GeriPal - A Geriatrics and Palliative Care Podcast Alex Smith, Eric Widera
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- Health & Fitness
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A geriatrics and palliative care podcast for every health care professional.
We invite the brightest minds in geriatrics, hospice, and palliative care to talk about the topics that you care most about, ranging from recently published research in the field to controversies that keep us up at night. You'll laugh, learn and maybe sing along. Hosted by Eric Widera and Alex Smith. CME available!
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PC Trials at State of Science: Tom LeBlanc, Kate Courtright, & Corita Grudzen
One marker of the distance we’ve traveled in palliative care is the blossoming evidence base for the field. Ten years ago we would have been hard pressed to find 3 clinical trial abstracts submitted to the annual meeting, much less high quality randomized trials with robust measures, sample sizes, and analytics plans. Well, as a kick off to this year’s first in-person State of the Science plenary, held in conjunction with the closing Saturday session of the AAHPM/HPNA Annual Assembly, 3 randomized clinical trials were presented.
Today we interview the authors of these 3 abstracts about their findings:
Tom LeBlanc about a multisite trial of palliative care for patients undergoing Stem Cell Transplant for blood cancers (outcomes = quality of life, depression, anxiety)
Kate Courtright about a pragmatic trial of electronic nudges to prognosticate and/or offer comfort-focused treatment to mechanically ventilated ICU patients/surrogates (outcomes = lengths of stay, hospice, time to discontinuation of life-support)
Corita Grudzen on a pragmatic trial of two palliative care approaches for patients with advanced cancer or organ failure discharged from the ED: a nurse-led telephone intervention or outpatient specialty palliative care clinic (outcomes = quality of life, symptom burden, loneliness, healthcare utilization)
Wow! I’m just stunned even writing that! We’ve come so far as a field. This isn’t to say we’ve “made it” - more to say that we’ve reached a new stage of maturation of the field - in which the evidence we are discussing is frequently high quality randomized trial level data.
We recorded this on Friday during the annual assembly, and Eric and I were a littttttle off our game due to the residual effects of the GeriPal pub crawl the night before, which were only compounded by technical difficulties. I believe these issues were more than made up for by our guests' forced accompaniment to the song “Feel Like Making Science.” (Credit to the Beeson singing crew for coming up with that one).
Enjoy! -@AlexSmithMD
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Electronic Frailty Indexes: Kate Callahan, Ariela Orkaby, & Dae Kim
What is frailty? Kate Callahan relates a clear metaphor on today’s podcast. A frail person is like an origami boat: fine in still water, but can’t withstand a breeze, or waves. Fundamentally, frailty is about vulnerability to stress.
In 2021 we talked with Linda Fried about phenotypic frailty. Today we talk with Kate Callahan, Ariela Orkaby, & Dae Kim about deficit accumulation frailty. What is the difference, you ask? George Kushel probably explained it best in graphical terms (in JAGS), using the iconic golden gate bridge as a metaphor (Eric and I get to see the bridge daily driving or biking in to work). Phoenotypic frailty is like the main orange towers and thick orange support cables that run between towers. Damage to those critical functions and the bridge can collapse. Deficit accumulation frailty is like the hundreds of smaller vertical cables that connect the thick orange support cables to the bridge itself. Miss a few and you might be OK. But miss a bunch and things fall apart. Resilience is the ability of the bridge to withstand stress, like bridge traffic, wind, waves, and the occasional earthquake (hey it’s California!).
Frailty research has come a long way. We’re now at a point where frailty can be measured automatically, or electronically, as we put in the title. Kate created an eFrailty tool that measures frailty based on the electronic health record (EHR) data. Ariela created a VA frailty index based on the EHR of veterans. And Dae created an index using Medicare Claims. Today we’re beginning to discuss not just how to measure, but how to use these electronic frailty indexes to improve care of patients.
We should not get too hung up on battles over frailty. As Kate writes in her JAGS editorial, “If geriatricians wage internecine battles over how to measure frailty, we risk squandering the opportunity to elevate frailty to the level of a vital sign. Learning from the past, a lack of consensus on metrics impeded the mainstream adoption of valuable functional assessments, including gait speed.”
To that end, modeled after ePrognosis, Dae and Ariela have launched a new tool for clinicians that includes multiple frailty measures, with guidance on how to use them and in what settings. It’s called eFrailty, check it out now!
Did I cheat and play the guitar part for Sting’s Fragile at ⅔ speed then speed it up? Maybe…but hey, I still only have 2 usable fingers on my left hand, give me a break!
-@AlexSmithMD
Additional Links:
eFrailty website is: efrailty.hsl.harvard.edu (efrailty.org is fine).
Dae’s Frailty indexes
CGA-based frailty index web calculator for clinical use: https://www.bidmc.org/research/research-by-department/medicine/gerontology/calculator
The Medicare claims-based frailty index program for research: https://dataverse.harvard.edu/dataverse/cfi/
Ariela’s VA-FI:
Original VA frailty index: https://academic.oup.com/biomedgerontology/article/74/8/1257/5126804
ICD-10 version
https://academic.oup.com/biomedgerontology/article/76/7/1318/6164923
Link to the code for investigators (included in the appendix):
https://github.com/bostoninformatics/va_frailty_index
As an FYI for those in VA the code is readily available through the Centralized Interactive Phenomics Resource (CIPHER)
Recent validation against clinical measures of frailty:
https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18540
Kate’s eFrailty Index
https://doi.org/10.1093/gerona/glz017 our original eFI paper
https://doi.org/10.1111/jgs.17027 & https://doi.org/10.1001/jamanetworkopen.2023.41915 on eFI and surgery
https://doi.org/10.1111/jgs.17510 editorial in JAGS
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Dysphagia Revisited: A Podcast with Raele Donetha Robison and Nicole Rogus-Pulia
Almost a decade ago, our hospice and palliative care team decided to do a “Thickened Liquid Challenge.” This simple challenge was focused on putting ourselves in the shoes of our patients with dysphagia who are prescribed thickened liquids. The rules of the challenge were simple: fluids must be thickened to “honey consistency” using a beverage thickener for a 12-hour contiguous period.
All of us failed the challenge. We then decided to challenge others and asked them to post their videos online using the hashtag #thickenedliquidchallenge. Here are some of the results of those videos: https://geripal.org/the-thickened-liquid-challenge/
On today’s podcast, we revisit dysphagia and thickened liquids with two researchers and speech-language pathologists, Raele Donetha Robison and Nicole Rogus-Pulia. We talk with them about the epidemiology, assessment, and management of dysphagia, including the role of modifying the consistency of food and liquids, feeding tubes, and the role of dysphagia rehabilitation like tongue and cough strengthening. We also talk about the importance of a proactive approach to involving speech-language pathologists in the care of individuals early on with neurodegenerative diseases like dementia and ALS.
If you want to take a deeper dive, take a look at these articles:
A nice overview of swallowing disorders in the older adults published in JAGS
A study in JAGS showing that 89% of feeding tubes inserted during hospitalization were in patients with no preexisting dysphagia
Nicole’s article on shifting to a proactive approach of dysphagia management in neurodegenerative disease
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End-of-Life Doulas: A Podcast with Jane Euler, Beth Klint, and John Loughnane
In the last several years, I’ve seen more and more articles about end-of-life doulas (like this NY Times article from 2021). Despite this, in my 20-year career as a palliative care physician, I have yet to see a death doula in the wild. I’m unsure what they do, how often they’re used, and who pays for their work. So, on today’s podcast, we try to get to the bottom of what exactly is an end-of-life doula.
We’ve invited two death doulas, Jane Euler and John Loughnane (who is also a family doc and palliative care physician), to talk about the role of a doula at the end of life. We also invited Beth Klint to speak about the doula's role within a traditional hospice organization. Why Beth? In addition to being a palliative and hospice RN, she is the Executive Director for Goodwin Hospice, a large non-profit hospice that added end-of-life doula care to their services in collaboration with Jane and John’s doula organization, Present for You.
If you are interested in learning more about death doulas, check out the following links
Goodwin Hospice’s article on the collaboration with Present for You
A HospiceNews article talking about the value proposition of death doulas for hospices
NHPCO’s End-of-Life Doula Council page that includes a lot of great links
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GeriPal 300th Episode: Ask Me Anything Hot Ones Style
Today we celebrate eight years, around 2 million listens, and 300 podcasts!
Eric and I take questions from you, our listeners, about: why we podcast, our most controversial podcast, which podcast changed our practice, favorite song request, should all nursing home residents complete the POLST, expanding access to durable medical equipment, palliative care in rural regions, do we have an advance directive, what we’d do to improve healthcare with 7 trillion dollars, treatment for poor appetite, and Eric on how to make a latte. Thank you to Lynn Flint and Anne Kelly who serve as hosts for this episode, asking us the tough questions.
We answer your questions hot ones style. I borrowed some screaming hot sauces from my friends Jerome Kim and Tony Le, and added them to my small collection of extra mild sauces. Every two questions we ate a chicken wing covered in hot sauce. The hot sauces progressed from mild to extreme (and I mean extreme) heat.
Can I just say…it works? Being asked a question with your mouth on fire, sweat streaming down your face, feeling the most awake and terrified you have ever been in your life, forces you to give an unadorned answer, straight from the heart.
Don’t take my word for it, listen for yourself! Or better yet, watch the video of this one on YouTube. Some of the funniest parts are caught on video, in the background. We will be re-watching this one for years to come.
Thank you, dear listeners, for sending us your questions, for your enthusiasm, and for your support. Enjoy!
-@AlexSmithMD
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Psychological Issues in Palliative Care: Elissa Kozlov and Des Azizoddin
In our podcast with palliative care pioneer Susan Block, she identified the psychological/psychiatric aspects of palliative care as the biggest are of need for improvement. As she said, when you think about the hardest patients you’ve cared for, in nearly all cases there was some aspect of psychological illness involved. That rings true to me.
Today we talk with two psychologists who are deeply invested in addressing psychological aspects of care for people living with serious illness. Elissa Kozlov, a geropsychologist and director of a new population aging MPH at Rutgers, surveyed AAHPM members, and found that doctors reported major shortcomings in level of comfort and knowledge caring for patients with psychological illness. She conducted a systematic review and meta-analysis of 38 palliative care trials, finding that many excluded people with serious illness, and a lack of impact on psychological outcomes. Analyzing the Health and Retirement Study, she found 60% of older adults screened positive for depression in the last year of life (related study here).
Des Azizoddin is a psychologist at the University of Oklahoma primarily focused on pain for people with cancer. Des delivered a plenary at this year’s National Palliative Care Research Center’s Foley retreat. She began by asking, “Raise your hand if you think there is a psychological component to cancer pain.” All hands go up. Then, “Keep your hand up if you frequently refer patients with cancer pain to a psychologist?” All hands go down. Unfortunately, we lack the financial structures to reimburse psychologists that would incentivize widespread inclusion on palliative care teams. Because we live in the world as it is, not as it should be, Des has helped develop an app (link to pilot trial hot off the press!) to help people with cancer pain engage in cognitive behavioral therapy in bite sized 3-4 minute sessions (there are other apps available now developed in the VA, who have been leaders in the psychology/palliative care space). Des additionally studied stigma associated with opioid use among patients with cancer in the context of the opioid epidemic; depression, pain catastrophizing, recent surgery and opioid use among people with cancer.
And, we talk about these issues and more (with far more nuance than I can include in this post).
Kudos and credit to my son Renn, age 15, for the guitar on Heartbeats (hand still broken at time of recording).
Customer Reviews
Great info, fun to listen
I love this podcast. Eric and Alex (and frequent guest cohosts) offer up-to-date and engaging information about hot topics in geriatrics and palliative care in a way that is fun to listen to. They have a really diverse group of guests and do a nice job with the interview. This is a great, easy way to stay informed! Definitely recommend.
Geripal
As a Geriatrician working in LTC I find Geripal a useful and enjoyable podcast. One of the best in the field.
Great Podcast!
I’ve learned so much!!