Aging: https://www.lgbtagingcenter.org/ Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE): https://www.sageusa.org/

On the one hand, every year we are fortunate to have new medications that help older adults and people living with serious illness. New treatments for lung cancer with remarkable survival outcomes come to mind, for example. On the other hand, the tremendous growth in medications has led to an explosion of prescribing, polypharmacy, with attendant side effects and harms. In this week's podcast, we talk with Nagham Ailabouni, a pharmacist and researcher joining us from Australia (song choice: Down Under!) about her review of major articles on medication safety and quality for older adults. Dr. Ailabouni summarized the top four hardest hitting in a recent publication in the Journal of the American Geriatrics Society, or JAGS. The four articles are: Older Medicare Beneficiaries Frequently Continue Medications with Limited Benefit Following Hospice Admission Prescribing of oral anticoagulants in the emergency department and subsequent long-term use by older adults with atrial fibrillation Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events: A Cluster Randomized Trial Intensification of older adults' outpatient blood pressure treatment at hospital discharge: national retrospective cohort study Dr. Ailabouni's pet peeve medication she sees prescribed to hospice patients? High dose metformin. Listen to the podcast for more! -@AlexSmithMD

Most of us know we are going to die. How often though do we actually let ourselves really internalize that understanding? To imagine it? To feel it? To try to accept it? On today's podcast we invited BJ Miller back on our podcast to talk about death using as our guide his recent NY Times editorial What Is Death? How the pandemic is changing our understanding of mortality. In addition to being the author of this NY Times article, BJ is a Hospice and Palliative Care doc, and the founder of Mettle Health which aims to provide personalized, holistic consultations for any patient, caregiver or clinician who need help navigating the practical, emotional and existential issues that come with serious illness and disability. We start off with BJ appropriately picking the song "Ebony Eyes" as our intro song, which is a good analogy to talking about death, as it was initially banned by the BBC from airplay as its lyrics were considered too upsetting to play on the radio. We then go into his thoughts on how we picture our deaths and dealing with those emotions we feel when we do, how we "live with death", and... Also check out BJ's article that is geared towards kids/students - https://www.nytimes.com/2021/01/06/learning/how-do-you-view-death.html. As BJ put it in an email to us: "It's fascinating to me how they're taking care to reach out to younger minds, further proof that the idea that no one wants to think or talk about death - especially youngsters - is bunk.

Many of us in geriatrics and palliative care assume that we are the experts in health care when it comes to understanding the caregiver experience. Every once in a while, we are humbled and reminded of what we don't know. Jessica Zitter had such an experience. Jessica, as many of you know, is an award winning author (link to our podcast about her book Extreme Measures) and was featured in an Academy Award winning film titled Extremis. She sought out to make another movie about the story of one of her patients who enrolled in hospice. The idea was it would be a film about all of the support that hospice provides and how it's a transformative experience. What she realized, however, is that the real story in this film is about the caregiver in the film, who is overworked, overburdened, and has few options for supportive to care for his wife's daily needs. The film is titled Caregiver: A Love Story. See links below about how to view it. It's not yet widely available via a major distributor, so your best bet is to view a screening locally or arrange for a showing to your hospital/hospice/palliative care team/social work group combined with a discussion with Jessica Zitter. The movie is less than 30 minutes, so leaves plenty of time in an hour for discussion. -@AlexSmithMD Link to Trailer Link to Caregiver: A Love Story website If you want info on the film or any stills to use for promotion, you can take a look at our PR folder. Available virtual screenings:Dec 18-Jan 28th at the Roxie Theater (link) Jan 1-Feb 4th at the Laemmle Theater (link) Education:CME program using the film plus education module, provides credits for physicians, social workers, and nurses (link) Jessica can also offer the CME program live. We also have a live educational program for family caregivers. To arrange any live event, you can reach out to caregiver@jessicazitter.com Info on Jessica Zitter:Website Book: Extreme Measures: Finding a Better Path to the End of Life Social media: Facebook Twitter