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.

The need for better palliative care in nursing homes is significant. Consider this: the majority of the 1.4 million adults residing in U.S. nursing homes grapple with serious illnesses, and roughly half experience dementia. Many also suffer from distressing symptoms like pain. In addition, about 25% of all deaths in the United States occur within these facilities.

Despite these substantial needs, specialized palliative care beyond hospice is rare in nursing homes. Furthermore, only about half of nursing home residents nearing the end of life receive hospice care.

So, how can we improve palliative care for individuals in nursing homes? Today's podcast explores this crucial question with three leading experts: Connie Cole, Kathleen Unroe, and Cari Levy.

Our discussion delves into:

• The specific palliative care needs of nursing home residents.

• How to think about primary and specialized palliative care in this setting.

• The obstacles hindering referrals to palliative care services.

• Practical strategies to overcome these barriers and enhance care.
  
  

We also take a dive into these 2 articles that Connie first authored:

• Palliative care in nursing homes: A qualitative study on referral criteria and implications for research and practice. JAGS 2024

• Nursing Home Palliative Care Referral Process, Barriers, and Proposed Solutions: A Qualitative Study. 2024

If you are interested in learning more, check out some of our other palliative care in nursing home podcasts including:

• Discussion of a primary palliative care multinational trial with Lieve Van den Block

• Understanding the variability in nursing home care

• A podcast on Palliative Rehab?!? with Ann Henshaw, Tamra Keeney, and Sarguni Singh

Have any of you watched the movie “The Notebook”? At the end, one of the characters, who has dementia, experiences an episode of lucidity. When I watched it, between tears (I’m a complete softie) I remember thinking, “Oh no! This will give people false hope! That their loved one is ‘in there.’ If only they could find the right key to unlock the lock and let them out.”

Today we talk about lucid episodes and what they might mean to the person with dementia, their family and loved ones, to philosophers, to clinicians, to neuroscientists. Our guests are Andrea Gilmore-Bykovskyi, a nurse researcher, and Andrew Peterson, a philosopher.

We had a wide ranging discussion that touched on (among many things):

• A consensus definition developed at an NIH conference, organized by the recently retired NIA program officer Basil Eldadah (we will miss you Basil!).

• Andrew complicates this definition, stating is raises more questions than answers.

• Hospice nurses know that terminal lucidity “is a thing” and have pretty much all seen it

• Family and caregiver stories of lucid episodes and what they meant to them, including early glimpses into a study Andrea is doing using video to capture episodes and show them to family.

• Potential for experiences to elicit “false hope”, misunderstanding/misinterpreting, and changing say code status from DNR to full code (rare but happens).

• Sam Parnia’s work on brain activity during CPR and near death episodes

• Ethical issues these lucid episodes raise

• Should clinicians treat people with dementia as always lucid? Having some level of awareness?

• Parallels between how we treat people with advanced dementia, who may or may not be lucid, and how we treat AI, who may or may not be conscious, or experiencing paradoxical lucidity on their way to full consciousness. I try to say please and thank you to the AI I interact with other than Alexa, who is obviously way behind.

• The Age of Aging podcast episode on lucidity, featuring Anne Bastings, Jason Karlawish, Elizabeth Donnarumma, and Justin Clapp

• Was Andrew’s song choice, “I can see clearly now” better than Eric’s suggestion “Silent Lucidity” by Queensryche?

Enjoy!

-Alex Smith

As you know, dear listeners, I love music. We start each podcast with a song in part to shift the frame, taking people out of their academic selves and into a more informal conversation.

Well, today’s guests love music at least as much if not more than me, and they each make a strong case for music as medicine. Jenny Chen is a palliative care fellow at Yale who regularly sings for her seriously ill patients. Look for Jenny to potentially appear on the show America’s Got Talent (no lie).

Tyler Jorgensen not only plays music for his patients, starting out with just pulling up a tune on his iPhone, he and others at UT Austin and Dell med now wheel a record player into patients rooms and play vinyl, taking patients back to the sounds and routines - think taking the record out of the sleeve, placing the needle in the groove - of younger days. You can here Tyler and I having a great time singing together and sharing stories around his podcast My Medical Mixtape.

And Theresa Allison is a geriatrician and ethnomusicologist who studies the role of music for people with dementia. The ability to appreciate, recognize, and engage with music is preserved even until late stages of dementia, and Theresa is examining how music can be useful from the time of diagnosis, not only for the person with dementia, but their caregivers.

Many links today, including:

-Alive Inside Movie and Music and Memory movement

-Music and Creativity in Healthcare Settings - book by Hilary Moss

-Tyler Jorgensen’s article on Bringing Music to patients at the Bedside in JGIM

-Tyler’s reflection/story comparing palliative medicine to jazz - something I arrived at independently and tell all new trainees! This is not highly scripted orchestral music, people, it’s Jazz.

-Systematic review of music (and prognosis) in palliative care

-Review of music and dementia interventions (Theresa Allison author)

-Theresa Allison’s paper on Music Engagement in Dementia Caregiver Relationships in Gerontologist

-Jenny Chen’s YouTube channel.

Our main focus today was on nudging critical care clinicians to consider a more palliative approach to care. Our guests are all trained in critical care: Kate Courtright, Scott Halpern, and Jaspal Singh. Kate and Scott have additional training in palliative medicine.

To start. we review:

• What is a nudge? Also called behavioral interventions, heuristics, and cognitive biases.

• Prior podcasts on the ethics of nudging, and a different trial conducted by Kate and Scott in which the default for hospitalized seriously ill patients was to receive a palliative care consult.

• What is sludge? I’d never heard the term, perhaps outside of Eric’s pejorative reference to my coffee after adding copious creamers, flavoring, and sweeteners. Sludge is apparently when you create barriers or extra work for someone. For example, putting the healthy food at the back of the grocery store is sludge; making an applicant for health insurance climb the flight of stairs to the office - weeding out those less fit - is also sludge. Prior-auth forms? Sludge.

• Examples of nudges, some based in health care, others in coffee.

This specific study, published in JAMA Internal Medicine, was conducted in 17 ICUs in North Carolina. Many were community hospitals. Participants were critically ill and intubated. Clinicians were randomized to 4 groups:

1. Usual care

2. Prognosis nudge - EHR prompt asking, do you think your patient will be alive in 6 months? This is called a focusing effect

3. Comfort care nudge - EHR prompt asking if they’d offered comfort-focused care. This is called accountable justification - an appeal to standards of care for critically ill patients endorsed by multiple professional societies.

4. Both the prognosis and comfort care nudge.

A few key points of discussion:

• Is an EHR prompt a nudge or sludge?

• The intervention was a negative study for the primary outcome, hospital length of stay. Why?

• The prognosis nudge did nothing. What to make of that? Would you think an EHR nudge to consider prognosis might move the needle, at least on some outcomes?

• The nudge toward offering comfort care led to more hospice and early comfort-care orders. Is this due to chance alone, given the multiplicity of secondary outcomes examined? Or is it a tantalizing finding that suggests a remarkably low cost EHR based nudge might, on a population level, lead to critical care clinicians offering comfort care and hospice more frequently? Imagine!

-Alex Smith

We’ve covered psychedelics on the podcast before—first in 2019 with Ira Byock, where we explored their potential role in medicine, and then again in 2023 with Stacy Fischer, Brian Anderson, and Theora Cimino, focusing on the reasons to approach psychedelic use in patients with caution.

In today’s episode, we’re taking a closer look at the current state of the science around one specific psychedelic: psilocybin. We'll discuss three recent clinical trials involving patients with serious illness, joined by our guests James Downar, Ali John Zarrabi, and Margaret Ross.

We begin with a refresher on psilocybin—what it is, how it might work, what conditions it may help treat (including demoralization), and how it’s typically administered. What makes this episode especially compelling is our deep dive into the three studies, which highlight two different approaches to using psilocybin: daily microdosing, similar to traditional antidepressants, and a more intensive model known as psilocybin-assisted therapy. This latter approach involves three structured phases—preparation, the dosing session, and post-session integration with trained therapists.