June Lunney famously characterized the end of life functional course of people with dementia as a slow dwindle over time. Tom Gill later found that people with dementia do indeed have persistent severe disability throughout the last year of their lives.

But from our clinical work, many of us are familiar with people with dementia who experience sudden shocks to their health, think hip fracture, think hospitalization for pneumonia. Those disruptive events or shocks often portend a major decline in function from which people with dementia never fully recover. And they’re often a sign of (or cause of?) worsening prognosis.

Today we talk about disruptive events, or health and wealth shocks. We start with Lauren Hunt, who described the incidence and outcomes of hip fracture and hospitalization for pneumonia in a pair of publications in JAGS, comparing people with dementia who experience these events to people without dementia. We then turn to social events, starting with Rebecca Rodin, who studied the effect of widowhood on mortality and function for people with dementia, cancer, and organ failure, published in JAMA Network Open. Finally, we turn to Tsai-Chin Cho, who studied the impact of a wealth shock (loss of 75%+ of wealth in a short time period) on cognitive decline in 4 countries. Tsai-Chin’s article, published in Lancet Healthy Longevity, found a tantalizing hint that countries with stronger safety nets had lower incidence of wealth shocks, and less of a deleterious impact of the wealth shock on cognitive function.

Wait, so one key message is that social health is linked to physical and cognitive health?!? And the government can do something about that?!? Yes indeed, we like to hammer that home regularly, dear listeners.

And I enjoyed singing Leonard Cohent’s Who By Fire, about the many ways people might die…you know…typical uplifting GeriPal song lyrics!

-Alex Smith

Additional links mentioned by Tsai-Chin Cho:

-Wealth shocks and mortality in the US

-Change in marital status as a risk for wealth shock

Happy Pride Month GeriPal listeners!

Transgender issues are in the news. Just today (June 17th) as we record this podcast:

• Ezra Klein released a wonderful interview with Sarah McBride, the first openly transgender member of congress

• A judge ruled that cuts to NIH grants focused on minority groups, including transgender people, were illegal and ordered the government to restore funding.

• It’s Pride month, and our guests remind us of the leadership of two trans women in the Stonewall riots, which started the modern fight for LGBTQI+ rights and liberation.

Today’s guests are Noelle Marie Javier, a geriatrician and palliative care doc who tells her story of transitioning as a faculty member at Mt. Sinai in New York, and Jace Flatt, who started their journey as a gerontology researcher at UCSF and is now faculty at UNLV. Jace was in the news recently for having multiple federal grants cancelled because they included transgender participants. We cover many topics, including:

• Terminology: gender identity, sexual orientation, gender expression, transgender, nonbinary, intersex, what’s in LGBTQI+

• Gender affirming care

• Major health and medical issues associated with aging as a transgender person

• Allostatic load

• Accelerated aging

• What can clinicians do - pointers, pearls, and attitudes

• Dementia risk

• Caregiver issues

• Hormone replacement therapy at the end of life

• Sexual orientation and gender identity (SOGI) data, what is it, how to collect it respectfully and safely

• Mentioned: Harvey Chochinov’s Dignity Therapy question, and our prior podcast on LGBT Care for older adults and serious illness with Carey Candrian and Angela Primbas

So pleased to sing True Colors by Cyndi Lauper, with Kai on guitar for those of you listening to the podcast.

-Alex Smith

Many links!

-Rainbows of Aging: Jace Flatt’s research site.

-LGBTQcaregivers

-Callen-Lorde gender affirming trans health services

-GLMA: organization for health professional advancing LGBTQ+ equality

-Center of Excellence for Transgender Health at UCSF

-World Professional Association for Transgender Health

-Sage advocacy services for LGBTQ+ Elders: focus on impact of Medicaid cuts

-Trans bodies, Trans selves: resource guide

If you’re anything like me, you might find the process of what happens to patients when they visit a radiation oncologist somewhat mysterious. During my training, I didn’t receive much education about radiation oncology, and I’m not entirely sure what some of the terms mean (hypofractionated means fewer sessions, right?). Well, today’s podcast aims to clear up all these uncertainties.

We’ve invited Anish Butala, the Chief of the Palliative Radiotherapy Service at Penn Medicine, and Emily Martin, a palliative care doctor and past president of the Society for Palliative Radiation Oncology (SPRO), to explain everything we should know about radiation oncology. Additionally, Evie Kalmar, who suggested today’s topic, will join us as one of our guest hosts.

Tune in and we will walk you through the patient’s journey from the initial planning visit to the final treatment, discuss common indications like bone and brain metastases, hear about when to consider steroid therapy, and highlight radiation therapy emergencies.