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There are no currently approved disease modifying drugs for Alzheimer's disease, but in a couple months that may change.   In July of 2021, the FDA will consider approval of a human monoclonal antibody called Aducanumab for the treatment of Alzheimer's disease.  If approved, it will not only make this drug the defacto standard of care for Alzheimer's disease, but will create a monumental shift in the usage of other currently limited diagnostic tests, including Amyloid PET scans and other biomarkers. On today's podcast, we talk about all things Amyloid, including Aducanumab and Amyloid PET scans with Gil Rabinovici.  Dr. Rabinovici is the Edward Fein and Pearl Landrith Endowed Professor in Memory & Aging at UCSF.    I could talk to Gil all day long, but we try to fit all of these topics in this jam-packed podcast: The heterogeneity of dementia and potentially Alzheimer's disease Where are we now with disease modifying treatments for Alzheimer’s disease The Role of Amyloid PET scans and other biomarkers both now and in the future The wild story Aducanumab and the controversy surrounding its pending FDA approval

One of our earliest COVID podcasts with Jim Wright and David Grabowski a year ago addressed the early devastating impact of COVID on nursing homes.  One year ago Mike Wasserman, geriatrician and immediate past president of the California Long Term Care Association, said we’d have a quarter million deaths in long term care.  A quarter of a million deaths.  No one would publish that quote - it seemed inconceivable to many at the time.  And now, here we are, and the numbers are going to be close. In this podcast we look back on where we’ve been over the last year, where we are now, and what’s ahead. One theme that runs through the podcast is that if this level of death, confinement, and fear occured to any other population, change would have been swift.  But nursing home residents, for the most part, don’t have a voice, they’re not able to speak up, they lack power to move politicians and policy.   Mike Wasserman is a provocateur.  He is a needed voice for the nursing home residents and the nursing home staff who often are not able to speak for themselves.  He is regularly quoted in major news outlets, and was in the Washington Post about opening up nursing homes to visitation the day of our podcast.  If you don’t follow him on Twitter @Wassdoc you should! -Link to Wassmerm and Grabowski’s article in the Health Affairs blog on the need for financial transparency in nursing homes. -Link to webinar about what to do about COVID in long term care from April 2020 -@AlexSmithMD

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.   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  

Surrogate decision‐making around life-sustaining treatments in the hospital even in the best of circumstances is hard.   It’s maybe even harder when caring for those who are conserved or have a professional guardian.  The conservator may not have known the patient prior to them losing capacity, they may not know their values or goals that can help guide decisions, and they may be restricted by state statutes on what decisions they can make without getting a judge's approval.   The prevailing wisdom is all of the barriers to decision making while under guardianship likely leads to delays in decision making or one that errs on choosing high‐intensity treatment even if it is unlikely to benefit the patient.  But is that really the case?    On today's podcast, we talk with Andy Cohn, lead author of a recent Journal of the American Geriatrics Society (JAGS) paper titled “Guardianship and End‐of‐Life Care for Veterans with Dementia in Nursing Homes” and Liz Dzeng, the lead author of the accompanying editorial to the paper.    The big surprise finding of this study was veterans who were nursing home residents aged 65 and older with moderate to severe dementia and who had a professional guardian were no more likely to receive high‐intensity treatments than the same population who died with decision makers who were not professional guardians.   We talk to Andy about his study, potential reasons behind the study, and what, if anything, we should do differently knowing these results.   We also talk to Liz about whether substituted judgement is really all that it’s cracked up to be. So take a listen and also check out these articles to read more about it: Guardianship and End‐of‐Life Care for Veterans with Dementia in Nursing Homes.  We Need a Paradigm Shift Around End‐of‐Life Decision Making. Guardianship and End-of-Life Decision Making

“Diagnose and adios.”  That’s the sad phrase that I’ve heard quoted more than once, representing caregivers' sentiment of what it’s like to be told by a clinician that your loved one has dementia.  This week we talked with Zaldy Tan, Geriatrician and Director of the Memory and Aging program at Cedars Sinai in Los Angeles.  With David Reuben at UCLA and others working LA realized that current caregiver training programs were lacking.  Caregivers for people with dementia are stressed, short on time, and thirsty for high impact information and skills training that can be delivered efficiently.  To meet this need they launched a new caregiver “bootcamp” 1-day training (with the help of Archstone Foundation which also funds GeriPal).  We cover many topics, including dissemination of the bootcamp to Spanish-speaking caregivers, converting to video boot camp during COVID, and ways you can partner with them to create your own boot camp. Listen to the podcast to learn more!  (And “Remember Me” from Coco - great song choice) JAGS article on caregiver boot camp Dementia caregiver IcareD website (including upcoming bootcamp calendar) CAPC website on caregiver support -@AlexSmithMD

What does it mean to create a cultural shift to the end of life experience?  Is it even possible?  How do you even start something like that?   On today's podcast, we talk to Shoshana Ungerleider about her experience making that change.  Shoshana is one of those amazing advocates for palliative and end of life care.  She started the Ungerleider Palliative Care Education Fund to support innovative programs that further palliative care education.  She is Executive Producer of the Academy Award-nominated end of life documentaries, Extremis and Netflix’s End Game.  Oh yah.  She also started End Well back in 2017 which brought together people from all different backgrounds and professions with a goal to talk about end of life care.    This year she is taking the conference virtual with "Take 10" on December 10th.  Take 10 brings names like Maria Shriver, Taraji P. Henson, Andy Cohen, Justin Baldoni, and Atul Gawande to speak about issues within palliative care, caregiving, geriatric medicine, and end-of-life care, all in light of what we can learn from the COVID crisis.  And best of all it's free.   So take a listen to the podcast and sign up for Take 10 here: Date: December 10, 2020 Time: 10:00am PST - 2:00pm PST  Location: https://endwellproject.org/  Register for free here thru 12.10.2020: https://endwellproject.org/take-10-end-well-2020/#register

How long does it take to see a benefit of statin therapy for primary prevention of cardiovascular events in adults aged 50 to 75 years?  That's the question we try to answer with our two guests today, Drs Lindsey Yourman and Sei Lee, the lead and senior author of a JAMA IM study that tried to answer this question. In this podcast Drs. Yourman and Lee define what time to benefit is, why it is important in regards to decision making for older adults, and common lag time to benefits for common preventative interventions.  We then take a deep dive into the JAMA IM meta-analysis of 8 trials, which showed 2.5 years were needed to avoid 1 cardiovascular event for 100 patients aged 50 to 75 years of age treated with a statin. So give it a listen and tell us what you think on either our Twitter or Facebook posts about this podcast.

An age friendly health system is one in which everyone, from the doctors to the nurses to the people cleaning the rooms are aware of the unique needs of older adults.  These needs are categorized around the 4 M’s - Medication, Mentation, Mobility, and What Matters Most.   But we cannot achieve the ideal of an age friendly health system without, well, changing systems.  In this week’s podcast, we talk with Julia Adler- Milstein about the ways in which the electronic health records in hospitals and skilled nursing facilities are set up (or not set up) to document and track the 4 M’s.  We also talk with Stephanie Rogers about her work toward creating an age friendly health system at UCSF. Enjoy! -@AlexSmithMD

The Emergency Department (ED) is a hard place to have serious illness discussions, whether it be goals of care or code status discussions, or whether or not to consider intubation for a seriously ill patient.  Emergency physicians often don't have the time for in-depth discussions, nor have been trained on how to do so.  There often is limited information about the patient, their functional status, or their prognosis.  These are some of the most challenging and some of the most important conversations in medicine, as 75% of older adults visit the ED during the last 6 months of life (data thanks to this Alex Smith publication in Health Affairs!)   So how do we have these urgent conversations in a time of crisis to ensure that patients receive care that aligns with their goals?  We have Naomi George, researcher and ED physician extraordinaire from the University of New Mexico, and Kai Romero from UCSF and Hospice by the Bay to help answer this question. Naomi discuss her practical approach to crises communication that she published along with others (including previous GeriPal guest Kei Ouchi) in this Annals of Emergency Medicine publication titled "Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure."  We also talk with Kai Romero about her Academic Life In Emergency Medicine blog post on "Work Grief: A Practical Primer for Emergency Medicine Providers". 

In this week's podcast we talk with Kieran Quinn, author of a systematic review and meta-analysis of palliative care for non-cancer illness, published in JAMA.  We also talk with Krista Harrison, first author of an accompanying editorial.  JAMA editors cut out some of my favorite parts of Krista's editorial, possibly because they were more like a blog post than a JAMA editorial.  (I was senior author; go figure how it ended up reading like a blog post!) So here is the submitted introduction, unedited: "As with many people’s best ideas, inspiration struck in the shower. Dr. Balfour Mount, a urologic-cancer surgeon at the Royal Victoria Hospital in Quebec, Canada, needed a name to differentiate a new hospital-based service he created for people with serious life-threatening illness from Dr. Cicely Saunders’ English hospice programs. Dr. Mount coined the term “palliative care” to connote the core goals of the service: to improve quality of life and to mitigate sources of distress. The field of palliative care was born. The year was 1975.  Forty-five years later, palliative care retains its central focus on improving quality of life for people living with serious, life-limiting illnesses and their families by addressing physical and psychological symptoms, social and spiritual needs, and aligning patient and family values with available care options."   In our podcast, we talk about the surprising finding in Keiran's study that palliative care for noncancer illness was associated with a modest improvement in symptoms, reduced hospitalization and emergency department use, increased advance care planning but not improved quality of life.  How can palliative care, since inception designed to improve quality of life, not improve quality of life? Listen to the podcast to find out! -@AlexSmithMD

There are a lot of large numbers that involve heart failure, starting with the sheer number of patients diagnosed (6.5 million and counting), to the cost of their care (~$70 billion by 2030), to the amount of money invested by the NIH into research ($1 billion annually). But the smaller numbers deserve attention too - 50% of patients die within 5 years of their diagnosis, those older than 65 in the hospital die even sooner at ~2.1 years thereafter, the median survival on hospice since hospital discharge is 11 days, and