GeriPal - A Geriatrics and Palliative Medicine Podcast

Home-based palliative care is booming. And with the growth of home-based palliative care come unique struggles and challenges: how can it be financed, what does the ideal team look like (or do you need a team?), retaining clinicians who may feel isolated doing this work, identifying patients who are most likely to benefit. In this week's podcast we talk about these and other issues with Brook Calton, home-based palliative care physician in the Division of Palliative Medicine at UCSF and Grant Smith, a recent graduate of UCSF's palliative medicine fellowship now faculty at Stanford. To supplement our podcast, Grant has written a series of thought pieces that flesh out and complement our discussion. His first reflection was published in the Journal of Palliative Medicine last month. We will post one additional reflection per day for the next three days. Hope you enjoy my attempt at a Southern drawl while singing! -@AlexSmithMD

On this week's podcast we have the honor of talking with David Reuben about health care for older adults and how it's time to think different. It really is a smörgåsbord of topics, ranging from how to think about population health for older adults (and how we as individuals providers can provide at least some level of population health), the UCLA Alzheimer's and Dementia Care Program and its outcomes, Medicare Advantage for All, working with community partners through voucher systems, and tips for leading change. Dr. Reuben is Director of the Multicampus Program in Geriatrics Medicine and Gerontology and Chief of the Division of Geriatrics at the University of California, Los Angeles (UCLA). He is also the Archstone Foundation Chair and Director of the UCLA Claude D. Pepper Older Americans Independence Center and the UCLA Alzheimer's and Dementia Care program. If you want to read more about some of the topics, check out these links on our website at geripal.org: - Patient and Caregiver Benefit From a Comprehensive Dementia Care Program: 1‐Year Results From the UCLA Alzheimer's and Dementia Care Program - The Effect of a Comprehensive Dementia Care Management Program on End‐of‐Life Care - UCLA Alzheimer's and Dementia Care Program Website

We had fun on this in-studio podcast with Dan Matlock, geriatrician and palliative care clinician researcher at the University of Colorado, and frequent guest and host on GeriPal. We most recently talked with Dan about Left Ventricular Assist Devices and Destination Therapy. Today we talked with Dan about Implantable Cardiac Defibrillators (ICD) and Cardiac Resynchronization Therapy (CRT) - everything a geriatrician or palliative care clinician should know. Dan and his team have developed a number of terrific decision aids around ICD implantation (see patientdecisionaid.org), and have seen uptake and use of these decision aids skyrocket following CMS's mandate requiring an shared decision making interaction prior to ICD implantation. Enjoy! -@AlexSmithMD

In this week's podcast we talk about food insecurity in older adults with UCSF's Hilary Seligman, MD. Hilary has done pioneering work in this area. Some of this work was funded by Archstone Foundation (full disclosure: Archstone is a GeriPal funder). Hilary's expertise runs the gamut from federal nutrition programs (including SNAP), food banking and the charitable feeding network, hunger policy, food affordability and access, and income-related drivers of food choice. I have a confession. I knew almost nothing about food insecurity before this podcast. Is it hunger? Why should we think about food insecurity and health in the same sentence? Why is this an issue for older adults in particular? I was absolutely blown away by what I learned in this podcast. I have since quoted Hilary Seligman 4 or 5 times in other meetings. Food insecurity is one of those topics that people don't talk about but is likely far more critical to the health and well-being of the people we care about than other topics we spends gobs of time and money on (e.g. cholinesterase inhibitors for dementia). So take a listen and if you want to take a deeper dive in some of the topics we talked about, check out the links for this blog post at http://bit.ly/2vbEEZE or geripal.org. Enjoy! -@AlexSmithMD

Should Geriatric Assessments be part of the routine ontological care for older adults with cancer? On this weeks podcast we attempt to answer this question with national experts in Geriatric Oncology: Dr. Supriya Mohile from the University of Rochester and William Dale from City of Hope, as well as UCSF's Melissa Wong. Lucky for us, they also have a little evidence on their side thanks to a recently published JAMA Oncology article that they authored titled "Communication With Older Patients With Cancer Using Geriatric Assessment - A Cluster-Randomized Clinical Trial". We discuss not only the trial results, but also: - reasons why geriatric principles is important in oncology - what a geriatric assessment includes - who should do a geriatric assessment (including does it need a geriatrician?) We also talk about these resources if you want to take a deeper dive in geriatric oncology: - ASCO's Geriatric Oncology page - ASCO's guideline for geriatric oncology by: Eric Widera (@ewidera) P.S. Please visit our blog page at geripal.org for links to the referenced material above.

You've probably heard patients say, "Of course I'm depressed, I'm dying. Wouldn't you be?" This is a fundamental question - to what extent are depressive symptoms "normal" at the end of life? To what extent are they maladaptive, a fancy word for psychological conditions that have a negative impact on your life. In this week's GeriPal podcast we talked with Elissa Kozlov, a psychologist-researcher at Rutgers, and Claire Ankuda, a palliative care physician-researcher at Mt. Sinai about their JAGS paper describing the epidemiology of depressive symptoms in the last year of life. This was an interesting conversation, as Drs. Kozlov and Ankuda are pushing the boundaries of how we conceptualize depressive symptoms near the end of life. Their work suggests that depression is far more common than we suspect clinically. And they chose a great song - Hurt as arranged by Johnny Cash (not the Nine Inch Nails original). Enjoy! -@AlexSmithMD

Do opioids improve breathlessness? A simple question that unfortunately doesn't seem to have a simple answer. We get into the nitty-gritty of potential answers to this question with a preeminent researcher in this field, David Currow. David is a Professor of Palliative Medicine at University of Technology Sydney. His research has challenged common practices in Hospice and Palliative Care, including randomized control trials on oxygen for breathlessness, octreotide for malignant bowel obstruction, and antipsychotics for delirium in palliative care patients. His most recent study was published in Thorax titled "Regular, sustained-release morphine for chronic breathlessness: a multicentre, double-blind, randomised, placebo-controlled trial." It showed no differences between those that got sustained-release morphine and those that got placebo in regards to breathlessness, but the intervention arm did use less rescue immediate-release morphine. We talk to David about how to interpret these results, as well as what to make out of the broadened inclusion criteria and whether there was an issue with the primary outcome. Other articles we reference in the podcast include: * The safety study: No excess harms from sustained-release morphine: a randomised placebo-controlled trial in chronic breathlessness * And the oxycodone SA study: Controlled-Release Oxycodone vs. Placebo in the Treatment of Chronic Breathlessness-A Multisite Randomized Placebo Controlled Trial. by Eric Widera, @ewidera

In this weeks podcast we talk with Kirsten Bibbins-Domingo, general internist, Professor of Medicine and Epi/Biostats at UCSF, and chair of a National Academies of Sciences task force on Integrating Social Care into the Delivery of Health Care. See Kirsten's JAMA paper summary here (https://jamanetwork.com/journals/jama/article-abstract/2752359), and the full report here (http://nationalacademies.org/hmd/Reports/2019/integrating-social-care-into-the-delivery-of-health-care). This podcast spans the gamut from the individual clinician's responsibility to be aware of the social needs of their patients and impacts on health (think homeless person with no place to store their insulin), and adjustment to meet these needs (such as keeping on oral medications), to larger health policy issues including the need to integrate health and social policy. This was a fun podcast, as you'll hear. This is a topic that lends itself well to discussion. Eric really pushes this issue: to what extent are meeting the our patient's needs for housing, transportation, and food a health issue? Are these issues that a doctor should care about, and why? And our rendition of "Waiting on the World to Change" was perfect in every possible way!!! Enjoy! by: Alex Smith, @AlexSmithMD GeriPal is funded by Archstone Foundation (https://archstone.org/). Archstone Foundation is a private grantmaking foundation whose mission is to prepare society in meeting the needs of an aging population

On this weeks podcast we talk to Julie Bynum on the question "Do Nurses Die Differently?" based on her recent publication in JAGS titled "Serious Illness and End-of-Life Treatments for Nurses Compared with the General Population." Julie is a Professor of Geriatric and Palliative Medicine at the University of Michigan, and Geriatric Center Research Scientist at the Institute of Gerontology, as well as a deputy editor at the Journal of the American Geriatrics Society. Overall, Julie's study found small differences in end of life care for both dementia and CHF as seen in the chart on our blog post at https://www.geripal.org/2019/12/do-nurses-die-differently-podcast-with.html One can think of these numbers as so small of a difference that there really isn't a difference. With that said, my favorite part of this interview is Julie's take on this difference, which is that while the difference is small, there is a difference ("There is a signal!"). This means "I know it can be different, because it is different." by: Eric Widera

We have had some amazing guests on our Podcast. True luminaries in geriatrics and palliative care. This week we are fortunate to be joined by none other than Mary Tinetti, MD, to talk about her recent JAMA Internal Medicine trial of Patient Priorities Care (https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2752365). In this study of older adults with multiple chronic conditions, patients are guided through a process of identifying their health priorities and objectives, and this information is communicated to their primary care physicians. The trail resulted in more medications discontinued, fewer self-managment and diagnostic tests, and less report of treatment burden. This podcast builds on our prior podcast on this topic with Aanand Naik (awesome song choice, Lumineers' Gun Song). We talk with Mary Tinetti about what exactly Patient Priorities Care is, how it differs from geriatrics and palliative care (or does it?), and how to disseminate this program widely (hint: start by going to their amazing website at patientprioritiescare.org). And...ah...Mary made me sing Joni Mitchell's Ladies of the Canyon. My deepest apologies to fans of Joni Mitchell... by: @AlexSmithMD