GeriPal

Medical communication is tough, although fundamentally at its most basic unit of delivery, it includes really only three steps. First, a clinician’s thoughts must be encoded into words, then transmitted often via sounds, and finally decoded back to thoughts by a patient or family member. Simple, right? Not so much, as each one of these steps is fraught with miscommunication. For example, a surgeon may want to convey that all visible tumors were removed during surgery, but transmits that message to the patient by saying “we got it all” only to have the patient hear an entirely different message that the cancer is gone and they are now cancer free. On today’s podcast we talk with three communication experts, Abby Rosenberg, Don Sullivan, and Shunichi Nakagawa about the concept of miscommunication, including examples of it and ways we can mitigate this issue. This podcast was inspired by Abby and Don’s recent JAMA Oncology paper titled Miscommunication in Cancer Care—Do You Hear What I Hear? We also ask Shunichi Nakagawa about some of the amazing communication pearls he posts on his Twitter account (don’t tell me to call it X). Lastly, we also plan to have two more podcasts coming up on communication, one on the language of life sustaining treatments and one on surgical communication, so stay tuned! Eric Note: For more reading on this subject, check out these links: Shunichi Nakagawa’s Twitter account Miscommunication in Cancer Care—Do You Hear What I Hear? Patient Values: Three Important Questions-Tell me more? Why? What else? A "Three-Stage Protocol" for Serious Illness Conversations: Reframing Communication in Real Time

The proportion of people living with dementia who identify as Black/African Americans is on the rise, and so too are the proportion of caregivers who identify as Black/African American. As our guests talk about today, caregiving for people living with dementia takes a tremendous toll, and when this toll is set atop the challenges of racism in all its forms, the reality of caregiving while Black can be overwhelming. Today we talk with Fayron Epps and Karen Moss, two nurse researchers who are focused on improving the experience of Black/African American caregivers of persons living with dementia. We talk in particular about: Terminology. Acknowledging that the most sensitive terms shift over time, what terms are they using today and why? Black? African American? Black/African American? We also learn that the term stakeholder, so common in research, should be avoided for its early usage as White colonialists staked out land taken from Native American peoples. Why a focus on Black/African American caregivers and people with dementia? Why should interventions be culturally tailored for this group? Feyron has centered her work in Black/African American faith communities and churches - a program she titled Alter. Why this focus? Karen has a Cambia Sojourns award to pilot an intervention in which Black/African American former caregivers are trained to provide peer support to current caregivers (Peer2Care). This seems like a triple win - the bereaved former caregiver has the opportunity to be generative, share their story, and give back; the current caregiver connects with someone similar who listens when so many people are tuning them out; the person with dementia benefits from the caregiver’s improved sense of self-efficacy, decreased loneliness/social isolation, and better coping overall. Why are nurse researchers in particular critical to the study of these issues? And Karen brings a tambourine in the studio for I’ll Fly Away (see YouTube version)! -@AlexSmithMD

Hospitals are hazardous places for older adults. These hazards include delirium, malnutrition, falls, infections, and hospital associated disability (which about ⅓ of older adults get during a hospital stay). What if, for at least some older adults who need acute-level care, instead of treating them in the hospital, we treat them at home? That’s the focus of the hospital-at-home movement, and the subject we talk about in this week’s podcast. We talk with Bruce Leff and Tacara Soones about the hospital-at-home movement, which has been shown to reduce costs, improve outcomes and improve the patient experience. In addition to discussing these outcomes, we also discuss: The history of the hospital-at-home movement. The practicalities of how it works including who are good candidates, where does it start (the ED?), what happens at home, do you need a caregiver, what happens if they need something like imaging? How is it financed and what comes next? If you are interested in learning more and meeting a community of folks interested in hospital-at-home, check out the hospital-at-home user group at hahusersgroup.org or some of these publications: Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Annals of Int Med. 2020 Hospital at Home-Plus: A Platform of Facility-Based Care. JAGS Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department: A Systematic Review and Meta-analysis. JAMA Network Open

The comprehensive geriatric assessment is one of the cornerstones of geriatrics. But does the geriatric assessment do anything? Does it improve outcomes that patients, caregivers, and clinicians care about? Evidence has been mounting about the importance of the geriatric assessment for older adults with cancer, the subject of today’s podcast. The geriatric assessment has been shown in two landmark studies (Lancet and JAMA Oncology) to reduce high grade toxicity, improve patient and caregiver satisfaction, and improve completion of advance directives (can listen to our prior podcast on this issue here). Based on this surge in evidence, the American Society of Clinical Oncologists recently updated their guidelines for care of older adults to state that all older adults receiving systemic therapy (including chemo, immuno, targeted, hormonal therapy) should receive geriatric assessment guided care. We talk about these new guidelines today with William Dale, a geriatrician at City of Hope and lead author of the guideline update in the Journal of Clinical Oncology, Mazie Tsang, palliative care/heme/onc physician-researcher at Mayo Clinic Arizona who authored a study of geriatric and palliative conditions in older adults with poor prognosis cancers published in JAGS, and John Simmons, a retired heme/onc doctor, cancer survivor, and patient advocate. We talk about: What is a practical geriatric assessment and how can busy oncologists actually do one? (hint: 80% can be done in advance by patients or caregivers) Why is it that some oncologists are resistant to conducting a geriatric assessment, yet have no problem ordering tests that cost thousands of dollars? What can you do with the results of a geriatric assessment? How does the geriatric assessment lead to improved completion of advance directives, when the assessment doesn’t address advance care planning/directives at all? How does palliative care fit into all this? Precision medicine? What groups are being left out of trials? What are the incentives to get oncologists and health systems to adopt the geriatric assessment? And Mazie, who is from Hawaii, requested the song Hawaii Aloha in honor of the victims of the wildfire disaster on Maui. You can donate to the Hawaii Red Cross here. Aloha, -@AlexSmithMD Additional Links: Brief ASCO Video of how to conduct a practical geriatrics assessment Brief ASCO Video of how to use the results of a practical geriatrics assessment Time to stop saying the geriatric assessment is too time consuming

How do people react when they hear they have a serious illness? Shock, “like a car is rushing straight at me” (says Bill Gardner on our podcast). After the shock? Many people strive, struggle, crawl even back toward a “normal” life. And some people, in addition or instead, engage in deep introspection on how to make meaning or live with or understand this experience of serious illness. Today we talk with deep thinkers about this issue. Bill Gardner is a psychologist living with advanced cancer who blogs “I have serious news,” Brad Stuart is an internist and former hospice director whose book is titled, “Facing Death: Spirituality, Science, and Surrender at the End of Life,” and Juliet Jacobson is a palliative care doc who wrote a paper finding that geriatricians do NOT consider aging a serious illness. We have a wide ranging conversation that touches on how to place aging, disability, and multimorbidity in the context of serious illness conversations, “striving toward normal,” stoicism, existentialism, psychedelics, the goals of medicine, medical aid in dying and more. We could have talked for hours! And I get to play a Bob Dylan song that’s been on my bucket list to learn. Enjoy! -@AlexSmithMD Additional links: Bill Gardner’s article about MAID in Comment Magazine https://comment.org/death-by-referral/ Bill Gardner’s articles about living with terminal cancer in Mockingbird Magazine: https://mbird.com/art/cancer-in-advent/ https://mbird.com/religion/testimony/in-the-electors-school/ Brad Stuat’s website: https://bradstuartmd.com Juliet mentioned: On existential threat and terror management: The Worm at the Core: On the role of death in life by Soloman, Greenberg, and Pyszczynski On how existential threat is stored in the brain. https://pubmed.ncbi.nlm.nih.gov/31401240/ Papers on “striving toward normalcy” in the setting of serious illness https://pubmed.ncbi.nlm.nih.gov/36893571/ https://pubmed.ncbi.nlm.nih.gov/35729779/

I hear the word dignity used a lot in the medical setting, but I’m never sure what people mean when they use it. You’d imagine that as a seasoned palliative care doc, I’d have a pretty good definition by now of what “maintaining dignity” or “loss of dignity” means, but you’d be sadly wrong. Well that all changes today as we’ve invited the world's foremost expert in dignity at the end of life, Dr. Harvey Max Chochinov, to join us on the podcast. Harvey is probably best known for his work in developing dignity therapy, a psychological intervention designed specifically to address many of the psychological, existential, and spiritual challenges that patients and their families face as death approaches. We talk with Harvey about how he defines “dignity” and how we can understand what it means to our patients. We also talk about easy and quick ways to address dignity and personhood by using the Patient Dignity Question (PDQ), which asks “what do I need to know about you as a person to give you the best care possible.” In addition, we talk with Harvey about some other recent publications he has written, including one on “Intensive Caring” and one on the “Platinum Rule” (do unto others as they would want done unto themselves). So take a listen and if you are interested in learning more, check out these wonderful links: Harvey’s latest book is called, Dignity in Care: The Human Side of Medicine Intensive Caring: Reminding Patients They Matter Michael J. Fox gives patients hope there may be a place that illness doesn’t touch Depression is a Liar Why is Being a Patient Such a Difficult Pill to Swallow Better Patient Care Calls for a ‘Platinum Rule’ to Replace the Golden One. Scientific American Letter to the Editor: Response to Downar et al. Medical Assistance in Dying and Palliative Care: Shared Trajectories

It's been over two years since one of the worst product launches of all time - Aduhelm (aducanumab). Praised by the FDA, Alzheimer’s Association (AA), and Pharma as a “game changer”, but derided by others for the drug’s lack of clinical efficacy, risk of severe adverse effects, absence of diversity in trial populations, high costs, and an FDA approval process that was in the kindest words “rife with irregularities”. Instead of Biogen’s expected billions of dollars of revenue from Aduhelm, they brought in only $3 million in revenue for all of 2021 (here is my Twitter summary of this fiasco). The outlook on amyloid antibodies are looking brighter though in 2023. Phase III studies for lecanemab and donanemab have been published showing less worsening of cognition and function receiving these agents versus placebo. This led the FDA to give full approval for lecanemab, which will likely be followed by full approval of donanemab sometime this year. However, as noted in our editorial published with the donanemab trial, the modest benefits of amyloid antibodies would likely not be questioned by patients, clinicians, or payers if amyloid antibodies were low risk, inexpensive, and simple to administer. However, they are none of these. So what is the role of individuals like geriatricians in prescribing amyloid antibodies and caring for individuals who are receiving them? We invited three geriatricians and memory care doctors, Nate Chin, Sharon Brangman, and Jason Karlawish, to talk about this question and many others swirling around on how to safely prescribe these drugs and manage patients on them (like what to do about anticoagulation). Lastly, we also spend a little bit of time talking about the NIA-AA draft statement on redefining Alzhiemers disease. There is a lot to digest with these draft clinical guidelines but the big change from the 2018 guideline is moving Alzheimers to a biological diagnosis (biomarker evidence only) not just for a research framework but now from a clinical one. One outcome would be a very large population of older adults with normal cognition could now be classified as having Alzheimer's disease (maybe about a 1/3 of cognitively normal 75 year olds based on PET). So if you have thoughts on the matter, please give your feedback here to the NIA and AA. https://aaic.alz.org/nia-aa.asp By: Eric Widera

Insomnia. We’ve all had it. Lying in bed at 2 am staring at the ceiling, getting anxious every hour that you’re not falling asleep as you have a busy day coming up. Insomnia sucks. Chronic insomnia sucks even more. For those with serious illness, sleep problems and insomnia are all too common. Instead of reflexively jumping to melatonin or ambien, on today's podcast we talk with two sleep experts, Cathy Alessi and Brienne Miner, about a better approach to sleep problems and insomnia. We will go over epidemiology of insomnia, how these experts think about work up including which medications to avoid or discontinue, non-pharmacological treatment such as cognitive behavioral therapy for insomnia (CBT-I), and what if any is the role of pharmacological therapy in including newer agents like melatonin receptor agonists (ramelteon) and dual orexin receptor antagonists (like suvorexant).

There’s a saying, “never let a crisis go to waste.” The pandemic was horrific in many ways. One positive change that came about was the lifting of restrictions around the use of telemedicine. Clinicians could care for patients across state lines, could prescribe opioids without in person visits, could bill at higher rates for telemedicine than previous to the pandemic. Many patients benefited, not only those isolating due to covid, but also patients in rural areas, patients who are homebound, and many others. So now that the emergency response has ended, what’s to be done? In this podcast, Joe Rotella, Chief Medical Officer of the American Academy of Hospice and Palliative Medicine, Brook Calton, Palliative Care doc at Massachusetts General Hospital and Medical Director at Devoted Health, and Carly Zapata, Palliative Care doc at UCSF and fellowship director, talk about the importance of maintaining access to telehealth for the good of patients with serious illness. This DEA is taking 6-months to consider how to move forward vis a vis restrictions and requirements for telehealth in a post-pandemic world. Now is the time to act, dear listeners! You can: Write an Op-Ed to your local paper as Carly Zapata and colleagues did. Start with a story as Carly did in her Op Ed. Stories trump data. Write to your congressperson. See the AAHPM Legislative Action Center https://www.votervoice.net/AAHPMORG/home Write to the DEA, with guidance from AAHPM’s comments to the DEA March 2023. Advocate for the CONNECT for Health Act, which would permanently expand access to telehealth for Medicare beneficiaries: https://www.schatz.senate.gov/imo/media/doc/connect_for_health_act_2023_summary1.pdf Much more on this podcast, including puzzling out who the characters in Space Oddity by David Bowie might represent in an extended analogy to telehealth. Enjoy! -@AlexSmithMD

Today’s podcast is a follow up to our 2018 podcast with Randy Curtis about the Jumpstart intervention. On that podcast he and collaborators tested a combined patient and clinician facing communication priming intervention to promote goals of care conversations. Today we discuss a new paper in JAMA that tests a stripped down version of the clinician only facing intervention in a pragmatic randomized trial for older adults with serious illness and those 80+. They found a difference of 4% in documented goals of care discussions. Is 4% meaningful? You’ll have to decide for yourself, though it likely is meaningful on a population basis. Intriguingly, in a sub-analysis, they found a much higher rate of difference among minoritized older adults - more like 10%. In a compelling editorial, Doug White and Sarah Anderson argue that even a 4% difference is important on a population basis, and that higher rates of difference among minoritized older adults demonstrate the potential of the intervention to address long-standing disparities in goals of care. Randy Curtis was first author of the JAMA paper. Randy died February 26, 2023. We begin today’s podcast asking his co-authors Erin Kross, Bob Lee, and Ruth Engelberg, all from the University of Washington and the Cambia Palliative Care Center of Excellence, to reflect on Randy and his dedication to seeing this work completed while living with ALS. Eric and I also reflect on the podcast Randy generously did with us on his experience living with and studying serious illness. We have lost a giant. He is sorely missed, and celebrated. And…the guests torture me about songs I can’t play with the word Jump. -@AlexSmithMD

You may have heard of Area Agencies on Aging, but do you really know what they do or how they do it? What about State Departments of Aging or state master plans for aging? Do you know how these agencies fit in with programs like Meals-on-Wheels or other nutritional support programs? Is your brain hurting yet with all these questions? No? Ok, what about Aging and Disability Resource Connection (ADRC) services? Well, if you are like me, you’ve probably heard of these programs but are at a loss to know exactly what they do. On today's podcast we dive deep into how state and local governments are addressing the needs of older adults, answering all of these questions and more thanks to our three amazing guests: Susan DeMarois (the Director of California Department of Aging), Greg Olsen (the Director of the New York State Office for the Aging), and Lindsey Yourman (the Chief Geriatric Officer for the County of San Diego). It’s a fun podcast with our guest bringing in a ton of knowledge and passion for the work that they do. If there is one take-away from the podcast, it is something Dr. Yourman emailed me after we met: “My hope is that every geriatrics clinician/Geriatrics Department/Division that listens to our podcast will be motivated to reach out to their Area Agency on Aging (if they haven't done so previously) to ask for a meet and greet and to learn about their resources, services, and recommended community-based organizations for older people.” To learn more about what we talked about, check out the following links: Eldercare Locator, a public service of the U.S. Administration on Aging connecting you to services for older adults and their families California’s Master Plan for Aging New York’s Master Plan for Aging

I don't know 'bout religion I only know what I see And in the end when I hold their hand It's both of us set free These are the ending lyrics to Bonnie Raitt’s song “Down the Hall”, an ode to the Pastoral Care Workers who care for their fellow inmates in the hospice unit at the California Medical Facility in Vacaville, California. On last week’s podcast we interviewed the medical director and the chaplain of the prison’s hospice unit (Hospice in Prison Part 1). This week we turn our attention to the inmates. Pastoral Care Workers are inmates who volunteer time to care for the dying who come from all around California to spend their last days, weeks or months in the prison’s hospice unit, fulfilling a mission that “no prisoner dies alone.” On today's podcast we talk with three of these Pastoral Care Workers, Jerry Judson, Jeffrey Maria, and Allan Krenitzky. We discuss with them why they decided to volunteer for the hospice unit, what a day in the life of a Pastoral Care Worker looks like, and among other things their thoughts on forgiveness, redemption, rehabilitation, and compassionate release. We also had the pleasure to take a walk through the hospice unit garden with Mr. Gerald Hite. He taught us a little about the different flowers and plants, and along the way a little about why he does what he does. While this is a podcast about volunteers in a prison hospice, I think it also serves as a lesson for us all about how we make meaning to our own lives and define ourselves by not only what we have done in the past, but what we do now. One story that Allan told perfectly sums this up. He said one day his son asked his wife what he does for a living, and his wife said “Papa helps sick people.”

In the early 1990’s, California Medical Facility (CMF) created one of the nation’s first licensed hospice units inside a prison. This 17-bed unit serves inmates from all over the state who are approaching the end of their lives. A few are let out early on compassionate release. Many are there until they die. Today’s podcast is part one of a two-part podcast where we spend a day at CMF, a medium security prison located about halfway between San Francisco and Sacramento, and the hospice unit housed inside its walls. We start off part one by interviewing Michele DiTomas, who has been the longstanding Medical Director of the Hospice unit and currently is also the Chief Medical Executive for the Palliative care Initiative with the California Correctional Healthcare Services. We talk about the history of the hospice unit, including how it was initially set up to care for young men dying of AIDS, but now cares for a very different demographic – the rapidly aging prison population. We also talk about the eligibility for the unit, what makes it run including the interdisciplinary team and the inmate peer workers, and the topic of compassionate release. Afterwards, we chat with the prison’s chaplain, Keith Knauf. Keith per many reports, is the heart and sole of the hospice unit and oversees the Pastoral Care Workers. These are inmates that volunteer to work in the hospice unit, serving a mission that “no prisoner dies alone.” We chat with Keith about how hospice in prison is different and similar to community hospice work, the selection process and role of the peer support workers, the role of forgiveness and spirituality in the care of dying inmates, and what makes this work both rewarding and hard. Part two of the podcast, which comes next week, is solely focused on the Pastoral Care Workers. We interview three of them in the hospice unit and take a little tour of the hospice gardens.

Artificial Intelligence, or AI, has tremendous potential. We talk on this podcast about potential uses of AI in geriatrics and palliative care with natural language processing guru Charlotta Lindvall from DFCI, bioethicists and internist Matt DeCamp from University of Colorado, and prognosis wizard Sei Lee from UCSF. Social companions to address the epidemic of loneliness among older adults Augmenting ability of clinicians by taking notes Searching the electronic health record for data Predicting mortality and other outcomes We talk also about the pitfalls of AI, including: Recapitulation bias by race and ethnicity, and other factors, exacerbating disparities Confidentiality concerns: do those social companions also monitor older adults for falls? 24/7? Hallucinations, or when the AI lies or bullshits, then denies it When the AI approaches sentience, is it ethical to unplug it? I’m sure this is a subject we will return to, given the rapid progress on AI. Enjoy! -@AlexSmithMD Links: Papers on AI and palliative care and concerns about bias: https://www.healthaffairs.org/do/10.1377/forefront.20200911.401376/ https://academic.oup.com/jamia/article/27/12/2020/5859726 Comparison of machine learning vs traditional prognostic methods based on regression: https://www.ingentaconnect.com/content/wk/mcar/2022/00000060/00000006/art00011 Other links on the issue of AI and racial or ethnic bias: Are Robots Racist? Greenwall Foundation Bill Stubbing lecture Are Robots Racist? Rethinking Automation and Inequity in Healthcare https://www.nber.org/papers/w30700 https://www.science.org/doi/10.1126/sciadv.add2704 https://theconversation.com/including-race-in-clinical-algorithms-can-both-reduce-and-increase-health-inequities-it-depends-on-what-doctors-use-them-for-206168 MD Calc approach to inclusion of race https://www.mdcalc.com/race

Diabetes is common. When I’m on nursing home call, the most common page I receive is for a blood sugar value. When I’m on palliative care consults and attending in our hospice unit we have to counsel patients about deprescribing and de-intensifying diabetes medications. Given how frequent monitoring and prescribing issues arise in the care of patients with diabetes in late life, including the end of life, Eric and I were excited when Tamryn Gray emailed us requesting a follow up podcast on this issue. Our last podcast was with Laura Petrillo in 2018 - 5 years ago seems ancient history - though many of the points still apply today (e.g. Goldilocks zone). And yet we’re also in a different place in diabetes monitoring and management. To answer our questions, we invited Nadine Carter, a current hospice and palliative care fellow at Dartmouth who previously worked as an NP in outpatient endocrinology, and Alex Lee, an epidemiologist at UCSF interested in diabetes monitoring and management in the nursing home. And we invited Tamryn Gray from the Dana Farber joins us to ask insightful questions, including: What blood sugar range should we target for patients in the nursing home or hospice? How high is too high? Should considerations differ for people with dementia? What are the risks and rewards of new classes of medications? How do caregivers fit into this? Continuous glucose monitoring (CGM) is commonplace in Type 1 and gaining traction in Type 2. We debate the merits of use of CGM in the nursing home and other late life settings (Eric and I argue against CGM and lose). Ozempic is a new fancy med that, by the way, leads to weight loss among celebrities, resulting in shortages of the drug from people using it off-label for that purpose. Should we use Ozempic (if we can find it) in patients with serious illness, which often results in undesirable and profound weight loss? Listen in to learn more! -@AlexSmithMD Additional Links: -Fingerstick monitoring in VA nursing homes (too common!) -Improving diabetes management in hospice -Continuous Glucose Monitoring complicating end of life care

Our guests today present an important rejoinder to the argument that we should refocus away from advance care planning (ACP). Sarah Nouri, Hillary Lum, and LJ Van Scoy argue that diverse communities are asking for ACP. Sarah Nouri gives an example from her work in the LGBTQ+ community of a trans woman who was buried as a man because existing laws/rules did not protect her wishes. Others cited the call from communities to meet them where they are - be they senior centers, Black-owned businesses, or churches (we have a podcast planned in the fall with Fayron Epps and Karen Moss on the church setting). It does seem that if communities, particularly historically marginalized communities, are interested in ACP, that fact should carry some weight in how resources are allocated to research and health care financing. We additionally have a debate/discussion about which outcomes of ACP matter most, including Terri Fried’s commentary in JAGS that caregiver outcomes matter more than goal concordant care (the “holy grail”), completion of advance directives, or changes in health care services use. Did the caregiver feel heard and understood? Did they have PTSD? Complicated grief? Depression? Group visits are one way of reaching diverse communities to which advance care planning has not traditionally been targeted. In a group visit there is a social norming effect - “if my neighbor is doing it, perhaps I should be doing it to?” Please tune in to hear more, and listen to the whistle of the “Friendship train!” -@AlexSmithMD Links: Community Based Participatory Research and ACP in Latinx communities: https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.18236 Community based ACP in the Black Community: https://link.springer.com/article/10.1007/s11606-023-08134-2 ACP in the Chinese American Community: https://www.sciencedirect.com/science/article/pii/S0885392423000982 Group ACP in primary care: https://www.annfammed.org/content/14/2/125.short and https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16694 Project Talk Website: www.ProjectTalkTrial.org Project Talk Trial Protocol Paper: https://journals.sagepub.com/doi/pdf/10.1177/1049909116656353 Hello Article (including Black churches): https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2765685 Communication Quality Analysis: https://www.tandfonline.com/doi/abs/10.1080/19312458.2022.2099819 Conceptualizing Surrogate Decision Making: https://www.tandfonline.com/doi/abs/10.1080/19312458.2022.2099819 What counts as a surrogate decision: https://journals.sagepub.com/doi/abs/10.1177/10499091231168976 For e-training modules on ACP group visits: https://cuelearning.org Click on the Register link (upper right corner). A pop-up box will appear and enter your email address and set up your password. For Registration Code, enter: ENACT (not case sensitive). The ACP Group visit implementation guide is available here: www.coloradocareplanning.org. Scroll down to “Innovations in ACP page”

Hot off the press is a brand spanking new updated 2023 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The Beers Criteria is one of the most frequently cited reference tools in geriatrics, detailing potentially inappropriate medications to prescribe to older people. We’ve invited two members who helped update the criteria including Todd Semla and Mike Steinman. We discuss a little history of the Beers criteria, including the original Beers Criteria that was published by the late Dr. Mark Beers, and how it has evolved over the last three decades. We also discuss specifics about how to use and not use the Beers Criteria, how medications are selected for inclusion in the criteria, and specifics about certain medications. And of course, take a deep dive by downloading the JAGS paper on the updated Beers Criteria or any of the great links from AGS including the: 2023 AGS Beers Criteria App Beers pocket card

We’ve had multiple GeriPal episodes about treatments for dementia, including aducanumab (here, here, and here) and lecanemab (here). As today’s guest, Kristine Yaffe notes, part of the reason for that emphasis is that in the US we prioritize treatment, whereas other countries are ahead of us in prioritizing prevention. Deb Barnes and Kristine Yaffe published a landmark paper in Lancet Neurology finding that up to half of dementia risk is due to modifiable factors. If we focused on prevention, from a public health standpoint, we would achieve far more than spending millions billions on treatment. Today we talk about steps we can and should take to reduce the risk of dementia, including: Education and cognitive games (I reveal my embarrassingly poor average time on the NYT mini cross word) Physical activity Sleep Depression Smoking Social isolation Blood pressure control (listen also to our podcast on Sprint Mind with Jeff Williamson) We also delve into an exciting new trial Kristine led with others on the impact of risk factor reduction on cognition - here’s a link to press about the trial from a fall meeting presentation - article forthcoming. And because we can’t resist, we dip into aducanumab and lecanemab at the end. -@AlexSmithMD

I haven’t worked with many adolescents and young adults (AYA, roughly teens to twenties). But when I have, I find that they’re often some of the hardest patients to care for. Why? We talk about why it’s so hard with Abby Rosenberg (chief of PC at DFCI and Boston Childrens), Nick Purol (clinical social worker at DFCI and Boston Childrens), Daniel Eison (pediatric PC doc and co-host of PediPal). We are grateful to Andrea Thach (PC doc at Sutter East Bay) for bringing this topic to our attention and for asking questions as a guest host. Here are just a few of the explanations for why it’s so hard: They are closer in age to some of us (younger clinicians). Countertransference hits hard. There’s an in-between space between adolescence and adulthood - and there’s something that we identify with in that in-between space, tugging at our heart strings Everyone has been a teenager. Everyone has lived through their early 20s. Every member of the interdisciplinary team. Adolescence and young adulthood is a romanticized time of life in our culture. We remember bucking the rules, figuring out who you are, hair on fire, feeling invulnerable, trying to figure out who you are - and now those adolescents are stuck in the hospital, with doctors and parents telling them what to do, having their autonomy crushed by the medical institution, realizing they’re not invulnerable. We talk about these issues and more - what resources to leverage, how to cope as a team. We in geriatrics and adult palliative care clinicians have so much to learn from our colleagues in pediatrics - and though many of these lessons are specific to adolescents and young adults - many of the lessons are valuable for the care of patients in older life stages. Links to resources for working with AYA, from Nick Purol): The Courageous Parents Network has a wealth of information/resources/videos/articles on many overlapping issues and topics related to caring for children/adolescents/young adults with serious illness (from both the provider and clinician perspective): https://courageousparentsnetwork.org Courageous Parents Network Empowering parents caring for children with serious illness through video, shared community, professional guidance, and palliative care. You are Not Alone. courageousparentsnetwork.org Voicing My Choices is a wonderful tool for discussing goals/wishes and introducing advance directives in the context of serious illness. It's based off 5 Wishes and validated for AYA through direct feedback from the population: https://store.fivewishes.org/ShopLocal/en/p/VC-MASTER-000/voicing-my-choices The Oxford Textbook of Palliative Social Work has several chapters relating to working with AYA (either due to family illness or their own), with many psychosocial clinicians in our field contributing: https://www.amazon.com/Oxford-Textbook-Palliative-Social-Work/dp/0197537855 Same is true for the Interdisciplinary Pediatric Palliative Care Textbook: https://www.amazon.com/Interdisciplinary-Pediatric-Palliative-Joanne-Wolfe/dp/0190090014/ref=sr_1_1?crid=33YG2UAKDZ8DO&keywords=interdisciplinary+pediatric+palliative+care&qid=1682288312&s=books&sprefix=interdisciplinary+pediatric+palliative+car%2Cstripbooks%2C101&sr=1-1&asin=0190090014&revisionId=&format=4&depth=1 -@AlexSmithMD

We have a special extra podcast this week. During the last AAHPM - HPNA meeting in Montréal, we went around asking attendees what one thing that they are most worried about and one thing they are most hopeful for when thinking about the future of our field. We couldn’t fit everyone’s responses in but came up with the big themes for questions and edited them into this weeks podcast / YouTube video. Eric and Alex DISCLAIMER While we filmed in Montreal during the Annual Assembly, all opinions expressed in this podcast are independent of AAHPM and HPNA, or the Annual Assembly. Furthermore, direction to external websites is not an endorsement from AAHPM or HPNA, or the Annual Assembly. Palliative Care the Next Generation: How the Service May Grow and Evolve https://hospicenews.com/2023/04/14/palliative-care-the-next-generation-how-the-service-may-grow-and-evolve/ AccentCare, a portfolio company of private equity firm Advent International, is another example. The company has expanded its palliative care services through partnerships with hospitals and other managed care providers, according to AccentCare CEO Stephan Rodgers. “We’ve got a very large palliative care practice,” Rodgers told PCN. “What we’ve seen to make it really work is you either have to be in the hospital, where we’ve taken over palliative care in the hospital, or you have to be contracted with managed care and get it at some kind of risk, because community-based palliative care is very difficult to make operate right now from a profitable [perspective].”