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Podcast: Updates on Alzheimer’s Treatment

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Podcast: Updates on Alzheimer’s Treatment

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The Curbsiders - An Internal Medicine Podcast

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#511 Alzheimer's Disease: Updates in Diagnosis and Treatment - The Curbsiders

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Transcript available via YouTube Blood-based Biomarkers, Anti-Amyloid Therapies and Beyond From blood-based biomarkers to anti-amyloid treatments, join us as we explore the latest in Alzheimer's disease diagnosis and treatment with Dr. Halima Amjad.

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Article: Scott et al. 5 steps for deprescribing

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Article: Scott et al. 5 steps for deprescribing

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JAMA Perspective: Can we agree to disagree

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JAMA Perspective: Can we agree to disagree

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Article: Cognitive Impairment Evaluation and Management

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Article: Cognitive Impairment Evaluation and Management

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A nice overview on how to approach patients with concern for cognitive impairment

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calculators, communication guides, and more!

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You can also get the app! https://www.vitaltalk.org/vitaltalk-apps/

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Our one-page guides offer quick, actionable insight. Free to print and share with others.

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Review of communication tips from the Gerontological Society of America

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Time Stamps
[Click on time stamp below to start that time mark in the audio]

02:43 What is prognosis?

03:58 Why offer prognostication?

08:28 Why is prognostication hard?

16:17 How do we improve at communicating prognosis?

21:37 How should we approach uncertainty?

30:26 Take Aways

Outline

Introduction

What is prognosis?

Why offer prognostication?

Clinician perspective

Changes medical decision making

Ex. Cancer screening, Diabetic control

Patient perspective

Desire to know

Changes treatment preferences

Helps organize social goals

Consequences to patient, clinician, and health system

Why is prognostication hard?

Learned skill

Incomplete information

Shortcomings of prognostic calculators

Emotional intesity

Fear of getting it wrong ("chagrin factor")

How do we improve it?

Use prognostic calculators

Beware of overestimation bias

Balance multiple estimates

How do we approach uncertainty?

Discuss among colleagues

Acknowledge it upfront

Use a range of time

"Best case/worst case/most likely case"

Communication tips

Understand patient perceptions and goals first

Establish patient communication preferences

Avoid medical jargon and euphemisms

"Hope-Worry" statements

Conclusion

Prognostic Calculators

BODE Index for COPD (52mo mortality)
Brain Metastases Prognostic Index
Chronic Kidney Disease (Stage IV or V)
Diffuse Large B-Cell Lymphoma
Palliative Performance Index (Advanced Cancer, 3mo mortality)

Multiple Myeloma (5yr mortality)
Myelodysplastic Syndrome
Renal Cell Carcinoma (2 and 5yr mortality)

Seattle Heart Failure Model (1 and 5yr mortality)

Walter's Prognostic Index (Inpatient Geriatrics, 1yr mortality)

Transcript

Margot: "But doc - how long do I have to live?"

Jafar: "How much time does my mom have?"

Tamar: "Should I think about moving in with my son?"

Margot: I find that questions about prognosis are some of the hardest to answer. So many things race through my head as I stand there trying to figure out what to say. How am I supposed to know how much longer they have? How sure am I about my estimate, and what am I supposed to do with all my uncertainty? How can I tell the patient what I think, without taking away their hope? Today we're going to try to answer those questions. I'm Margot, an internal medicine resident at NYU.

Tamar: I'm Tamar. I trained in internal medicine at NYU and am now pursuing research in bioethics.
Smith: What is prognosis? So my interest in prognostication started, well, it started with my dad who died while I was in medical school and I had a disturbing experience. Um, he had a glioblastoma multiforme, uh, which is a brain tumor and he had stage four. It was incurable and the first treatment for it is surgical debulking of the tumor. And I went with my dad to the follow up meeting with the surgeon after the debulking and the surgeon said to my dad, I got it all, Blake-I got it all. And you know, I was in med school at the time. My dad worked at a medical school. He's a researcher. We knew from all of the data that you cannot get all of the glioblastoma multiforme when it's advanced, you know, the little cells have intercalated into the other neurons in the brain. And that was really, you know, uh, it was, uh, it was shocking to me at the time and, um, disturbing. Smith:So prognosis is the likely outcome of a test or treatment or procedure. And when we talk about prognosis, we're usually talking about prognosis for life expectancy, but prognosis can be so many more things than that. It's a prognosis for expected positive outcomes as well as risks and harms. So, for example, prognosis for recovery of function following an ICU admission, prognosis for developing a negative reaction to a new immunotherapy drug for example. So prognosis is really sort of wide raging.
Tamar: Dr. Smith's personal story really moved us. It underscores exactly what we hope to explore here: the lifelong effect a conversation like this can have on a patient and his family. To start, we'll turn it back over to Dr. Smith to define prognosis. He emphasized that this topic and its applications are somewhat broader than how we usually think of them.
Why offer prognostication?
Margot: To give a quick disclaimer, the things that we find hardest are these conversations about lifespan, so that's what we'll be focusing on today. We also wanted to say that most of the literature on prognosis comes from studying geriatric patients, patients in the ICU, or those with advanced cancer. But the broader concepts we'll be focusing on are relevant for anyone who cares for patients with serious or life-limiting illness.

Jafar: So before we get into any more details, it's worth just coming out asking: why do need to give any prognosis to our patients? I mean, we can't see into the future with any certainty anyways, right?
Smith: So for example, in general medicine, cancer screening is the area where prognosis is probably discussed the most. And when you have a cancer screening, again, just to remind listeners is designed to detect slow growing cancers. It takes about 10 years for you to benefit from being screened for a slow growing cancer. And if your life expectancy is less than 10 years, then you're unlikely to benefit from the cancer screening, uh, in your lifetime. The other sort of side of the coin is about the harms of cancer screening. And those typically occur up front within the first few, either immediately, for example, with colonoscopy, the risk of colonic perforation, the burden of taking that go-lytely, which does not make you go lightly, it makes you heavily. And, um, you know, burden of false positives, you know, detection of cancers that wouldn't hurt you in your lifetime.
Tamar: Right. But maybe also not right? We certainly can't see into the future, but we can give an informed guess. And our informed guess can help our patients make an informed decision. The risks and benefits of so many interventions change with the patient's prognosis, and not just in decisions about end-of-life care.

Tamar: Along with cancer screening, there are many other examples where this same concept applies. Patients' age and overall health status are important when we think about how tightly to control diabetes, or choosing between a bioprosthetic or mechanical cardiac valve, to name just a few.

Jafar: So it's critical to think about prognosis on our end when it comes to the calculus of medical risks and benefits, but it's also important to note that - at a certain point in their health - most patients want to discuss prognosis with their doctor. Not everyone is ready to talk about it, but patients generally grow more interested in talking about prognosis the more limited it gets. A national survey of nearly 900 older adults conducted in 2016 showed that most would like to talk about it if they had less than two years of expected life.

Tamar: Unfortunately, even when life expectancy is short, studies show that clinicians are not very good at having these discussions with patients. In one large study of patients with advanced cancer and a median survival of less than 6 months, 70% wanted to be told their life expectancy, but only about 18% could recall ever being given a prognostic disclosure by their physician.

Margot: If these conversations don't happen, patients and their families will end up trying to guess for themselves. But that has its own problems: people often have very different ideas about how long a patient has to live. A study of patients with advanced cancer found that two thirds of patients surveyed had prognosis estimates that were different from their oncologist. Almost all of these discordant estimates were more optimistic, and only 11% knew that their estimates were different than their oncologist's. This really made us wonder - are these conversations not happening? Or if they are, why isn't it sinking in?

Tamar: And these are crucial questions because hearing about their prognosis really makes a difference in patients' treatment preferences. One study found that patients who thought they had even just a 10% chance of dying within 6 months made significantly different choices than people who were more optimistic.
Smith: Patients often want to know, not because it's going to help them make these medical decisions, but because they want to plan for the social decisions they have to make in their lives, you know, like, should I move in with the grandkids if time is short? You know, are there financial affairs that I need to put in order? Do I need to make sure my will is in order? Should I, you know, think about taking that trip I've always wanted to take? So patients want to know because they want to make primarily social decisions.
Jafar: And prognosis doesn't just change the way people think about their medical care-it can shape their whole world.
Why is prognostication hard?
Margot: So the flip side of the scenario that Dr. Smith is describing is that patients without an idea of prognosis can suffer the consequences. It can hurt patients and their families, who end up struggling with anxiety, undesired hospitalizations, and who may opt for aggressive treatments that just end up prolonging the dying process. It can hurt physicians, who end up feeling burnt out, and the healthcare system, which bears the cost of end-of-life care. So if it's that important, then why are these conversations so hard to start?
Smit h: So when I was in residency, I was caring for this woman in her mid seventies, uh, who'd had regular mammography, uh, for years, decades, right. And I had just read Louise Walter's seminal paper in JAMA about individualizing cancer screening, cancer screening decisions in the elderly. And she argues that rather than using sort of arbitrary age based cutoffs, we should be individualizing decisions about whether to continue or stop screening in older adults based on their prognosis. And this particular woman because of her function and because of her comorbid conditions and her age, um, did not seem, it did not seem like she would, uh, continue to benefit from mammography to screen for breast cancer. So I being, you know, sort of a naive resident went in the room and I, you know, outpatient primary care clinic, I said to her, you know, good news, you don't need to be screened for breast cancer anymore, we can stop the mammograms. And she said, why not, I've been getting these for decades? And I said, you're unlikely to live long enough to benefit. And I could feel the temperature in the room just dropped. And I realized I had, you know, stuck my foot in my mouth and I had no idea what I was doing in terms of communicating prognosis. Um, so that really got me thinking, you know, as much as the science of estimating prognosis is challenging, the art of communicating prognosis is also challenging and is this skill that you can develop. And there are better ways to do that, and there are worse ways to do that. Smi th: So this was, you know, a challenge, and most oncologists might just defer prognostication entirely because they're so used to prognosticating based on the disease itself. You know, in trials of people with X condition, this is what happens. We didn't know that. But in his case, because of his advanced state of disability, because of his advanced age, because he had other chronic conditions, we were able to estimate for him that he likely had a prognosis on the order of weeks, and maybe a few months, but months on one hand. And that was helpful information to the patient and to his son as they went about planning for their financial future. Smith: This will likely resonate with many of your clinicians, when they get an estimate of prognosis from an oncologist. Often we're like, huh, that doesn't really sit with what I'm seeing, you know? And that's because the oncologists - if they're relying exclusively on that prognostic disease-specific index - are likely overestimating the patient's prognosis because they're not seeing the complete patient. You know, the patient has dementia, that patient is in bed most of the time and eating very little. Those factors are not well captured in these studies that go into these, you know, single disease, prognostic indices.
Margot: There are a lot of challenges clinicians face in delivering prognosis. Dr. Smith shared a particularly humanizing story with us that illustrated his first point: communication is tricky, and clinicians need training in it like they would any other skill.
Smith: These conversations are really often highly emotional. And one of the key components of an effective conversation is being able to respond to emotion. James Tulsky has done some work, looking at, you know, physicians who care for people with serious illness, primarily in cancer but also in other conditions. And he's tape recorded their conversations, in clinic and other settings. And what he's found is that when patients make highly emotional statements, clinicians, our tendency is often to terminate the conversation, and to move off in a different direction. And what he and his colleagues and others have suggested is that that's a real disservice to patients, and that we need to do a better job of acknowledging that emotion, and bringing it out in conversation, so that we can help patients work through it. So we can understand their inner lived experience. Smith: How do we improve it? So I would say that one of the reasons that clinicians often avoid prognostication is the chagrin factor. You know, they told a patient they were going to live X long amount of time, and they ended up exceeding that, you know, dramatically. And so they feel burned, so to speak, and they act on their last bad experience. There is a tremendous amount of uncertainty because of the heterogeneity in the patients who we're seeing. There are individual responses to illness or to treatment. Because we study populations of patients and we are talking about the individual in front of us, and as you say, there's a bell curve of a distribution. And as one person famously put it, the median is not the message, right? You need to individualize that curve further for the patient in front of you, and even when you do that there's still quite a bit of uncertainty around it.
Margot: The second problem is that we're often working with incomplete information. Dr Smith shared a story of a patient he cared for, a gentleman who was elderly, pretty frail, who was hospitalized and found to have a metastatic cancer of unknown origin. They didn't have a tissue diagnosis at the time of the family meeting, and the son asked the question on everyone's mind: how long did the patient have to live?

Tamar: And while this was a win for this patient without a known diagnosis, even when we do know what disease a patient has, that alone does not give us the whole answer to prognostication. Often specialists look to disease-specific clinical trials to guide prognosis, but this data usually comes from younger, healthier patients than the individual patient sitting across from me, now. This data can also be outdated as improved treatments become standard of practice and supportive care has improved.

Jafar: So while the science of creating an accurate prognostic estimate is fraught with difficulties, even when we feel we have a clear view of a patient's prognosis, there are still a lot of factors that hold us back from saying it. What if the patient isn't emotionally prepared to hear their prognosis? Am I taking away their hope? Actually, that have described patient reflections from prognostic disclosures actually cited no harm to their emotional state or the doctor-patient relationship because of that conversation. Again, most want their doctor to be realistic and honest with them.
Smith: So in 2009-2010, a UCSFs medical student named Lindsay Yourman took a year off to do research with me and I gave her this book by Nicholas Christakis, called "Death Foretold: Prophecy and Prognosis," and she read it, loved it, and got really excited about this issue of prognosis. How can we incorporate prognosis in everyday decision-making? So we worked together and conducted a systematic review of prognostic indices for older adults. It's just sort of general prognostic indices for older adults, not disease specific, and sent it to JAMA and eventually they accepted it. So we told Lindsey, um, congratulations, you're a med student and you have a first author publication in JAMA, you've won the game. And Lindsay said, that's not actually what I want to do. I actually want to change practice. I want people to use prognostic indices. So we developed ePrognosis, which is a compendium of multiple prognostic indices for older adults. Uh, and it's E we made, it is our, Our mantra is trying to make these prognostic tools easy for clinicians to use. So we have prognostic indices that are for the inpatient setting, we have prognostic indices that are for the outpatient setting, and we have prognostic indices that are for the nursing home setting. Smith: The second interesting wrinkle is that the longer the clinician knew the patient, the more likely they were to make an error in prognostication, usually on the optimistic side. I think that's an important lesson too, that we grow to bond, you know, we bond with our patients. We hope for the best for them, with them. And the longer we have that relationship, unfortunately, the more biased we tend to be in our formulating a prognostic estimate. So sometimes people tell me, you know, we should go to the primary care doc because they know the patients best-and they do know the patient's best! That is absolutely right. On the other hand, they may be at risk of the bias of, you know, hoping with their patients that they may have longer to live than their empirical evidence would otherwise suggest. How should we approach uncertainty?
Tamar: Another way to phrase this hurdle you're describing, Jafar, is that this topic is emotionally intense, and that's just something we can be tempted to avoid.

Margot: To wrap up this section on challenges, I want to share a story about a challenging case I had, one which has made me hesitant to start these conversations. There was a patient I cared for in the ICU whose heart and kidneys were failing, and who had underlying dementia - all diagnoses that take a huge toll on length and quality of life. I had a 27 hour call one night where I spent an hour or two talking with the daughter. I wanted to communicate honestly without taking away her hope, but that's a difficult thing to do when you're speaking with someone who can't imagine letting go. I wanted to prepare the daughter for the possibility that her father wouldn't survive this long hospitalization, but she wasn't ready to hear it. The patient ended up pulling through, and I lost track of him when he was discharged from the hospital. A year later, I was walking past the dialysis unit when the daughter ran up to me. "He's doing great!" she said - and while I was so glad he'd had a good outcome, part of me wondered whether I'd put her through all that stress for nothing. I definitely became more cautious about starting conversations about prognosis after that.

Jafar: Wow, ok so this is a pretty difficult task to take on, but as we've pointed out there are a host of good reasons why we should step up to the plate. So the next obvious question is: how do we get better at it?

We'll divide the answer into two parts: first, the science of creating a more accurate prognostic estimate, and second, the art of communicating it effectively to patients. To start with the first point, despite all the limitations we've pointed out with them, it is still a best practice to at least start with a prognostic index relevant to the patient in front of you-and there may be more than one. Prognostic calculators exist for many major life-limiting illnesses, including heart failure, COPD, chronic kidney disease, and almost every malignancy. Check out the show notes for links to some of the bigger ones.

Margot: But what if the patient has more than one major medical problem, and doesn't really fit into any specific calculator? There are a few more holistic calculators, which focus on a big picture view of the patient rather than one specific disease. The first one we want to talk about is Walter's Prognostic Index , which is aimed at predicting one-year mortality for hospitalized patients over 70 years old who are about to leave the hospital. The second is the Palliative Performance Scale , which is meant to predict the three-month mortality of patients with advanced cancers or who are enrolled in hospice. Both share a focus on basic functioning - how much is the patient eating? Can they walk? Do they need help getting dressed or bathing? These simple questions are powerful predictors of prognosis.
Smith: In palliative care, our procedure is the family meeting, right? The cardiologists have their caths and the nephrologists just have the dialysis. We've got the family meeting and when I'm teaching about how to have a family meeting, one of the things I tell my trainees is the pre meeting that you have before the family meeting is as important or more important than the family meeting itself. Why? Because it's the opportunity for all of these clinicians to get on the same page. And one of the key components that needs to be addressed before every family meeting is what they think the patient's prognosis is. Smith: Like I say to patients, I could pick a date and I guarantee I'd be wrong. Right? I'm acknowledging uncertainty upfront. No one knows for sure. Right? And yet, because we have seen many patients like you and because we have information, medical knowledge from studies about other patients like with you, we can give you an idea. Um, is that something that you'd be interested in talking about? So normalizing the uncertainty, right? I wish we had more information, this is what we have.
Jafar: But if you're starting to get overwhelmed with too many tools and numbers and caveats-don't panic! Our guest for this episode has invested a lot of time in tackling this for you. Well, not JUST him:

Tamar: So inspirational that Lindsay had such a large role in helping develop ePrognosis during medical school. These tools and indices are an important first step because they help us stay objective. We have lots of biases when it comes to our patients, and, as it turns out, these biases lead us to overestimate survival. Nicholas Christakis and his colleagues have published a number of papers on this. In , over 300 physicians studied were accurate with their prognosis for hospice patients less than 20% of the time, and most predictions overestimated survival by a factor of about 5. But it gets even more interesting...
Communication tips
Jafar: And these survival estimates get even stronger when we average the input from multiple clinicians. A found that using resident and fellow prognostic estimates together predicted survival in the ICU better than either of them alone. Moreover, using this average created an estimate that was even more accurate than their attending's solo judgment. Trainees, unite and conquer! So phone a friend, use a prognostic calculator-we should use all the tools we have.
Smith: Just because we've guessed, estimated prognosis and communicated to the patient does not mean they believe it. There are other things they rely on, you know. They don't realize the strengths and inner resources this patient has and you know, my loved one has or you know, they've been through so much or religious resources or you know, faith in a higher power. So that our prognostic estimates are, you know, when we communicate to the patients, we need to check in with them and see where they are and what they think the prognosis is even after we've communicated it to them. Cause it may still be wildly different from what we estimate.
Tamar: So all these tools make it easier to estimate lifespan, but this still leaves an elephant in the room that we felt should be addressed here, and that's the fact that there will always be uncertainty in predicting prognosis. So how should we approach and manage this uncertainty? Firstly, don't let it scare you out of having these conversations.
Smith: Before I say what my prognostic estimate is, could you tell me a little bit more about what you think it might be? Right. So you have some sense of where they are. So you have like a structured approach to having these conversations. And then, well, you know, based on what you said, I think you're in the right ballpark, but it might be a little bit shorter than what you're thinking. You know, it's probably this sort of range in here. And then how do you react to that information? You know, what's going on for you? Is that, you know, is it hard for you to hear that cause it wasn't exactly what you were expecting. So reacting to that emotion and trying to bring it out.
Smith: I guess the first lesson where we're talking about uncertainty is don't hide behind uncertainty, don't use the uncertainty as either an excuse not to discuss prognosis, because it's uncomfortable for you, it's emotional, et cetera. And don't use it at the uncertainty as an excuse to give them a wildly optimistic prognosis.

Jafar: And as I was mentioning before, clinical clarity is almost always improved with the input of others:
Conclusion
Smith: I manage, operationally, I manage that uncertainty by talking with other clinicians, uh, openly about it and trying to, you know, see, you know, reflecting with them about their experiences of uncertainty where the patients who we're caring for. And together we can often, you know, develop a fuller picture of the patient's prognosis so that we can give them a more accurate estimate, and we feel more comfortable ourselves that we've considered multiple aspects of that patient's prognosis, not just say one disease or one lab test.

Margot: I would say, though, that it's important to hash out everyone's different opinions before walking into the patient's room. Dr. Smith recommended having a pre-meeting before the family meeting.
Smith: And so it's important to gain skills and offering to talk about that with patients. Not forcing it on them, but offering to talk about the prognosis, responding to questions they might have, acknowledging the uncertainty inherent in prognosis, but not hiding behind it, and responding to the emotional content of those discussions.
Tamar: And it's also crucial to remember that prognostic uncertainty causes distress for us as clinicians, but it's doubly so for patients, which should motivate us to try to offer them some clarity, even if these conversations are imperfect. And it's good to acknowledge your uncertainty.

Tamar: That's also why we should offer prognosis with a range of time that recognizes that there is uncertainty, like saying "days to weeks" or "weeks to months." Dr. Smith also suggested another method that uses really useful, plain language when comparing treatment choices.

Smith: Another technique that's really coming into favor is called the best case, worst case, most likely case. And that's something that's particularly useful when you are comparing two treatment options. You know, like with uh, chemotherapy and radiation. The best case for you would be that the chemotherapy is effective at controlling your symptoms, that you don't have a poor reaction to the chemotherapy or the radiation, and you're able to be functional and spend time with your family. And the worst cases, the treatment actually is more harmful to you than it is helpful. You get an infection because of the chemotherapy, and it's depressing your immune system. The most likely case is there'll be good days and bad days, and they'll be really hard up front when you have the chemotherapy and radiation. But overall over time you, you probably have some benefit from it and have fewer symptoms.

Margot: There is one caveat - patients and family members don't take clinicians' estimates as the final word.

Jafar: To me, this means that if I want to have a productive and honest conversation about life expectancy with a patient or their surrogates, I need to first understand what their reasoning structure looks like, so I can meaningfully add to it. If I try and steamroll or ignore it, I'm less likely to be able to address mistaken beliefs than if I came to it from a place of curiosity and respect. As Teddy Roosevelt famously put it: "People don't care what you know until they know that you care."

Margot: I personally have a bad habit of jumping right into heavy conversation, both in medicine and in life. One thing I'm working on is asking how patients want to communicate, before I start, you know, trying to communicate with them. Here are a few questions I've been trying to incorporate: Can we talk about the results of your scan? Do you want a friend in the room? Would you rather be alone? Would you prefer that information go through a family member? Giving patients control makes it more likely that they'll hear and retain information, and you'll be less likely to overwhelm them with news they weren't ready for. Dr Smith also recommends that you ease into the conversation by first asking a patient what think their prognosis is.

Tamar: And importantly, when your patients are the ones asking to discuss prognosis, make sure you try to understand they're asking. Is it because you are thinking about moving in with your daughter for help? Are you hoping to live another three months to be around for your grandchild's birth? Knowing an individual patient's priorities can help tailor medical decisions.

Jafar: Finally, we wanted to emphasize just a few basic communication tips. We know how medically complex these topics can be, and it's easy to get lost in the weeds trying to address uncertainty by getting into all the medical details. Try and stick with plain language first: avoid medical jargon wherever possible, and if they ask, then you can go into more detail.

Using language that reflects what the patient themselves are telling you can be particularly effective. Some palliative folks I've worked with describe this as using "Hope-Worry" statements. For example, "I really hope you can see your daughter graduate from college next year, and we will work toward that goal. I also worry that may not be possible if you get sicker." When breaking bad news about a more limited prognosis, using so called "Wish" statements can also work to align you with that person in front of you; for example, "I wish we had more effective treatments for you." Be especially aware of avoiding euphemisms. Don't say "pass" or "expire"; instead just come out and say "death" or "dying process."

Margot: Remember to recruit expert opinion when possible, since disease-specific factors often play a big role. But since everyone may have a different perspective, remember to balance multiple estimates and keep the overall view of the patient in mind.

Jafar: Lastly, studies show that patients want and benefit from discussions of prognosis. Some patients may not be ready to talk about it, we should at least open it up - even if uncertain - because other clinicians may not. It's not easy, but deliberate practice can definitely make us better:

If you enjoyed listening to our show, give us a review on itunes or whichever podcast app you use; it helps other people find us. We work really hard on these podcasts so we'd love to hear from you. Let us know what we are doing right and how we can improve. And as always opinions expressed in this podcast are our own and do not represent the opinions of any affiliated institutions.

Finally, special thanks to all our collaborators on this episode, our wonderful audio editor Julia Skubisz, our illustrator Michael Shen, endless technical support from Harit Shah, and most importantly thanks to you, our listeners!

References

https://eprognosis.ucsf.edu/walter.php

http://www.npcrc.org/files/news/palliative_performance_scale_PPSv2.pdf

https://www.vitaltalk.org/vitaltalk-apps/

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The Curbsiders - An Internal Medicine Podcast

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Surrogate decision-makers, POLSTs, code status and more!

Advance your care planning with tips from our esteemed guest, Dr. Rebecca Sudore, @prepareforcare ( UCSF). She helps us up our ACP game by defining advance care planning, and giving clear examples of how it can be incorporated into a busy primary care practice. It's her life's mission is to improve advance care planning and medical decision-making for culturally and ethnically diverse older adults. She is the creator of an interactive ACP website called PREPARE For Your Care, (after this episode, we are sure you'll be sending patients there for advance care planning!)
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Written by: Leah Witt, MD

Produced by: Leah Witt, MD & Molly Heublein, MD

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Guest: Rebecca Sudore, MD

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Intro, disclaimer, guest bio

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Picks of the Week

Case from Kashlak Part 1: General ACP

Defining Advance Care Planning

Case from Kashlak Part 1: Dementia & ACP

Surrogate decision makers

POLST

Outro

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

1. Flawless advice from Dr. Sudore: "What if it's easier than I think it's going to be?" A way to intervene in catastrophizing thoughts!

2. You don't have to do all advance care planning in one sitting- normalize and do it step by step, one visit at a time.

3. Start with values/goals/preferences, then align with treatment options/recommendations.

4. Advocate for your patients and help out your colleagues! It is important to document your advance care planning conversations with patients to make sure that this information is easily accessible in the medical record and to ensure that patients' wishes are honored.

5. "PREPARE for your care" resources are free for clinicians and patients- check them out today!

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The definition is evolving!

Traditionally: One time, check box form completion (randomized studies failed to show benefit here!)

Consensus definition (Sudore et al 2017): "Advance Care Planning is a process that supports adults at any age or stage in health in understanding and sharing their personal values, life goals and preferences regarding future medical care."

Advance Care Planning Pearls

What is Advance Care Planning (ACP)?

ACP is a complicated and heterogenous process (not just a form!) ( McMahan 2020)

ACP studies that did show benefit showed that ACP decreases burden/stress/cognitive suffering from caregivers who are making decisions on behalf of loved ones.

The nitty gritty of ACP

If your patient brings up a concern (and opens the door for ACP):

Start by responding to emotion- dig out those NURSE statements!

"The Conversation"

An incremental approach is JUST FINE! The whole conversation doesn't need to happen in one visit.

Health care proxy/agent/surrogate/representative (all terms are roughly equivalent and vary by state): "Is there someone you trust to help make medical decisions for you if there ever came a time you could not speak for yourself?"

Use PREPARE for your care for pre-visit homework for your patient (AND YOU! There are simple scripts for advance care planning that anyone (front desk staff, nurses, physicians, etc) can use (see PREPARE Tools for Providers and Organizations). People who have gone through PREPARE are more empowered to start a conversation about ACP ( Freytag et al 2020)!

Ask if they have a previously completed advance directive. If so, do they remember what is in it? If not, orient them to advance care planning.

If you have 5 minutes or less... ask about a surrogate decision-maker and orient to the process of ACP!

If yes: "what have you talked about together?"

If you have 15 minutes (or more)... dig into values, experiences, and preferences:

Ask about prior experiences with illness (personally or in family/friends)

"What brings your life joy and meaning?"

"What is quality of life to you?"

"What do you think went well, what didn't go well and why?"

"It can sometimes be helpful to think in general about what kind of medical care would be important to you. For example, some people feel that living as long as possible is the most important thing to them, no matter what their quality of life may be or the pain they may go through. Other people feel that there may be some health situations they know they would not want to go through, such as not being able to wake up from a coma or needing to be on machines to live. Have you thought about this before? What type of person are you?"

Document that conversation!

Literally document the conversation you had with your patient (use direct quotes!). This ends up being so much more valuable than just listing the code status. Think about what is clinically meaningful documentation.

Unfortunately, in many cases much of this important info is buried in hard-to-find primary care notes, so ideally your EMR/health system would identify a central location to hold this information ( Walker et al 2018).

ADVANCED ACP Quick Hits...

Is there an automatic order of surrogate decision-makers if nothing is documented?

Every single state has its own laws! It is important to know if there is a default order in your state ( DeMartino et al 2017).

1. Can they communicate a choice?

2. Can they demonstrate understanding of the situation/consequences?

3. Can they talk about the "why" and reasoning to support choices?

4. Are the decisions consistent over time?

ACP & Cognitive Impairment

Determining capacity for ACP is the same as assessing capacity for any other critical medical decision ( Sessums 2011). Dr. Sudore suggests considering:

Should we also be addressing financial advance planning?

Yessss!! All of this advance planning is interrelated and most people are thinking about it together. Medical-legal partnerships and elder law attorneys are useful for financial planning.

What about people who cannot identify a surrogate decision-maker (sometimes called "unbefriended")?

Many people report that they don't have someone they trust to play this role ( Chiu et al 2015, Pope et al 2020). In these situations, Dr. Sudore makes an extra effort to have more extensive ACP conversations.

How to mediate your own judgment about what is "best" for the patient

Moral distress is real ( Dzeng 2020), and this can lead to tension and urgency about communicating our worry about a patient's health and our perceived judgment about the "right" course of action.

Consider this: if you walk into a room with an agenda, it's pretty much game over. Try to leave your agenda at the door, and approach the conversation as above. Who are you as a person? What brings you joy? What outcomes of this treatment would be unacceptable? Use the spectrum analogy. Allying yourself with the patient and family opens the door for time trials of treatments and evolving care discussions.

Discrimination, racism, and ACP for diverse populations

Health disparities are based in real discrimination and racism in our health system, which has resulted in frequent mistrust of the medical system. PREPARE was created particularly to address these issues, and allow for ACP within families, communities-outside of the clinical context. There are easy-to-read advance directives downloadable in many languages.

POLST vs advance directive

Physician's Order for Life Sustaining Treatment (POLST) (called different things in different states) is an order that a clinician writes/signs and is just about life sustaining treatments like CPR. It was created originally for very frail older adults in nursing home settings. POLSTs are supposed to be completed at each care transition (hospital discharge, etc).

1. Get yourself some Recchiuti chocolate (thanks Rebecca for the rec!)

2. Rebecca's picks of the week: zone and zen out to Snoopy on the Disney Channel, Essentialism by Greg McKeown

3. Leah's pick of the week: Your Unapologetic Career podcast by Kemi Doll, MD

4. Paul's pick of the week: The Green Knight

5. More media with Dr. Sudore! GeriPal podcast, NPR

6. PREPARE for Your Care, PREPARE for Your Care (COVID19 resources)

In contrast, an advance directive (AD) is something a patient can complete on their own (without any assistance from a physician).

Links

Goal

Listeners will confidently discuss advance care planning with patients and feel equipped with strategies for empathetic discussions that account for individual health concerns to develop a plan to achieve goal-concordant care.

1. Learn how to approach advance care planning discussions in ambulatory settings where non-urgent decision-making is required

2. Adopt a strategy and framework for having ACP conversations

3. Learn resources for completing documentation

4. Discuss how an advance care planning discussion will differ when discussing a particular anticipatory event (eg COVID-19 pneumonia) or progressive illness (eg dementia)

5. Understand the difference between an advance directive (AD) and physician order for life sustaining treatment (POLST)

Learning objectives

After listening to this episode listeners will...

Disclosures

Dr. Sudore reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Citation

Witt LJ, Sudore RL, Williams PN, Watto MF. "#295 Advance Your Care Planning with Dr. Rebecca Sudore". The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date September 20, 2021.

Contact Us

We love hearing from you.

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#295 Advance Your Care Planning with Dr. Rebecca Sudore - The Curbsiders

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Surrogate decision-makers, POLSTs, code status and more! Advance your care planning with tips from our esteemed guest, Dr. Rebecca Sudore, @prepareforcare (UCSF). She helps us up our ACP game by defining advance care planning, and giving clear examples of how it can be incorporated into a busy primary care practice.

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JAMA article: Patient Goals-Directed Care

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JAMA article: Patient Goals-Directed Care

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Article: 4 stage approach to deprescribing

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Article: 4 stage approach to deprescribing

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Article: 2023 Beers Criteria for potentially inappropriate meds

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Article: 2023 Beers Criteria for potentially inappropriate meds

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Article: Alternatives to Beers Criteria meds

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Article: Alternatives to Beers Criteria meds

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Article: STOPP/START criteria for potentially inappropriate meds

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Article: STOPP/START criteria for potentially inappropriate meds

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Over 25% of older adults living in long-term care (LTC) have diabetes. In Ontario, more than half of LTC residents with diabetes are treated too strictly (i.e. A1c < 7%). This puts residents at risk for harms like low blood sugar and its consequences (e.g., falls,...

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Deprescribing.org - Optimizing Medication Use

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Deprescribing.org - reducing medications safely to meet life's changes. Online resources for clinicians and patients to help with deprescribing.

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The Curbsiders - An Internal Medicine Podcast

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#503: Falls with Dr. Alyson Michener and Suzanne Zukoski, MSPT - The Curbsiders

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Transcript available via YouTube More than just mechanical! Keep older adult patients on their feet, literally! Learn to map the Age-Friendly 5Ms Framework onto multifactorial risk factor assessment and management and incorporate other evidence-based fall prevention interventions with the expertise of an interdisciplinary team. We are joined by geriatrician Alyson Michener (@AlysonMichener University of Pennsylvania)

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Stanford Medicine 25: Gait abnormalities

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Stanford Medicine 25: Gait abnormalities

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Some good videos and explanations!

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I'm now going to demonstrate a couple of gaits. It would be a great shame for a patient to come to us with an abnormal gait and for us to send the patient for testing or consultation when the diagnosis might be fairly evident in the gait. The most common gauge you will see is the hemiplegic gait and this is one that you see in hemiplegia where the arm is typically in this posture and the leg on the affected side is typically somewhat stiff.

They will then have a gait that looks something like this and the characteristic of the gait is the circumduction of the foot. The fact that the foot is making a circle like that is what makes this gait so characteristic. If the condition is mild the hand may not be flexed up like that and the only manifestation might just be a little circumduction and the hand may not be swinging normally the way the other hand swing. That is called the hemiplegic gait. It's important to understand why they do what they do when you cut the pyramidal tract. On the left side you have abnormalities of tone that manifests on the right side. So you develop flexion hypertonia in the upper limb and extensor hypertonia in the lower limb and that accounts for the leg being like that and the hand being like this. In addition, they develop much more distal weakness than proximity weakness. Their shoulder is strong and the fingers are very weak.

The tie is strong but the foot is weak and so they have foot drop and so the circumduction comes about because a) they have extensor hypertonia. The length of the leg is stiff. Otherwise. they could just step like this you know they could go like this. And b) because they have foot drop because their weakness distally. They can't lift up the leg and step like that so they wind up circumducting so this is the most common gait we will see around here probably. It's called the hemiplegic gait.

Another case that we would commonly identify is the gait of Parkinson's disease. It's a posture that's characterized by universal flexion. Every joint is flexed and the patient typically will take very small steps. This is called a festination gait. The French call it the marche. A petit power walk of little steps and there might also be an associated tremor with the gait. The patient may have a myriad other abnormalities related to the Parkinson's that we are not going to cover in this session.

Another gait that's very helpful to recognize and it may be one that you're all familiar with from watching police videos and hopefully not from personal experience is the cerebellar gait. The cerebellar gait is characterized by a broad stand and by a wide staggering quality to it. People will tend to fall towards the side of their illness so if the illness is in the cerebellar hemisphere on the left they might fall in that direction. When asked to stand still, their trunk may sway like this and that is called titubation and obviously they would have problems with all the other cerebellar tests.

One caveat: many people think of the Romberg test as being a test of cerebellar disease. Now the Romberg test has nothing to do with the cerebellum. The cerebellum patient is already swinging and it gets a lot worse when you have them proprioception. When you and I are standing like this with our eyes open we are getting signals from our joints to tell us where we are in space. If however you have a problem with proprioception because of your peripheral nerves or posterior columns, then you're relying on your eyes to tell you where you are in space. Therefore, the moment you ask the patient to stand still and close their eyes the patient begins to sway and that is a positive Romberg test it has very little to do with the cerebellum.

Talking about proprioception leads me to the other gait related to proprioception. Once again if you have trouble with your proprioception and cannot feel when your foot has arrived on the floor you are relying on a lot of visual cues and especially in the dark. You might develop what's called a stomping or stamping gait where you tend to walk like this needing to slam your foot down to get the vibration in your trunk to let you know that your foot has landed. So this gait may be much more prominent in the dark and not as evident in the daytime because they can see where they're going.

I get that we should mention in the context of the hemiplegic gait. This is the gait that is commonly seen in cerebral palsy. It's a diplegia gait, if you will, with hemiplegia on both sides. It's a gait that I'm sure you've seen often in children and in adults affected by this from childhood. Typically the patients have extensor spasm and almost seem to be walking on tiptoe and although they have some circumduction they have a lot of adductor spasm that keeps their feet close together so they tend to be walking on tiptoe the arm is flexed like this. The adduction is a prominent feature in fact in some parts of the world where children do not get adductor releases you might actually see a scissors gait where the leg swings all the way over to the other side and again. That is another manifestation of the diplegia gait.

I want to talk about a gait that happens in people with myopathy and this is a gait where the patient develops a waddle. In order to understand this gait you have to do a couple of things with me. If you don't mind put your hands on your hip and appreciate that when you take a step to step forward the hip on the side where you are stepping forward that hip actually moves up. It moves up and it's a function of having very strong pelvic girdle muscles that allow you to do that if you have a myopathy when you lift your leg up to take a step because you can't hold your pelvis up and stabilize it. There's a tendency for the hip to fall on that side and for you to fall over and to compensate for that you lean your trunk this way.

So you develop a waddling kind of gait compensating for the fact that your pelvis and your pelvic muscles aren't strong. You're getting a waddling kind of gait leaning away from the side where you have the weakness. You know in a sense it's a manifestation also of the Trendelenburg sign. The Trendelenburg sign says that when you lift the hip on the affected side the pelvis sags down and it's a suggestion that you have weakness in the pelvic stabilizing muscles.

Another gait that I will discuss is the neuropathic gait. If you have a peripheral neuropathy and you have foot drop, then typically you have to have a high step in gait. Otherwise you will trip on your foot and fall forward. So patients in neuropathy especially if it's bilateral will have a gait like this which is nicely also called the equine gait or the stepping or step edge gait. The reason they do this is they can't step forward without tripping on their foot because they can't really dorsiflex their foot because of weakness. The foot is weak and so to overcome that weakness they have to lift it up like so.

The choreiform gait does not in my mind strictly constitute a gait. These patients are already exhibiting driving movements and voluntary movements when seated and when they walk they can have the most bizarre sorts of gaits. I don't think it's fair to call it a gait because really the involuntary movement is manifest and pretty much everything they do.

I would offer as a caveat that all our hospitals have long corridors, great opportunities to watch patients walking towards you and away from you and I encourage you to make a habit of studying gaits as people come and go and realize what a miracle it is for people to have a normal gait and how easily it is rendered abnormal by disease.

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Abnormal gait (walking disorder) types include: hemiplegic, diplegic, neuropathic, myopathic, Parkinsonian, choreiform, ataxic, and sensory.

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CDC STEADI initiative to prevent falls: algorithm

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CDC STEADI initiative to prevent falls: algorithm

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CDC STEADI initiative to prevent falls: resources

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CDC STEADI initiative to prevent falls: resources

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STEADI: The Pharmacist's Role in Older Adult Fall Prevention
Developed in collaboration with CDC and the American Pharmacists Association (APhA).
As some of the most accessible members of the healthcare team, and as medication experts, pharmacists play a critical role in older adult fall prevention. To begin preventing falls, pharmacists can:

Screen to identify patients at risk for a fall;

Assess to identify modifiable risk factors, such as medication use;

Intervene to use effective clinical and community strategies to reduce risk.

Take the Training

Take the free online application-based training and earn accredited CPE.

In order to take this training you need to register within the APhA learning management system. If you are not an APhA member, registration is free and simple: just click log-in/register on the training webpage to start the process.

Download the Resources List

Use these resources from the training to learn how to conduct a medication review, minimize high risk medications, and implement fall prevention.
STEADI Pharmacist Training Resources List [PDF - 102 KB]
Watch the Trailer

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stopping elderly accidents deaths and injuries

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Provider Training & Continuing Education

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STEADI provides training, tools, and resources for health care providers to help prevent falls and help their patients stay healthy, active, and independent longer.

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The Curbsiders - An Internal Medicine Podcast

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Challenge your beliefs on the efficacy of pervasive treatments used in dementia with expert Eric Widera, MD, Professor and clinician-educator in the Division of Geriatrics at the University of California-San Francisco. We explore the use of cholinesterase inhibitors, antipsychotics for behavior disturbances, feeding tubes, medications and supplements used for weight gain (inspired by Choosing Wisely and the American Geriatric Society's "Ten Things Clinicians and Patients Should Question"). Plus, we introduce our new correspondent, Dr. Leah Witt, Geriatrics Fellow at UCSF.

Written and produced by: Jordana Kozupsky, NP, Nora Taranto, MS3, Leah Witt, MD; Edited by: Matthew Watto, MD

our mailing list and receive a PDF copy of our show notes every Monday. Rate us on , recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Self Assessment Questions

1. Delivering a dementia diagnosis is a delivery of serious news. Use SPIKES for communication ( ): Setting (think about environment/participants/distractions, get chairs for all participants); Perception ("ask, tell, ask"- ask what patients know before you tell them); Invitation (obtain permission from patient/family about what they would like to know); Knowledge (share information with the family and patient) ; Emotions (address emotions with empathy); Summarize & strategize. Talk to patients/families about what to expect/disease progression.

2. Don't fall for the red herring of only focusing on pharmacologic therapies (e.g. cholinesterase inhibitors) for dementia, because at best they are marginally effective, and have significant side effects (GI most common) ( ).

3. Non-pharmacologic approaches are first-line to treat dementia-related behaviors. Try the DICE approach ( ). Use pharmacologic means (e.g. antipsychotic agents) only if necessary, and for as short of a time as possible.

4. Prepare families and patients for the natural history of dementia progression, including progressive functional decline, anorexia, and aspiration ( Involve the multidisciplinary team.

5. Feeding tubes do not decrease risk of of aspiration or improve comfort. Avoid appetite stimulants (e.g. megestrol acetate). Thickened liquids do not improve patient-centered outcomes and comes at the risk of dehydration and UTIs (try it for yourself and take the #thickenedliquidchallenge).

Case from Kashlak Memorial:

Cholinesterase inhibitors:
AGS Choosing Wisely #6: "Don't prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects."

The benefit of cholinesterase inhibitors in mild-moderate dementia is modest at best- an average of a 3 point improvement on the 70 point ADAS-Cog scale, though the clinical significance of this is questionable ( ). Treatment with donepezil does not appear to reduce progression of disability or rates of nursing home residence over a 3 year course ( ).

Side effects of cholinesterase inhibitors include GI symptoms like nausea and diarrhea (most common), weight loss, and bradycardia. In an observational study of adverse events in patients taking donepezil, galantamine and rivastigmine, 81.2% reported adverse events (

Don't let the discussion about pharmacologic therapies become the focus- it is most important to discuss the natural history of dementia with patients and families and to plan for the future. In a study of the course of advanced dementia, 54.8% patients died over 18 months, 41.1% had pneumonia and 85.8% had an eating problem (

Treating Dementia-Related Behaviors
AGS Choosing Wisely #2: "Don't use antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia."

First line treatment for dementia-related behaviors (e.g. agitation) is non-pharmacologic treatment, e.g. via the DICE approach ( ).

Patients with Alzheimer's Disease, prescribed antipsychotics, have a long-term increased risk of mortality (DART-AD trial, ). The number needed to harm with antipsychotics in patients with dementia is 26 for haloperidol, 27 for risperidone, 40 for olanzapine and 50 for quetiapine ( .

Citalopram may have a role in reducing the dementia-related behavior of agitation along with caregiver distress, but its cognitive and QTc prolonging effects may limit its use ( ). Max dose is citalopram 20 mg daily in the elderly.

Dextromethorphan-quinidine ("tussin and tonic", TM Eric Widera) is gaining wider use, based on a 2015 study showing improvement in agitation in patients with dementia ( ), however the risk of adverse events is significantly increased compared to placebo (falls, diarrhea, and UTIs)

AGS Choosing Wisely #4: "Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium."

AGS Choosing Wisely #10: "Don't use physical restraints to manage behavioral symptoms of hospitalized older adults with delirium".

AGS Choosing Wisely #1: "Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding."

Talk to families early on about the progression of dementia and the high prevalence of eating problems with advanced dementia. Read this JAMA case discussion of a 93 y/o man with advanced dementia and eating problems, and consider patient, family and provider perspectives as you plan your communication strategy around this issue ( ). Among family members who had relatives with dementia in whom a feeding tube was placed, almost 60% had not had a discussion about feeding tube placement, and their relatives were less likely to report excellent care at the end of life ( Teno et al. JAGS. 2011 ). Feeding tubes often bother patients, leading to restraints (pharmacologic or physical), increased time in bed, and pressure ulcers.

There is wide variability in feeding tube placement rates by nursing facilities, states/regions, and demographics. Increased feeding tube placement has been noted in facilities housing non-white patients, for-profit status facilities, and high Medicaid populations ( ).

AGS Choosing Wisely #8: "Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, discontinue medications that may interfere with eating, provide appealing food and feeding assistance, and clarify patient goals and expectations."

High calorie supplements do increase weight, but they don't improve patient-centered outcomes such as quality of life, function or survival ( ). All appetite stimulant medications are off-label. Megestrol acetate should be avoided- 1 in 12 patients given this medication will gain weight but 1 in 23 will have an adverse event leading to death ( ).

Thickened liquids are one of the most common food-related interventions that we inflict on patients with dementia, due to concerns about aspiration. Thickened liquids may decrease aspiration on videofluoroscopy, but they do not change the rates of aspiration pneumonia ( ). AND thickened liquids increase dehydration, fever and UTI, as compared to the chin-tuck posture ( ). Try it yourself and take the #thickenedliquidchallenge. Change your practice!

Learning objectives:
After listening to this episode listeners will...

1. Decide how and when to re-evaluate cognition during use of a cholinesterase inhibitor for dementia.

2. Utilize nonpharmacologic therapies for behavior disturbances in dementia.

3. Recall the risk of using off-label pharmacologic therapy for behavior disturbances in dementia.

4. Counsel caregivers on benefits, risks, and limitations of pharmacologic therapy for patients with dementia.

5. Know why percutaneous feeding tubes are not recommended in patients with advanced dementia.

6. Counsel patients and families about the use of high calorie supplements and/or appetite stimulants like megestrol

00:00 Disclaimer00:37 Guys set up the show02:00 Dr Widera's bio03:15 Getting to know our guests13:10 Picks of the week16:40 Clinical case: new diagnosis of dementia17:40 Discussing dementia with patients and caregivers23:42 Cholinesterase inhibitors27:35 Stopping cholinesterase inhibitors33:35 Follow up to therapy36:05 Dealing with behavior disturbances39:15 DICE approach44:17 Risks of antipsychotic medications 49:45 Melatonin for delirium or sleep52:00 Mirtazapine53:54 Clinical case: patient with dementia not eating54:40 Feeding tubes59:40 Dysphagia and NPO orders62:04 Misinformation on malnutrition and girth creep65:10 Thickened liquid challenge70:25 Appetite stimulants72:38 Megestrol Time Stamps

73:54 Take home points from Dr Widera

48:00 Use of benzos or sedative hypnotics

79:17 Outro

1. Top 10 Reasons Eric Widera is the Best Fellowship Director Ever

2. : An international sensation, originating in New Zealand, which builds muscle (and physician wellness) via choreographed weight lifting set to music. Run, don't walk, to your nearest class.

3. Dr. Widera's book pick: Drive, The Surprising Truth About What Motivates Us

4. Dr. Witt's book pick: Extreme Measures: Finding a Better Path to the End of Life

5. Dr. Widera's favorite medical app: . Tweet about Hospice-Palliative Medicine using #hpm or Geriatrics using #geriatrics

6. Dr. Williams's pick of the week: (documentary) on Netflix

7. Thomas Finucane (Audio Digest) Misinformation on Malnutrition

8. American Geriatrics Society Choosing Wisely: Ten Things Clinicians and Patients Should Question

9. Take the Thickened Liquid Challenge (and tweet the video with #thickenedliquidchallenge)

Contact Us

We love hearing from you.

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#82: The GeriSiders: Dementia Dos and Don'ts - The Curbsiders

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Challenge your beliefs on the efficacy of pervasive treatments used in dementia with expert Eric Widera, MD, Professor and clinician-educator in the Division of Geriatrics at the University of California-San Francisco.

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The Curbsiders - An Internal Medicine Podcast

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A memorable dive into office evaluation and management

Dust off your dementia playbook and re-evaluate your approach as Dr. Josh Uy walks us through this common (yet perplexing) condition. Dr. Uy (@joshuy) is the geriatric fellowship director at University of Pennsylvania in addition to a nursing home director and shares his skills in simplifying dementia screening, management, and treatment. Set your chairs up for the "triad visit" and prepare to 'stew in the milieu' of dementia!
Free CME for this episode at curbsiders.vcuhealth.org

Producer, cover art, infographic: Emi Okamoto MD, FACP

Hosts: Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP

Editor: Leah Witt MD (written materials); Clair Morgan of nodderly.com

Guest: Josh Uy MD

!
Credits

Join the American College of Physicians today! Post-training physicians can take advantage of a special limited-time $100 dues discount. Visit acponline.org/acp100 and use the code CURBSIDERS. Membership discount is available only until May 31, 2021.

Go to GreenChef.com/90curb and use code 90curb to get $90 off including free shipping!

CME Partner: VCU Health CE

Intro, disclaimer, guest bio

Guest one-liner and picks of the Week*

Case from Kashlak

Definitions of dementia and cognitive impairment

Subtyping dementia

Cases to refer and basic laboratory testing

Potential imaging

Management of dementia

Take-home points, Outro

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org.

1. The pillars of dementia prevention and treatment rest on maintaining an overall healthy lifestyle, good physical health/optimal comorbidity management, and adequate social support (notice we didn't say medications...)

2. Standard assessments for dementia include the MOCA, MMSE, and SLUMS. While MOCA is sensitive for picking up mild deficits, it is a longer test and may be challenging for those with a higher symptom burden.

3. Removing the stigma and shame of dementia is important. The clinician should ameliorate this by respecting patients and offering ways to achieve their overall goals for a good quality of life.

4. Keep things simple. If you are scratching your head about ordering complex tests or imaging for atypical cases (e.g., younger patients or people with rapidly progressive dementia), these patients should be referred.

5. Acetylcholinesterase inhibitors and memantine show marginal clinical improvement in trials and the number needed to harm for acetylcholinesterase inhibitors is 12.

6. In rare cases, antipsychotics are needed to manage dangerous dementia-related behaviors (though this is not the first-line treatment!) If needed, use at the lowest dose possible for the shortest duration. The number needed to harm (where harm is an associated death) is 26-50.

Show Segments

Dementia Pearls

Cognitive Impairment and Dementia

Let's define some terms...

Cognitive impairment is impairment at any time, including congenital.

Dementia is acquired cognitive impairment which impairs function (functional impairment is key to diagnosis!). Epidemiology: more common with increasing age. Ask about instrumental activities of daily living, particularly medication and financial management, which are the most cognitively taxing iADLs and subtle impairments often present first by impacting these functions.

Mild cognitive impairment is typically used when there is a cognition change that does not impair function. Dr. Uy notes this distinction is rather arbitrary, and varies widely between patients and what their daily activities are. Approximately 10% (range 7-15%) of MCI cases/year will advance to dementia ( Oh, 2019).

The triad and approaching the topic

Dr. Uy recommends a "triad visit", where there is attention to both the caregiver and the patient. He particularly prioritizes this on new patient visits, and sets ground rules for everyone to contribute. For example, family members should not interrupt the patient.

Providers should feel comfortable communicating openly and set the emotional tone of not being fearful or embarrassed to name 'dementia' and discuss it. Starting with a gentle question can help: "Tell me about your memory- do you feel it is not as good as it used to be?"

Alzheimer's dementia: Speed unaffected, older or younger (if younger, could be frontotemporal dementia (FTD)

Frontotemporal dementia (FTD): Speed unaffected, younger-onset often before 65

Vascular: Slower speed, with vascular risk factors

Parkinson's disease dementia: Slower speed with cogwheeling, tremors, or rigidity; motor symptoms precede memory symptoms by more than a year (and thus patients often diagnosed with Parkinsonism before dementia)

Lewy body dementia (LBD): Slower speed with cogwheeling, tremors, or rigidity; memory symptoms appear concurrently with motor symptoms

Subtyping Dementia
-Dr. Uy on his approach to dementia based on patient's speed of speech and movement
Dr. Uy roughly ballparks dementia types by assessing a patient's speed of movement & speaking; and considering age.

"If it's fast and they're older, most likely Alzheimer's. Fast and they're younger 50/50 Alzheimer's, FTD. If it's slow with afib, HTN, diabetes - vascular dementia. And if it's slow with Parkinson's type features then it's either PD or Lewy Body dementia. And as a non-neurologist that gets me in the ballpark. No one will laugh me out of the room."

Referring atypical cases

For a patient with rapidly progressing dementia or who is "young" (e.g. <65), Dr. Uy refers the patient immediately to a specialist (neurology or neuropsychology) to do systematic testing. Quirky personalities/mental health overlap may be harder to tease out, and he sends for formal neuropsychology evaluation. These or other atypical cases warrant a more specialized evaluation.

Evaluation of Dementia

Laboratory

Dr. Uy orders CBC, BMP, B12, and TSH for his basic evaluation ( Oh, 2019).

Quick Binary Screeners

The MiniCog or Clock Drawing test are binary screening tools.

Assessments

MMSE, MOCA, and SLUMS are all validated assessment tests to consider ( Oh, 2019). Dr. Uy suggests MOCA for patients who have mild symptoms or the history/physical do not indicate a clear diagnosis, as the MOCA is challenging and was designed to pick up mild cognitive impairment. MMSE is copyrighted and SLUMS is not. Both of these are useful tools to show more of the spectrum of cognitive impairment.

The Functional Assessment Staging of Alzheimer's Disease ( FAST) is validated for staging Alzheimer's Disease and is helpful to follow patients over time. Dr. Uy also checks a Geriatric Depression Scale and evaluates psychiatric symptoms, which may complicate the diagnosis/exacerbate cognitive symptoms.

Imaging

Look for prior imaging from any previous visits. If Dr. Uy sees a patient with "typical dementia" without red flags he may not order imaging. If he does order imaging, a non-contrast head CT may be used to rule out larger, common structural issues.

Management of Dementia

Prioritize safety at home, ask about ADL and iADL impairment, offer management suggestions, and address caregiver needs. It's helpful to enlist home health aid support and build a schedule.

Dr. Uy encourages that patients continue to live their life as fully as possible and keep healthy habits. Healthy eating, good sleep, intellectual stimulation, social interaction, physical activity are important! ( Livingston 2020)

Education for the family

Caregiver education helps prevent or delay institutionalization and is meaningful for both caregiver and patient ( Vandepitte, 2016)
Treatment of dementia with cholinesterase inhibitors and memantine can result in statistically significant but clinically marginal improvement in measures of cognition and global assessment of dementia.
Medication

The American College of Physicians' evidence review is a succinct summary (though slightly older) ( Raina et al, 2008):

As an example, 14 studies examined 2459 patients on donepezil with MMSE and showed a 1.14 (95% CI 0.76-1.53) point decrease compared to placebo; however >3 is considered a clinically significant change. A 2018 meta-analysis also did not reach clinical significance, showing an average improvement in MMSE score of 1.0 for acetylcholinesterase inhibitors and less for memantine ( Knight, 2018) at 6 months. Another recent review similarly concluded that the efficacy of pharmacological therapy remains limited ( Arvanitakis, 2019).

For acetylcholinesterase inhibitors, the number needed to harm is ~12. Side effects include gastrointestinal symptoms (e.g. diarrhea) and cardiac issues (e.g. bradycardia), so the benefit often does not justify the harms ( Lanctot, 2003). Notably, these medications (acetylcholinesterase inhibitors and memantine) do not have FDA approval for MCI.

Discontinuation

A recent Cochrane review showed some decline in function upon stopping anti-dementia medications, but these results did not reach clinical significance ( Parsons, 2021).

Antipsychotics

Antipsychotic medications can be dangerous for patients with dementia, with a number needed to harm 26-50 to cause one death ( Maust, 2015). But, suppose these medications are needed to manage dangerous dementia-related behaviors. In that case, Dr. Uy uses them at the lowest dose and for the shortest amount of time if he believes it could help avoid institutionalization. Then, he targets a specific outcome. Notably, Dr. Uy always optimizes non-pharmacologic management before prescribing medical therapy.

This was also reviewed in episode #82 (Dementia Dos and Don'ts), and other geri-psych pharmacologic management for sleep and behavior were covered in episode #110,

1. The Chronicles of Narnia, book series by C.S. Lewis.

2. Pretending I'm a Superman: The Tony Hawk Video Game Story, movie

Talk to the patient!

Communication with patients with dementia must be concrete and complete. While talking to the patient, assess mood, thought content, and process to evaluate for an affective or psychotic component. Stew with the patient. This gives the individual dignity and allows them to be comfortable.

Prevention

1. Define mild cognitive impairment (MCI) and dementia

2. Build a toolkit of questions and cognitive tests to uncover even subtle cognitive impairment

3. Develop an approach to recognizing dementia subtypes

4. Educate patients and families on key lifestyle management that can help with dementia prevention and management

5. Recognize the limitations of benefit and potential harms of medications for dementia treatment

Healthy habits could prevent an estimated 40% of dementia ( Livingston 2020). Show note special: Dr. Uy's favorite article on prevention shows a high level of fitness in midlife among a Swedish women cohort had an 88% decrease in dementia over a 44-year follow-up! ( Horder, 2018)

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don't pay any extra.

Goal

Listeners will build a framework to confidently approach dementia assessment and its basic management.

Learning objectives

After listening to this episode listeners will...

Disclosures

Dr. Uy reports no relevant financial disclosures. Drs. Okamoto, Watto, Brigham, and Williams report no relevant financial disclosures.

Citation

Okamoto EE, Uy J, Williams PN, Brigham SK, Watto MF. "#268 Dementia with Dr. Josh Uy". The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list April 12, 2021.

Contact Us

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#268 Dementia Made Simple with Dr. Josh Uy - The Curbsiders

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The challenges of multiple medical conditions and disease-specific evidence (or lack thereof) in geriatric populations

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JAMA article: Multimorbidity and our health system

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How multicomplexity needs to be incorporated into our health systems from a payment/incentive perspective

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Podcast: Case Management and Social Work

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CME-MOC

Time Stamps

03:54 What are the various roles within a multidisciplinary teams?

10:48 Understanding limitations of social workers and case managers

15:55 The "behind the scenes" paperwork

18:42 Insurance and medications

22:17 Insurance and disposition options

25:15 The importance of creating a safe space for better communication

Show Notes
Part 1: Setting the stage

The demands to our healthcare system - increased volume of patients, new metrics to which we are held, documentation requirements - have compressed the pace of our day-to-day work on the wards and in the clinics.

This compressed pace impacts all members of the interprofessional team - including social workers (SWs) and case managers (CMs).

Part 2: 5 Ways to Improve Collaboration and Understanding

"Role confusion" is defined as a lack of knowledge around the precise scope of practice of SWs or CMs (or how these two roles differ from one another). This is thought to contribute to workplace tension on interprofessional teams .

The codes of ethics for each role emphasizes empowering patient autonomy and facilitating patient decision-making .

Training:

SW: Bachelor's or a Master's degree in social work (BSW or MSW) as a minimum requirement. Those with additional training in providing mental health services and counseling are called Licensed Clinical Social Workers (LCSW).

CM: Less standardized, varies by state. Usually hold a bachelor's degree, but can sometimes be nurses or SWs by training About 4% of CMs are SWs .

Team care roles:

Both: experts in facilitating and coordinating transitions of care and accessing community resources

As above, LCSWs can provide counseling to address social and/or mental health needs

CMs have emphasis on addressing barriers to care. They often follow patients longitudinally and act as an advocate in:
Accessing resources such as housing, medications, transportation, equipment, medical appointments.

In practice, these roles are defined differently at every institution. Ask your SW/CM colleagues early and often what their individual scope of practice is (and remember - social workers often ask each other!)

#2: Understanding limitations of SW and CM

Because we aren't always 100% clear on what's in the purview of our interprofessional colleagues, our referrals to SW or CM often lack specificity or a clear "ask".

We may be making things worse by over-promising solutions that are not feasible. SWs and CMs often have their hands tied by insurance, time, and other limitations.

Be realistic of the limited resources our case manager and social work colleagues have in their toolboxes.

#3: The "Behind the Scenes" paperwork and documentation

IPT members are often sensitive about approaching clinicians to sign off on documentation (e.g. peer-to-peer reviews, wheelchair scripts, letters of medical necessity for hospital bed).

Takeaways:

Although seemingly mundane in the scheme of sick patients, these requests are important.

Moreover, IPT members may have already spent hours on the phone interfacing with insurance companies before they come to you - meaning that the "last minute form" may represent a significant amount of work and coordination on their part.

#4: Insurance and medications

Harness your EMR's ability to make insurance status front and center.

Become familiar with "big-ticket" medications that may receive approval by insurance (see below for examples). When you see these on your med list, give a heads up to the CM so she/he can run a test claim:

#5: Disposition planning

Insurance status can impact where a patient can go after hospitalization (more on that in the next episode).

If you have a medically stable patient waiting for authorization or making a choice for disposition options, consider speaking to the patient regarding their expectations, fears, goals. That extra "nudge" from the clinician may very well be exactly what they need to make a decision!

Part 3: Improving Teamwork

In organizations such as healthcare, we often don't prioritize intentional training around teamwork:

" It is naïve to bring together a highly diverse group of people and expect that by calling them a team, they will, in fact, behave as a team. It is ironic indeed to realize that a football team spends 40 hours a week practicing teamwork for the 2 hours on Sunday afternoon when their work really counts. Teams in organizations, though, seldom spend 2 hours per year practicing when their ability to function as a team counts 40 hours a week. "

Consider creative ways to create psychological safety among the interdisciplinary team.

Vocalize your appreciation for the work your IP colleagues do.

Not only does it feel great to share in the gratitude - it often fosters a culture of goodwill and cooperation at your workplace!

Transcript
Part 1: Setting the Stage Drew: I got into this to like be a part of a system that helps people and heals people and provides kindness. I don't think we actually make them that much more healthy in the long term. We fixed an acute thing and we were like one of my fingers in this hole, but man... the next crack in the dam is about to burst. But I was here to fix this thing so I'm holding it in, you know, and that's overwhelming, right? I don't know how many, what your caseload is, but it's so long and all you really want to do is... I just want to be off shifts so I can go home and be on call, but I won't be here. Susan: Everybody's always under a tremendous amount of pressure to get people out of the hospital quickly. Susan: It used to be in the old days, we had time, you know, we had time to plan for some of this. And I think that's been one of the biggest changes in our current medical system is we rarely have much time.
Shreya: Those aren't the voices of tired residents or attendings, those are actually the voices of social workers and case managers, Susan Hedlund and Drew Grabham at OHSU.
D rew: ...you kind of just get caught in the machine and as you're doing the 20 of those discharges, you kind of lose touch of the human side of things. And then you kind of get dehumanizing and it's a lot easier to just kind of like churn people out. And then once you sort of realize that release for me, I would recognize like, "Oh that's not who I was. That's not how I got in this. But really just recognizing that oftentimes we're the messengers, especially in hospitals of a broken system." Drew: We have these multidisciplinary teams but we aren't really talking. We don't, we don't get a chance to like kind of talk about that or, or even dialogue with our colleagues about the pressures we feel like when it's happening and kind of commiserate. But when we can slow, slow down and step back, we often find like, yeah, none of us liked this, this discharge.
Shreya: Truthfully, I never really thought about how the new demands of of our health system impact social workers and case managers. It's so easy to feel bad for myself, four new admissions, 20 notes to write and billing to do. The more I spoke with our interprofessional colleagues, the more it became apparent that we all feel the strain. And Drew speaks to that tension he sees and has felt in the past:

Shreya: We do become messengers for the system. And unfortunately, that means most of the exchanges we have are just reflections of our to-do lists, "Did you fill out that shelter packet?" "When is transport coming?" "Is the patient medically cleared?"

Shreya: Without much pause in the day, it's easy to fall into the trap of thinking it's us against the SW and CM who want to get these patients out. But we are all being held to these metrics, this volume, this pace. I have rarely got to think what's it like to be in the shoes of a social worker and case manager nowadays.

And importantly, if we are all so busy with trying to get done our piece of the pie, when do we get a chance to learn from each other?

That's where the beauty of podcasts come in, let's go places we don't go and the perspectives of people that we don't usually get to hear. Welcome to our 2nd interprofessional education series on Core IM. I am Dr. Shreya Trivedi, an internist at NYU. And today I am joined by:

Ryan: I'm Dr. Ryan Chippendale, a Geriatrician and the Geriatrics Fellowship Program Director at Boston University. Thanks for having me on!

Gaby: I'm Gaby Mayer, a 4th year medical student at NYU. It's been great to learn alongside you all.
Part 2: 5 Ways to Improve Collaboration and Understanding
Shreya: I hope you will be curious with us and learn with us.

Ryan: So today, we will start with hearing 5 ways for potentially improving collaboration and understanding with case managers and social workers.

Shreya: I do have to give a heads up that the latter points are geared towards inpatient or nursing homes but Ryan did sprinkle in her outpatient geriatrics hat. After those 5 points, we will end hopefully on an inspiring and creative note on how to better work together.

Gaby: I have a confession to make...

Shreya: Safe space!
Dre w: In our residency they're not like, "Hey this is the medicine floor. This is your case manager. They do discharge planning, here's the social worker. They do stuff and that's what they told you. You're like, okay you do stuff so I'll just send you stuff." Susan: I was really young and it was new in my career, but I remember there was an occupational therapist who, uh, didn't think that social work did anything other than apply for Medicaid...And so those were early pain points for me of trying to figure out how do I try to show the value that I might bring to our patients, uh, while not alienating my colleagues, you know, and that, and that took, took some years to finesse, if that makes sense.
Gaby: Before doing research for this episode, I wasn't entirely clear on what SWs and CMs do and what the differences were between the two.
Susan: We also have skills in individual, family and group therapy. So this is a little known fact that the largest number of mental health providers in the United States are our clinical social workers.
Ryan: I can say with certainty, Gaby, that you're not alone. I've been working on interprofessional teams for 8 years now as a geriatrician and I'm still learning on the regular about the many areas of expertise that these folks offer our patients.

Gaby: Ok that makes me feel better, medicine is lifelong learning, this included. What's interesting is that this lack of knowledge around what social workers and case managers do - what we'll call "role confusion"- is actually cite d as a main factor contributing to tension between physicians and SWers.

Gaby: Just as Drew describes...I can't remember getting taught what social workers do during medical school or while rotating on the wards. So if we don't have explicit training in this - who does teach us? Answer often the social workers or case managers themselves:

Gaby: What this shows is the way in which role confusion can impact a SW's lived experience in the workplace. So let's try to alleviate a little bit of this role confusion and define the jobs that so many are confused about.

Let's start by talking about SWs. Social workers hold either a bachelor's or master's degree in social work (BSW or MSW). In addition, some social workers have additional training in mental health services and counseling. These SW will have the initials LCSW behind their names (standing for licensed clinical social worker).
Susan: What confuses the issue is that in many health systems, social workers are the discharge planners. And so, um, and a lot of people will tell us that they, social workers feel frustrated that they're not getting to practice at the top of their license using their clinical skills because instead they're calling nursing homes and things like that
Shreya: Quite an important skill and role that SWs play on a population level! What about case managers? What's their training like?

Gaby: Case managers at the minimum only need to hold a bachelor's degree, however many have a nursing background, and a few (cited as few as 4% or so) have a background. Regardless of their degrees, the majority learn their roles from on-the-job.

Shreya: Sounds like intern year. But how do these distinct trainings play out in practice?

Gaby: This is where it gets confusing. Despite different training and skills on paper, in practice the roles of social workers and case managers can overlap a fair amount. Both can be responsible for facilitating transitions of care and accessing community resources (e.g. housing, financial assistance, insurance applications).

The one hard and fast that is worth highlighting. However - because social worker training has that extra emphasis on counseling, they can provide counseling services for i.e. those with substance use disorders, mental health diagnoses or other social needs.
Drew: I've gotten much better at being like, Hey, what's your title and can you tell me exactly what's kind of in your scope or not in your scope? I go to different hospitals and there's different, you know, some hospital systems, he has a social worker here, all just discharge clinician, some they're just therapists and all these things. So we just got to get better at understanding like what does it, you define your role as just to have an understanding.
Ryan: To hammer that point home, if I think about all the different SWs I work with, their roles differ a ton based on the site of care we're in. In the outpatient world, I consult them mostly for counseling and resources vs. the inpatient or nursing home settings, where they're more involved in care coordination.

Ryan: I think we can all relate to that feeling of - " wait a minute, the responsibilities of the job that I'm currently doing are not exactly matching all that training I did." And that certainly doesn't feel good...
Drew: Social work referral: "homeless". And I'm like, "Okay, you want me to confirm that? Like what is it you want me to do with that?" And it's very impersonal. So I think it feels overwhelming. Drew: I mean, I still think homelessness is an appropriate referral. Like I think if someone has addiction, mental health, um, lots of trauma, um, homelessness. But, but the, the reality is, we're not going to solve those, but maybe we can just acknowledge them and then reflect on how those things might be at play during their hospital stay or during their engagement after the hospital system. I think it kinda starts with the physician because often they're the first person with this very morally distressing case. And it's not that they intentionally want to pass it on. But sometimes like, "Oh, and they're homeless like, well, and I'm going to just do a social work referral." Drew: Let's just get a little bit more specific and have a better communication style. "What is it you think I can do?" Cause again I get a referral. Homelessness, I don't know what you want me to do. Confirm it? Acknowledge it? Fix it? I don't know. Tell me a little bit more. You know, they think I'm going to house them then. And then they start to get mad and then they already have like a negative interaction towards this patient - some do, I should say, when they're burned out. Of like, "Oh you know they want me to house them." And if there's not that clean dialogue and conversation and so it's just, it gets back to the systems that we can do better.
Shreya: Not at all. So if SWs have these counseling skills, what distinguishes CMs on the job?

Gaby: They focus on getting to know the patient's barriers to care. They'll use this knowledge to advocate for the patient in terms of: psych care, meds or housing (how many stairs does this pt have to climb?). They also keep an eye on patient navigation (i.e. making sure patients don't have conflicting appointments) and what's going to be cost effective for that patient .

Ryan: And to add to that... what I distinctly see in my geriatrics practice is that case managers build really intimate relationships with pts and families long-term.. often over the span of years, but sometimes even decades.

Gaby: So we're starting to get a sense of how these roles occupy different niches. But like most things in medicine, we have to take these role descriptions with a grain of salt because in reality, the responsibilities for CM vs. SW can look very different across different hospitals, their prior training, and inpatient vs. outpatient, and everything in between.
Susan: For example, the um, palliative care social worker I was speaking about yesterday. She's dealing with this really complex situation with a patient who has longterm houselessness. And the hospitalist said to the patient, we'll find you a place to live before you're discharged. And that's probably not possible. [laughs] And so I think, I think one of the things it's helpful, if people ask before they promise services that we may or may not be able to deliver on.
Gaby: So I'd say the biggest take away here is ask your SW or CM colleagues what their scope of practice is. There's no shame in asking - even social workers have to ask each other.

Ryan: Understanding the training and roles of our interprofessional colleagues is definitely the starting point. But once we're there (which we hopefully are now!), we need to be mindful of the limitations that social workers and case managers face.

Shreya: Just like how clinicians face the limits everyday of what we can do for tough conditions. Our second point gets at that: what is actually in the purview of our interprofessional colleagues? This point comes up more and more often for complex patients.

Ryan: Drew reminded me of so many times in my training when I was managing a complicated patient, that I truly had no clue what I was asking or who I was asking my question to, but just wanted to scream HELP! Drew called this "passing along the moral distress." The point being... that it's not that these referrals to social work are wrong or inappropriate, but we have to acknowledge our SWs and CMs are also limited in what they can do.

Ryan: There's no magic wand. But when we do loop in our team members, it's important that we are as specific as possible with our "ask".

Ryan: For example, in the clinic, I get really detailed with my consults to our social worker. Using the example Drew gave regarding homelessness, I instead may write something along the lines of: "pt is facing eviction, please assist in connecting her to resources to help with an urgent housing application." Or "please provide counseling over the stress of this pt losing her home."

Ryan: Years of practice!

Gaby: So, this is kind of like how I have been taught to never place a cardiology consult that just states "chest pain". And instead on my Sub-I, would rehearse my well-formulated, specific question before calling to make sure we got the most out of the consult.
Susa n: Where doctors unfortunately get harassed by those of us trying to get pre-authorizations is that we often need the physician to either write a letter or sign off on why this particular treatment is essential for this patient's care.
Shreya: Exactly! It's a best practice across the board regardless of who you are consulting. But you know what can be even worse? Overpromising things to our patients when we really have no idea what our colleagues are actually capable of offering either from an insurance angle, time or resource limitations.
Todd: We'll get a call from the oxygen company and you know, then you sit on the phone with them and talk to them and they're like, well we can't do it. And I'm like, well what do you need that so that we can get it. And then, you know, I've gone on this back and forth thing now like five times and that's when they usually come to the physician. So know that, you know, by the time we get to you and knowing that it can be covered, that and then it has to be worded that way. We've had, you know, maybe five conversations up until that point. So we've spent a lot of time on that too.
Ryan: I wish I could say I didn't see this all the time. But often a very eager and well-intentioned clinician will tell a patient...without consulting anyone... that they can go to rehab or get home services that a social worker or case manager could literally tell you in 6 seconds flat won't be possible with their particular insurance.

Gaby: Yikes I can totally see myself doing this as an intern.

Ryan: Yep, I've definitely done it.. And then guess who's forced to go in and undo the damage? The case managers and social workers! Which usually doesn't lead to a satisfied patient. And can contribute to lots of frustration for our colleagues.

Gaby: And I bet if that's repeatedly happening that can fracture our sense of cohesiveness and lead to burnout.
Tod d: If they don't have insurance that's going to cover, you know, let's say it's Lantus and we're going to have to put them on as a 70/30 which is like $25 where the Lantus is let's say $260. One of the big things is to start looking at that during the treatment process so we can work with our, our medical team and say, "Hey, did you know they're unfunded? You have them on Lantus, can we switch them to something else so we can get them on a, an insulin regime that is going to work when they leave the hospital with, with the funding that they have if it's out of pocket, if it's insurance and what the coverages are."
Ryan: I'm afraid so. So the biggest take-away for this point is to be realistic of the limited resources our case manager and social work colleagues have in their toolboxes. And the more specific our question is, the better.

Shreya: And once they are involved with that specific Q, the third point that SWs and CMs spoke about was the misunderstanding and tensions that can come with some of the "behind the scenes" work.

Ryan: And by "behind the scenes work", I know you're referring to paper- work, right Shreya? Our favorite!!!
Todd: Some of the IV stuff, we have an infusion team that works in our hospitals, so we'll give them a heads up when we think someone's going to need, you know, six weeks or a month of an antibiotic for osteo and we'll have them do a test claim to see, you know, what their insurance is going to cover, what's the out of pocket for the patient. And so anytime we're looking at like big ticket items or would that, you know, you realize that have gotten denied by insurance before is you got to keep those in the back of your head when you're starting to send a patient out.
Shreya: Ughh... hope you are kidding there

Ryan: Clearly! It's what every clinician dreads... peer-to-peer reviews, wheelchair scripts, letters of medical necessity for hospital beds.

Ryan: It's interesting that Susan uses the word "harassed" here. Gosh, I hope that I'm not giving off that vibe. I get that we often feel inundated with these requests and I worry that some of that push-back can get misdirected and we end up shooting the messenger with rude tones or eye rolls.
Todd: I think the main thing is, is not giving us the information soon enough when you know that they're going to have some dispo problem. Um, I, I think one of the big things that I see in our, in our meetings is, is that we'll hear from PT that oh a patient needs a skilled nursing facility and then we look at the insurance and we're like, ah, sorry, they're unfunded. And then that's like, "Oh, now we've got to start shifting gears and figure out what we can do for them to make them have a discharge."
Shreya: Yes, many times as clinicians we only see that one extra phone call we have to make or piece of paper we have to sign, but don't see the very time consuming behind the scenes work that our SW/CMs are doing to even get us to that point.

Shreya: That's Todd Selmer a registered nurse case manager at the University of Utah. And since talking to him, I've been looking more at the CM notes. Some of the documentation reflects this run-around "called X nursing home Y times, got put on hold for Z minutes, transferred to different unit and told to call back tomorrow."
Tod d: If you hear your case managers just saying like, wow, the patient will make a choice, they won't make a choice and you know, push them to, you know, get with that patient because that is where you're really going to get your days on the end that you are going to be staying in the hospital where you're, you stand around and be like, we're just waiting for auth. But one of the big driving forces of that is being proactive when patients come in and getting that choice, helping them, guiding them in the direction of picking a facility.
Ryan: And when we are finally pinged about that last bit of paperwork, it can seem in that moment, frankly, less important. We are not saying that this makes that "extra-thing-to-do" is an easy pill to swallow, but now understanding all the work that goes into it, I'm hoping all of us, myself included, can be a little less "emotionally charged" when it comes our way.

Shreya: A lot of behind the scenes work like prior auths or letters of medical necessity is dictated by insurance policies. And, insurance is a pain point for us all.

Ryan: Preach.

Shreya: But from the perspective of a case manager, they point out its when we don't not taking into account the patient's insurance status, particularly with choosing medication options during the hospitalization or for their long-term trajectory:
Part 3: Improving Teamwork
Shreya: I've seen this too often - we titrate a patient's hyperglycemia on glargine. And say the CW comes in on Monday and point, "OH wait - the pts insurance won't cover that." And we change to 70/30 insulin or a cheaper regimen an hour before discharge. Which means you are GUESSING how they are sugars will respond.

Ryan: I know it's hard to add another thing to keep in mind! But some EMRs can actually (if you can believe it) be helpful with this - by either allowing us to add an insurance column to our inpatient lists or adding it to the top banner, making it front and center.

Shreya: OH YES! Plug for that - I recently added the insurance status column right after the patient, room # and it's been easy and useful to get a quick heads up if a patient is uninsured or medicaid and let me loop in the CM early in terms of expensive meds.

Ryan: And especially because some hospitals have charity care or extra services for uninsured patients, our SWs and CMs can help pull in how to still access some of these treatment options.

Shreya: While I wish I had this all stored in the back of my mind, I feel learned those big ticket items that may not get insurance coverage trial by fire and getting some deep sighs for not looping people on the earlier side.

Ryan: All the time! I spoke to some of our case managers here about what those common big-ticket items are and the ones that we came up were the DOACs, certain insulins or newer diabetic regimens, oral chemotherapeutic agents, newer antiplatelets like Ticagrelor. So with these.. giving a heads up to the CM allows them to run that test claim of how much a med will cost and then they'll go and talk to the patient to see if they can afford it. If not, back to the drawing board and discharge delayed!

Shreya: Very similar to being mindful of the patient's insurance status with big-ticket medications options, we also heard from the SWs and CMs, about being mindful of how a patient's insurance status can impact the patients disposition.

Ryan: Now wouldn't it be great if we had 15 hours to be on pre-rounds, being as thorough as possible with things like insurance for every patient. Likely not gonna happen in this lifetime. But I do think, with experience, we can learn which patients have risk factors that lead to dispo issues.

Gaby: Hopefully we'll help give you framework for dispo options based on insurance with the next IPE episode.

Shreya: Another dispo point is on collaborating on how we can help move a pts care forward, especially after the pt is not medically active anymore or is unfortunately a "rock".

Shreya: It's easy when a patient who is waiting for a SAR to just pop-in and out of a room, esp on this busy days I just have to ration my time but Todd's point is well taken - when I do go in, ask about how he or she may be thinking about the options for facilities and maybe I can help navigate some of that.
Daisy: I was precepting residents in clinic and uh, one of the residents was presenting a patient who, um, had been homeless with multiple complex medical problems The patient was there for followup and the resident mentioned, uh, that the patient had recently moved in to temporary housing and, um, that their medical problems were under much better control. And I said, you know, who was the social worker helped you? And she told me who it was. And I said, well, why don't we go and find her and let's go in and celebrate this moment with the patient together. Since then, you know, I felt like whenever I need anything in clinic, like that social worker is really, you know, she's just so appreciative of, um, our including her in that a successful moment.
Ryan: I've definitely had CMs on my team thank me for that extra nudge or info I collected to get things moving for a patient.

Gaby: It's almost like a two-hit hypothesis.

Ryan: Uh - a what?

Gaby: It can sometimes take multiple differen t members of the care team to nudge a patient towards a final decision about their dispo options. So it's not redundant for an intern to go talk to a patient about dispo if the social worker's already been in. It's just part of the process!

Shreya: Hearing about some of these areas of better collaboration that SWs and CMs shared makes me reflect on a quote that I found a few years ago a MedEd article from 1974.

Gaby: I love this quote. Let me share it with the audience: "It is naïve to bring together a highly diverse group of people and expect that by calling them a team, they will, in fact, behave as a team. It is ironic indeed to realize that a football team spends 40 hours a week practicing teamwork for the 2 hours on Sunday afternoon when their work really counts. Teams in organizations, though, seldom spend 2 hours per year practicing when their ability to function as a team counts 40 hours a week."

I don't even like football and I love this quote.

Ryan: Exactly, it is naive to bring together a resident, attending, CM, SW and nurse and think that just because we call it a "team" that they will in fact behave like a high functioning team, without any practice or pause.

Gaby: So how do we navigate these assumptions around interdisciplinary collaboration? How do actually build up our teams and practice working within them?

Shreya: No right answer. We are moving more and more to team based care but how do we create space to talk about how best to work with each other, hear those frustrations that come up and navigate them. A recent Q.I project I tried. I took a 5 min pause on the 1st day of an inpatient rotation at the start of multidisciplinary rounds and we actually went around and introduced ourselves and our role.

Gaby: Wait, cool - this is exactly what Drew recommended to alleviate Pain Point #1!

Shreya: Yes after we're on the same page of who was the SW vs the CM their role or which intern was who, we then in a very appreciative, non-judgemental way talk about - What does ideal communication look for everyone and how do we get there?

Ryan: The underlying thing you're doing there, Shreya, is intentionally creating that psychologically safe space.

Shreya: Yeah it was really great to hear feedback on what is actually helpful for the nurse to hear on those rounds or have the CM feel comfortable speaking up more instead of the resident monologue running through patient. But the best part was the next week, we took time to give positive shout outs on things we talked about the past week - [not euphemistic person] it was close to magical to seeing the SW give my borderline burned out intern a shout out in front of everyone for helping out with a difficult dispo situation or the senior resident giving a nurse who went out of her way a shout out and its was eye-opening to see how far people feeling appreciated can go.

Gaby: Dr. Daisy Smith from the ACP also spoke to us about the power of appreciation:

Ryan: And It's just much more fun to come to work when you've developed great relationships with the people you work with. We're all on the same team. We all got into medicine to help patients. Yes we work under less than optimal conditions with less than optimal pressure and pace, but we do need each other to move our patients care forward and our patients need us to truly collaborate in a cohesive way!

Shreya: Absolutely. To summarize what I am taking away from hearing these SW and CM are 5 potential opportunities to better collaborate: #1 is gonna be the foundation of understanding their unique roles and responsibilities in your work setting,

Ryan: #2 knowing the limitations of what they can practically do, #3 lets not shoot the messenger of a less than ideal system that we work and be a little bit more empathic to all the behind the scenes work that we all have do, #4 being mindful of a patient's insurance status particularly for expensive medications and, #5 being mindful how the patient's insurance might impact the disposition(which we will cover in the next episode).

And last but certainly not least (its a bonus point!), the importance of taking the time to appreciate and even celebrate each other's wins, however big or small!

We know all of this is easier said than done, when you might have more days than you'd like where you're being pulled in every direction, but hearing the SW and CM perspectives definitely gave me food for thought and opened my eyes to opportunities to better work with each other

We would love to hear from you how you may be creatively building that psychological safety among the multidisciplinary team members. We would love to hear this episode was helpful for you, and if so how? Tell us if you are inspired to make any changes and continue this conversation with us on twitter or via email. Please share with your colleagues or team members.

If you liked this episode, give it us a rating on itunes or whatever podcast app you use. It certainly helps people find us. Remember you can get CME credit with ACP from this episode. Link will be in the show notes. Thank you to Arra Maklein for audio editing. And as always opinions expressed in this podcast are our own and do not represent the opinions of any affiliated institutions. And thank you! Take care!

References

https://nam.edu/implementing-optimal-team-based-care-to-reduce-clinician-burnout/

Mizrahi, T., & Abramson, J. S. (1985). Sources of strain between physicians and social workers: Implications for social workers in health care settings. Social Work in Health Care, 10(3), 33-51.

Demoratz, M. (2018). The Social Worker Case Manager:"Owning" the Psychosocial Issues. Professional case management, 23(4), 228-230.

American Case Management Association. (2013). Standards of practice & scope of services. Little Rock, AR: American Case Management Association.

Wise, H., Rubin, I., & Beckard, R. (1974). Making health teams work. American Journal of Diseases of Children, 127(4), 537-542.

Song, H., Ryan, M., Tendulkar, S., Fisher, J., Martin, J., Peters, A. S., ... & Singer, S. J. (2017). Team dynamics, clinical work satisfaction, and patient care coordination between primary care providers: a mixed methods study. Health care management review, 42(1), 28-41.

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Case Managers and Social Workers: Interprofessional Education Series | Core IM Podcast

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CME-MOC Get CME-MOC credit with ACP! Time Stamps What are the various roles within a multidisciplinary teams? Understanding limitations of...Read full post

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SNF, SAR, NH, ALF, and More Discharge Options: Interprofessional Education Series | Core IM Podcast

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CME-MOC Get CME-MOC credit with ACP! Time Stamps SAR vs SNF Long term Nursing Home Care Assisted Living Facility Acute...Read full post

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The Curbsiders - An Internal Medicine Podcast

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Geriatrician Josh Uy Schools us on why multimorbidity is like Juggling and Jenga™

Learn how to approach the geriatric patient with multimorbidity and how to parse through and prioritize a mile-long problem list with Dr Josh Uy, master geriatrician at the University of Pennsylvania. We review different approaches to a clinic visit with a patient who takes fifteen daily medications with just as many chief complaints, all in a thirty minute (or less!) appointment time. We discuss what the term "multimorbidity" even means, how to ask about patient preferences and use them to inform the treatment plan, and what the evidence has to say about adjusting treatment goals of common conditions for individual patients. (Spoiler alert: It all depends on the patient, comorbid conditions and goals!)

Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Credits

Producer: Nora Taranto MD

Writer: Nora Taranto MD, Leah Witt MD

Infographic: Leah Witt MD

Cover Art: Nora Taranto MD

Hosts: Stuart Brigham MD; Matthew Watto MD, FACP; Leah Witt MD, Paul Williams MD, FACP

Editor: Matthew Watto MD, FACP; Clair Morgan

Guest: Josh Uy MD

Time Stamps

00:00 Pun, Intro, disclaimer, guest bio

04:30 Guest one-liner; Career advice;

Picks of the Week*: Unbroken (book), Down Dog Yoga (app); Check out Dimash's music on YouTube; Off Your Rocker (TV show); Finishing Well to the Glory of God (book)

12:30 A case of multimorbidity; Where to start?

15:30 How to focus the visit; Lumping and the problem list;

18:20 Dr Uy's framework for multimorbidity

28:08 Questions (scripts) for eliciting patient preferences

30:20 Hypertension; All cause mortality; Number needed to treat; The danger of adding blood pressure medications in the hospital, the Jenga analogy

35:30 How to frame potentially ineffective treatments (e.g. statins for primary prevention of stroke) and align treatments with a patient and family's goals

44:18 Dr Uy runs through common comorbid conditions and time to benefit starting with longevity minded (45:43); Palliative minded approach (47:50)

48:49 Afib, anticoagulation and falls; Cancer screening

54:30 Take Home Points

"a functional goal or a goal of care...is a unifying goal for multiple medical problems...it's a lot like putting your TV in the living room. It lets you know what you should point all of your furniture at".
Josh Uy, MD

1. It's normal to feel overwhelmed when you see the multimorbid patient. Try to prioritize problems and pick a few to focus on per visit.

2. You and the patient get to share the agenda of the visit. Always start by asking "What's most important to you?"

3. In considering whether to start or stop a treatment, first take into account the patient's preferences and goals, for the short and long term. Then, consider the time frame to benefit, the risk (and time frame) of adverse effects, and the number-needed-to-treat for expected benefit.

4. The conversation about stopping preventive screening and medications can be emotionally charged for patients and caregivers.

5. Our evidence base is limited for evaluating treatments in patients with multimorbidity and frailty. That's because older and/or medically complex patients have been excluded from many major trials.

6. Disappoint the right people (listen to the first part of the episode, y'all! There's some profound stuff there).

Infographic - Set the Agenda - The Curbsiders 181 The Multimorbidity Games with Josh Uy MD. By Nora Taranto MD

Lots of different terms that are related: multimorbidity, multiple chronic conditions, multi-complexity. Simply put, it means patients who have multiple issues. The American Geriatrics Society definition suggests that it applies to patients with 3 or more chronic disorders ( JAGS 2012). NICE guidelines broaden it further, to include individuals with 2 or more "long-term health conditions" ( NICE 2016). Even dealing with just two chief complaints can be a challenge when we have 30 minute appointments. The challenge is to streamline things, and to simplify.

A few different guidelines have come out recently about how to think about multimorbidity. This year, the American Geriatrics Society Multiple Chronic Conditions recommended Actions ( JAGS 2019) came out. In 2016, the NICE (National Institute for Health and Care Excellence) guidelines on "Multimorbidity: clinical assessment and management" were published. And while these guidelines are useful and meticulously crafted, they tend to be long, and include relatively broad suggestions about practice. But in all of them, there are common themes that can come in handy to think about in structuring your patient visit.

There are a bunch of different ways to break this down. Per the American Geriatrics Society, the five domains/elements of quality care in complex older patients ( JAGS 2012) are:

1) Patient Preferences

2) Interpretation of evidence base

3) Framing of clinical decisions in the context of risk, patient benefits, burdens, and prognosis

4) Assessment of clinical feasibility in light of treatment options

5) Optimization of treatments

Dr. Uy uses these values to approach the multimorbid patient, but with slight variation.

Set the Agenda (The patient gets a vote, and you get a vote!)

First, make sure that you identify the health issue that is most important to the patient (and that may very well be bringing them in), as well as the issue that is most important to you. Try to focus on these issues during the visit. Let the patient go first. (And often you'll have multiple family members who are stakeholders as well participating in this discussion as well). Try to get everything out on the table, early in the visit. You can even go so far as to state that these will be the issues you talk about, to make sure you and your patient are aligned about what the patient will be able to get out of the visit, and what may have to wait. Acknowledge that not everything will get done today, and try to make the appointment as valuable as possible by asking the patient "What is most important to you? How do you want to spend this time?"

Patient preferences: Ask about them!

This goes hand in hand with the agenda-setting. If you don't know what your patient wants, then the encounter is likely to go far less smoothly. And, especially early on, you may not know what the patient's priorities are in terms of quality of life and goals of care. Knowing the patient's goals in terms of function, health, and happiness is essential in thinking about the multimorbid patient, because it will likely inform how and what you choose to prioritize on a long problem list. There are many ways to get at this, but you need to assess the patient's goals in terms of longevity, function, and quality of life.

A few lovely phrases that Dr. Uy uses to get at this: "Tell me, what does a good day look like to you?" or "What do you look forward to when you get up in the morning?" And, conversely, ask "What does a bad day look like to you?"

Now vs. Later: Is the patient worried about things that will affect them now, or are they worried about their future? And are the benefits and risks of a given treatment likely to affect the patient now or later? For example, when deciding a diabetes glycemic treatment target, it is important to consider the long time-to-benefit for "tight" glycemic control versus the immediate risk (hypoglycemia!) of tight control.

For Each Problem, Consider the Evidence:

Next, synthesize. Ask yourself how treating each problem on their problem list would affect their health in the context of their goals regarding longevity, function, and quality of life.

Time-to-benefit of a given treatment

Potential treatment-related adverse effects (and what the timeline is for these)

Discussion with the patient/caregiver about managing handle complexity of care (i.e. multiple medication administrations or complex disease monitoring)

The yield of the treatment: how likely is it to benefit the patient

A great pearl from Dr. Uy: If someone can't handle complex care, you should cut out low yield treatment. "If someone has food insecurity, and they don't have enough food to eat to begin with, you are not going to tell them about the potential (largely unproven) benefits of organic, expensive asparagus water."

Infographic - Interpret the evidence - The Curbsiders 181 The Multimorbidity Games with Josh Uy MD. By Nora Taranto MD

This involves multiple considerations, for any given disease and potential treatment:

Now about that evidence....

It turns out that the exclusion criteria for many of the large trials kept patients with multimorbidity and frailty out of the trials. So it can be a challenge to interpret the guidelines for common medical conditions (e.g. hypertension) in the multimorbid patient on more than ten medications. But there are a few conditions the treatments for which have very clear mortality benefit: atrial fibrillation (tx: anticoagulation) and hypertension (tx: anti-hypertensives). This proven mortality benefit does not apply so clearly to treating other common chronic conditions such as high cholesterol, diabetes, or diastolic heart failure in the elderly.

Geriatric Conditions, and Numbers Needed to Treat (A few examples)

Briefly, there are not that many conditions for which treatment reduces all-cause mortality (read: hypertension, atrial fibrillation) in the geriatric population. But important to keep in mind that, in the complex older adult, there is not a one-size-fits-all solution. In this discussion, it's important to be clear with patients about what treatments will most likely help them now vs. later, and what treatments will make them feel better vs prevent future disease. And re polypharmacy: Be a little bit more scared to add medications.-Dr. Uy

Hypertension: Treat! But to what goal?

The SPRINT trial identified a number-needed-to-treat of 63, over three years, to reduce all-cause mortality and morbidity (heart failure, stroke, heart attack) by improving blood pressure control with anti-hypertensives ( SPRINT, NEJM 2015) in older adults. This is a relatively low number-needed-to treat, over a relatively short time period, to prevent the composite CV outcome and reduce mortality. Blood pressure control is, as Dr. Uy states, one of the few things we can do in the office that, within a relatively short time frame, can reduce the risk of common causes of death and disability in our population.

Now what about that more intensive blood pressure goal (<120 systolic versus 135-139)? The SPRINT trial excluded folks with frailty, diabetes, prior stroke, or multimorbidity. So, in patients with myriad conditions, it makes less sense to worry about the intensive blood pressure goals. But if you've got a two-problem visit that includes hypertension, maybe treat more aggressively. (And think twice (or more) about intensifying anti-hypertensive treatment on discharge from hospitalization. TLDR: short-term harms, no long term benefits ( Anderson; JAMA IM 2019)).

Hyperlipidemia: Maybe?

There's significant debate about the use of statins in the multimorbid older adult. How do we think about treating hyperlipidemia?

This is where the now vs. later framework can be helpful, because while statins can help to prevent future cardiovascular events, they don't improve immediate quality of life and contribute to pill burden. While evidence does suggest that in the geriatric population statins do reduce the risk of non-fatal heart attacks, they do not reduce the risk of stroke or overall total mortality ( PROSPER; Lancet, 2002). Time-frame to efficacy for statins is 6 months to several years, depending on the trial-with a number needed to treat of 48 over 3 years to achieve a significant reduction in risk of non-fatal MI. And they can add to the pill burden of an already overburdened patient, with some risk of side effects. So, if you're seeing a robust and healthy individual with high cardiovascular risk, statins most likely make sense. But, in the patient with multimorbidity and limited life expectancy, who is already taking myriad other medications, consider very carefully if this treatment makes sense.

Atrial fibrillation?

Anticoagulation to prevent strokes and overall mortality is one of a few treatments with a low NNT and a short time frame to benefit (around one year). Among those with a CHADS2 score of 2 ( CHF, HTN, Age > 75, DM, stroke/tia previously), there is a NNT of 38 over one year. With a CHADS2 score of 3, there's a NNT of 26 over the same time frame to prevent stroke. ( Annals IM 2007)

But the decision to start anticoagulation in geriatrics is made more complex for patients with frequent falls. And even though there is research looking at the number of falls needed to have a clinically significant event, that's population data, not data that applies to the individual (E.g. as the patient, you need fall only once, and hit your head, to have a real problem. So, as always, it's a balance of pros and cons for the specific patient. Will the patient be able to accept and tolerate the risk of potential complications? Some patients may not accept treatments with small therapeutic windows (like anticoagulation).

(And a quick primer on Diabetes, even though we didn't talk about the NNTs for it in the episode...)

Diabetes? Target A1c goals?

Well, there are no trials of glucose control and long-term outcomes in the elderly (the closest we get is the ACCORD trial, in which the average age of participants was 62). Dr. Watto points out that tight glycemic control does not conclusively prevent important clinical endpoints (e.g. microvascular disease (blindness, renal failure, symptomatic neuropathy) or macrovascular endpoints (e.g. stroke, all-cause mortality, fatal MI) with the exception of nonfatal MI ( Rodriguez-Gutierrez, 2016). The time to benefit for tight control with conventional therapies (metformin, insulin, sulfonylureas) is on the order of 10 years -see episode #96: Diabetes: A1C targets & ACP guidelines controversy. Notably, there are real downsides to tight control (risk of lows and syncope or falls). So, in general, in the multimorbid geriatric population, the goal is to prevent lows, even if that requires increased glycemic targets. Dr Uy cites an A1C goal of 8-9% for older patients with medical complexity at high risk for hypoglycemia.

This is where we come back to the "now vs. later" framework, yet again. If the patient's goals are "now" focused, then, simply put, we want to avoid the highs and the lows-avoid the symptomatic hypoglycemia (and falls) and the symptomatic hyperglycemia (polyuria and polydipsia), consider an A1c >7 and pick the safest medications to get into this window.

Table 1. Number-Needed-to-Treat and Time-to-Benefit for common geriatric conditions. Note: These are rough numbers supplied by Dr. Uy to illustrate the differing time to benefit and number needed to treat (NNT) amongst various treatment interventions.

When (and how) to stop treatments or screenings:

The discussion about when to stop preventive medicines (or preventive screenings) can be tough (or not! Patient may be waiting for you to bring this up!).

Framing the conversation is important, de-emphasizing the medical model that lots of care is always good care. This is a conversation that has strong emotional valence for patients and their families, even if it doesn't seem that way on the surface.

It is important to clarify what treatments will address symptoms and what treatments are preventive.

If a patient has longevity-focused goals with an eye on preventive medicine, a lipid-lowering medication may be indicated. But patients can also choose to focus on the "now" goals-the ones that will improve symptoms from a disease now instead of preventing development of disease later.

Time Frame and Goals of Care: It's ok to choose Now.

Make sure your patients and their caregivers know that choosing to focus on the "now" goals, and treating the conditions that will make someone feel better, and setting aside the preventive "later" goals, does not mean that they are neglecting their loved one's health, and it also does not mean that the patient cannot aspire to things for the future. It's all about reframing decisions to stop treatment (or continue) within the setting of a patient's goals, whatever they may be.
"We've Tried""I Wish" statements: "I wish that the evidence showed that Medicine X would prolong life and reduce symptoms, but it doesn't." : "We've tried our best to prevent death with cholesterol medications, but it's been disappointing that it hasn't worked."
Phrases to use in explaining what has benefit and what doesn't:

How to talk about cessation of cancer prevention screenings:

Infographic - Reframe Clinical Decisions - The Curbsiders 181 The Multimorbidity Games with Josh Uy MD. By Nora Taranto MD

When a patient's age or clinical context makes the potential harms of continued cancer screenings greater than the benefits, clinicians must discuss stopping these screenings. Discuss why the patient may derive less benefit. For example, someone with limited life expectancy will not benefit from early cancer detection and has a higher risk of harm from screening. e.g. diagnosis related harms: invasive procedures, anxiety; or treatment related harms: radiation, chemotherapy or surgery. It is critical to convey that you deeply care if your patient gets cancer, but also deeply care about sparing them of tests with higher potential for harm and limited benefit.

A great tool to use in these discussions:

E-Prognosis has substantial, easy to interpret data about the risks and benefits (and time to benefit) of cancer screening.

1. Think about the goals of care and the consequences of your treatments. Does treating this achieve a longevity benefit, functional benefit, or a quality of life benefit? Will it benefit the patient NOW or later.

2. Listen to the patient so you can learn about their goals of care. Then align your own treatment goals with a few things that the patient actually cares about.

3. The goal of geriatrics is to simplify complexity. Simplicity needs to be a goal in our care of patients.

We can use different unifying themes to frame problem lists, based on patient goals and preferences.
Listeners will develop an approach to managing older adults with multimorbidity in primary care
Table 2. How to think about the problem list. Focus on one overall goal, whether Longevity, Palliative/symptom management, or Simplicity-Minded goal setting. By Josh Uy MD from The Curbsiders Multimorbidity Games

Take Home Points:

1. Define multimorbidity and its implications for triaging multiple chief complaints and chronic conditions

2. Recognize the time frame to benefit of treatments for several chronic conditions

3. Learn to ask patients about health care values and goals of care in order to optimize shared decision-making

4. Identify the barriers to treating multimorbidity and strategize approaches for optimal primary care delivery for patients with multimorbidity

1. Book recommendations: Unbroken

2. Leah's pick of the week: The Down Dog Yoga App. Get that wellness on!

3. Stuart's pick of the week: Dimash performs SOS

4. A great prognostic tool: https://eprognosis.ucsf.edu/

5. Betty White's Off Their Rockers (TV show!)

6. Another book recommendation: Finishing Well to the Glory of God

Goal

Learning objectives

After listening to this episode listeners will...

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on my Amazon.com links and buy something we earn a (very) small commission, yet you don't pay any extra.

Disclosures

Dr Uy reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Citation

Uy J, Taranto N, Witt LJ, Williams PN, Brigham SK, Watto MF. "#181 The Multimorbidity Games". The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list November 4, 2019.

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#181 The Multimorbidity Games with Josh Uy MD - The Curbsiders

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Geriatrician Josh Uy Schools us on why multimorbidity is like Juggling and Jenga™ Learn how to approach the geriatric patient with multimorbidity and how to parse through and prioritize a mile-long problem list with Dr Josh Uy, master geriatrician at the University of Pennsylvania.

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Louise Aronson on how health care fails older adults

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Atul Gawande on aging and geriatrics

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Using the 4Ms to conduct an Age-Friendly Geriatric Assessment

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5Ms CoreIM podcast

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Time Stamps

Show Notes
Pearl 1: Approach to the initial office visit

First understand what matters most to the patient.

What do they value?

What does a good day look like?

Functional status is the ability to perform daily activities to meet basic life needs (ADLs).

There are basic and instrumental ADLs.
Assess baseline function, which can be used to later track disease onset and progression.

Think of toenail length as the hemoglobin A1c of functional independence.
If toenails are too long (>2mm increase in length per month) consider broad differential:

Loss of executive function

Decreased flexibility/muscle strength

Caregiver burnout, social isolation

Poor vision

Pearl 2: "Moves" for mobility

Falls are the leading cause of injury-related death in adults over 65 years old

Think of gait speed as a vital sign and important predictor for fall risk.

Stratify fall risk by assessing mobility.

Slowed gait speed increases risk

Timed get up and go test (TUG): Time how long it takes for a patient to stand up from chair without pushing off with arms, walk to a line on the floor (10 feet away), turn, walk back to the chair and sit down.
If the patient takes longer than 12 seconds to complete TUG they're at risk for falling.

Chair stand: Have the patient cross arms over chest and stand up from chair. If they can't stand up without using hands for support, they're at higher fall risk.

Interventions to decrease fall risk are most effective when combined together and include physical and occupational therapy, home modifications (safe furniture, remove environmental hazards), use of appropriate assistive devices for ambulation and medication review.

Pearl 3: Cognitive evaluation

Cognitive decline is a common concern in the primary care setting

Cognitive Screening Tests

The Mini-Cog is a quick screening test which assesses the ability to recall three words and draw a clock. If unable to complete successfully, need a more elaborate test

Montreal Cognitive Assessment (MOCA): Scored out of 30 points and evaluates naming, memory, attention, language, delayed recall, among other domains.

Delirium is an acute change in mental status from baseline.

Start with quick orientation and attention questions. Ask the patient to name days of the week or months of the year backwards

If cognitive tests show impairment, rule out reversible causes like hearing loss, medications, hypoglycemia, nutritional deficits, thyroid disorders, or electrolyte abnormalities.

Pearl 4: How to manage medications

Ask patients to bring all their meds to the initial visit, including over the counter medications. Figure out what they're actually taking. May need collateral from pharmacy, family members or home health aid.

Match the medications to the problem list. Consider de-prescribing.

Are there extra medications that don't match anything on the problem list?

Are there medications with side effects that are contributing to the problem list?

Is there a less frequent alternative? Example: switching metoprolol tartrate to metoprolol succinate

Are the medications consistent with the person's goals of care and life expectancy?

Underprescribing is a problem too

Osteoporosis often goes undertreated. Use bisphosphonates.

Pain control with tylenol can significantly improve quality of life

Oral anticoagulants require weighing stroke risk versus fall risk

Throwback Pearl: PPIs

Divide adverse effects of PPIs into two big buckets: Malabsorption (Vitamin B12 deficiency, Hypomagnesemia and Osteoporosis) AND Infection (C difficile colitis).

Strategies to take patients off PPIs include short, finite prescriptions to begin with, managing expectations and using rescue meds.

Transcript

S: This is Dr. Shreya Trivedi, and this is Dr. Minali Nigam, a neurology resident . This is the CORE IM 5 pearls podcast bringing you high-yield evidence-based pearls.

M: Today we're going to dive into pearls on the geriatric assessment.
So when I'm meeting an older adult patient, whether it's in the clinic or in the hospital, I always look at the feet. Toenails are like the A1C of functional independence. when you look at, at the feet and you see this long toenail sign, you really get a sense how someone's been managing over the last few months and whether they're able to do this self care task or get help for themselves, if they can no longer do it.
M: That's Dr. Andrea Schwartz, a geriatrician at the Boston VA . [pause] She gave me that advice to look at the toenails when we were on rounds. We were seeing this 90-year-old whose mobility seemed fine so we were asking if physical therapy really needed to see him.

S: So Minali, what did his toenails look like?

M: Sure enough his toenails were several centimeters in length and clearly hadn't been clipped in months so we got PT onboard. Thinking about that toenail gem a bit more, it got me thinking about what are the other high-yield pearls when meeting someone for the first time, especially our geriatric patients.

S: So let's get into those pearls we'll be covering in the episode. Test yourself by pausing after each of the 5 questions. Remember, the more you test yourself the deeper your learning gains.

M: Pearl 1: Approach to the initial office visit

S: What high-yield questions should we be asking when we first meet an older patient?

M: Pearl 2: "Moves" for mobility

S: How do you test someone's mobility and assess their fall risk?

M: Pearl 3: Cognitive Evaluation

S: What are the main differences to know about the different cognitive assessments ?

M: Pearl 4: Managing Medications

S: What is your approach to deprescribing medications? And what are some of the meds that we underprescribe?

M: Pearl 5: Throwback Pearl
Pearl 1: Approach to the initial office visit: what questions should we ask?
S: Okay Minali, I remember so many times being in clinic and chart reviewing for an older patient I was about to meet. It was easy feeling overwhelmed because oftentimes I can tell from the chart that they had a ton of things going on and I wasn't actually sure where to start.

M: So what does that goal setting conversation look like?

S: So what I have learned from my geri colleagues over time is that opening with something like, "Mr. Jones, you have gone through so much, I'm curious after all of this, what matters the most to you?" or "could you tell me what a good day for you look like?" can be a really good starting point

M: You know, I relate to this so much because I can't tell you how many times in resident clinic I've thought the patient is coming in for one thing only to find out they want to talk about something completely different
PERRY: I think about what are the next periods of time that I'm going to meet this person? What do I absolutely have to do now and what can wait?
S: That's Dr. Laura Perry, primary care doctor and geriatrician at the San Francisco VA's Community Living Center.

M: Ok so once we get a sense of the patient's priorities, the geriatricians we spoke with said the next step is to gauge the patient's functional status
It actually takes a lot of flexibility and you can easily think of things that would get in the way of being able to reach whether it's spinal stenosis or, um, vision impairment or dexterity of your hands.
M: The one other thing i'm gonna add the ddx of long toenails is caregiver burnout - I've def seen that!
S: i would def fall into that category, seeing i haven't cut my toenails since my son was born!
M: In addition to the toenails, shreya what else should we think of when assessing someone's functional status?

S: Classically we think about digging into activities of daily living. These are things that I help my 1 year old with -things like bathing, eating, feeding, walking, toileting. Then asking also about their instrumental activities of daily living

S: Amen to those scooter grocery carts! But you know when we're asking our patient's functional status it can sometimes be a little awkward or even make our patients feel a little self-conscious

M: Alright so to recap pearl 1: Some take-aways on best practices for an initial office visit are to to ask explicitly what matters most to the patient, figure out what they can do and something i never considered was looking at the patient's toenails - As Dr. Schwartz says the HgA1c for functional independence
Pearl 2: Moves for Mobility - what tests can we do to decrease fall risk?
S: Ok so we get a good history on how much this patient can do and in what care setting, but then i see a lot of people gloss over seeing how they move objectively on the physical exam

S: Yep the support they need, especially to prevent a fall. Ok so whats the best way to go about assessing functional status objectively?

S: Ouch i feel like that was a little burn. But its true, the best functional test is just one you can actually incorporate into your practice. Noted.

M: I can say even for neurologists, sometimes we end up not really examining how a patient walks because it takes time and effort

S: Wow even coming from a neurologist I really appreciate that realness. Maybe it would be good for us to go over what the different objective assessments are so we can tailor which one might be the best to incorporate for a particular patient.

M: Probably the most well known test that we all learn in med school, is the Timed Get Up & Go. As a refresher, here's how the test works: the patient sits in the back of a chair and is asked to walk to a line about 10 feet away on the floor. You time the patient and say "go," at which point the patient stands up from the chair without using their hands for assistance, walks to the line, turns, walks back to the chair and sits down again.
And then sit back down. Some patients will need to use the arms of the chair to assist them. And that's helpful information as well... SCHWARTZ: I love the chair stand because even one chair stand gives you a lot of information. If a patient can't do even one chair stand they're at high risk for falls. And often those patients are really going to benefit from involvement of physical therapy and potentially occupational therapy.
S: Right, so If that patient takes more than 12 seconds from start to finish, the patient is at an increased risk of falls. And honestly if you don't have 10 feet worth of space or 10 ft measured out, Dr. Schwartz gave us an abbreviated version to assess mobility

M: The caveat here is that we can't just use these mobility tests as of falls - there is so much more that goes into fall risk - the patients comorbidities and even how safe their home is
SCHWARTZ: In his case, he had a painful Bunion. He needed to see podiatry. He was due for a new pair of shoes so that he could be in a steady, comfortable pair of shoes. And he benefited from the involvement of physical therapy that taught him further exercises that he could do at home as well as helped install, uh, helped him figure out where to install, grab bars and a raised toilet seat. like in many, uh, geriatric cases, it was multifactorial. He hadn't been leaving the house as much. Uh, his gym had closed. Uh, the partner he used to go walking with, uh, was at home caring for a loved one. And so, uh, he had had a major decline in his level of activity and he was stiffer. We were able to encourage him to do those chair stands and practice them at home when he was watching TV. And then we were able to do a little more investigation and try to figure out if anything else was wrong.
S: Even just watching the patient walk and eyeball how fast or slow they're going can give us a clue on subtle changes. And thats what happened with Dr. Swartz - she hadn't seen a patient in over a year because of Covid-19 and from gait speed alone she could tell he had a major decline.

M: Who would've thought that slow gait speed would crack the case of the bunion?

S: And probably helped prevent a future fall. And we will link a CDC website called in the show notes, which stands for Stopping Elderly Accidents, Death & Injuries. It lays out interventions and the research behind doing things like balance exercises , using safe furniture and reducing polypharmacy , which we'll dive more into later.
Pearl 3: Cognitive Evaluation - what's the work-up?
M: Great so speaking of being STEADI, let's wrap up this pearl on moves for mobility.

S: Let's recap. Remember that gait speed is the 5th vital sign, especially for older patients. So yes, if you have 10 feet of space use the timed get up and go or just watch the patient walk. And the simple chair stand can also be helpful in gauging balance and coordination.
SCHWARTZ: So many times I've been surprised by how someone could be very facile and completely socially intact and yet do very poorly on the mini-cog.
M: Here's where the neurology nerd in me comes out - thinking about thinking. Going back to Pearl 1 - for many patients and families what's most important to them is being able to think clearly.
SCHWARTZ: I like this tool because it's just a three word recall. The validated words I usually use are banana sunrise chair. And you have the patient repeat them to you two times to make sure that they've been able to register the words and they can hear them. And then you ask the patient to draw the face of a clock, put in all the numbers and set the time is 10 past 11 and you watch them while they draw the clock. And then you end with the three word recall and see if they can recall the banana sunrise chair. SCHWARTZ: So the Mini Cog takes about a minute, which is very quick, but it gives you an objective finding. First of all, if they can't do the recal test, it tells you that you've got to give them written instructions from your patient encounter. If they got ⅓ recall, they're likely to only remember about 1 out of 3 words you said. SCHWARTZ: And, um, in Dr. Soo Borson's work and others who validated the mini-cog, um, it's just a brief screening tool, so you can't diagnose anything off of it, but it tells you that you need to do a longer test.
S: So it's good to have some tools to assess that objectively than just going by our gestalt

M: Just as a quick refresher, how is the mini-cog properly administered and how do you score it
SCHWARTZ: So some of the things to consider when you get an abnormal cognitive screening test, we've already mentioned hearing that's an often overlooked one, but easily modifiable. Uh, another thing to consider is medication effects in particular medications that may impair cognition, such as sleep AIDS, opioids, or medications that indirectly may impair cognition. For example, through hypoglycemia, I've definitely seen patients whose diabetes is too tightly controlled given their age and co-morbidities and are having frequent episodes of hypoglycemia that can manifest as confusion and impaired cognition.
S: The mini cog is scored out of 5 points - 1 point for each correct word & 2 points for normal clock draw. Unfortunately, they get 0 points if the clock is drawn incorrectly or did it wrong. Anything less 5 is a reason for us to get a bit more curious

M: Ok what if they miss a word or can't draw 10 past 11 - What are the next steps?
SCHWARTZ: So A&O times three on a hospitalized patient, doesn't give you enough information to determine if they're delirious. You need to add a test of attention like months of the year backwards or days of the week backwards, which is a little easier. And the UB2, the ultra brief delirium screen is just orientation to day and months of the year backwards. And it's a very sensitive test for delirium. You wanna pick up acute brain failure before the patient is agitated and pulling out their lines and quickly intervene to figure out why they're delirious.
M: Right, so that's when we can think about a longer test like the Montreal Cognitive Assessment, better known as the MoCa. But I think twice on who I administer the MOCA to in practice.

S: A very important caveat indeed. But say you have a college educated, white person and the patient gets a score <26 out of 30 suggesting cognitive impairment, what are the things we should be considering?

S: Practically speaking I've never had any of those be the culprit for me. But, what I have been amazed at how much things like depression was playing into a patient's cognition and side effects of meds.

M: That's a great point. This all good stuff in the outpatient setting but these tests can't really give you an accurate idea when someone's acutely ill. So, if we're in the inpatient setting, we need to think about if the patient is in a state of delirium.

S: The teaching point here is that the hallmark of delirium includes 1) disorientation and 2) inattention, but i see so many just asking if the patient ONLY if they are orientation to name, place and time
Pearl 4: Managing Medications - How should we prescribe and de-prescribe medications?
S: You know since this interview I've actually started to ask my patients to tell me the days of the week backwards and its made me feel a lot more confident about something being off or saying the abx are actually working and their mental status is clearing up

M: I've started asking it too but make it more challenging I start with a day in the middle of the week like Wednesday and then ask them to go backwards.

S: Yep I guess by the time we get the neurologist involved, you really wanna be sure of their cognitive status and challenge them.

M: Happy for the consult! Alright so to wrap up Pearl 3, use the mini cog as a brief screening tool for cognitive impairment. You can do a longer test like the MoCA but in the right patient population, keeping in mind education level and race. If impaired, get a work-up for reversible causes, most importantly the overlooked ones like hearing, depression or a medication side effect.

S: And if you are in the inpatient setting testing for cognition and thinking about delirium, we really want to assess that attention part of it, which is the hallmark for delirium. Like testing for the days of the week backwards or the months backwards, can be helpful.

S: You know one of the big tenets with taking care of an older patient is deprescribing. And yes, in an ideal world this is probably one of the most important things we can do for our patients. But this is so hard to operationalize sometimes. M: Agreed So we asked our geriatricians how they do it
PERRY Like get people on their bisphosphonates, get your chronic pain patients on like a decent schedule dose of Tylenol. It can help like decrease how much opioid and other stuff that they need. Use the medications that don't have a lot of risks, but like make a big difference.
S: I think we've all been there, burnt way too often trusting the med list on paper and there's a big discrepancy with what the patient actually takes and how often. And it makes sense to really dig into this - until we actually learn what a patient actually takes, we can't deprescribe anything

I so wish our EMR systems carried forward the initial indication- or even with the med list, grouped all the HTN ones or the DM ones would make it easier for our overburdened clinical brains to see gosh, this person is on are 4 HTN meds and tamsulosin now or jeez, they're 3 sedative medications and just makes the work up and thinking why this person is unsteady on their feet a little bit easier.

M: I honestly think geriatricians are the true Sherlock Holmes of medicine. They really dig into all the clues to crack what's the best medication regimen for each person.

M: Another low hanging fruit are vitamins and supplements. So unless someone truly has a vitamin deficiency, most of the time you can knock the supplements off.
Pearl 5: Throwback Pearl - PPIs
S: Yep delete, delete, delete. Alright Minali, we've talked a good deal about the approach to deprescribing but there are other blindspots with meds. Actually thinking about things we underprescribe.

S: Ouch! I will think about that burn everytime I go to prescribe a lung CT in a older patient who smokes and not a DEXA

S: No I agree. I think about that a lot when it comes to the risk/benefit conversation. There's that shows that patients in their 80s do benefit from being on a blood thinner to reduce their stroke risk, which as you said can be pretty devastating.

M: Alright glad to know I have some back up here!

S: Maybe the last point to take away is if you do change around the medications, think about who you need to loop in. Especially because the reality is we have such a fragmented healthcare system

M: [much appreciated!] To recap the approach on deprescribing and underprescribing, start with writing down the problem list and matching medications to each problem. That's something I at least try to do mentally for each patient. Peel off the meds that are leftover or have blatant adverse effects. Quick wins are to treat osteoporosis and use tylenol when in pain. And not forgetting to weigh stroke versus bleeding risk for DOACs.

M: I remember that episode. There were two big buckets of harms of PPIs: malabsorption problems and infection.

S: Nice memory. With the malabsorption bucket, people who are on PPIs for a long time we think about Vitamin B12 deficiency, hypomagnesemia and osteoporosis - huge problem for patients who have high fall risk

S: Maybe before we even get to desprecribing... one of the big take aways is thinking about best practices when we actually prescribe. So if someone is having symptoms, I know only give a short duration - 2 to 3 weeks of PPI is enough. Also educating them about lifestyle changes with foods and things like weight loss.

M: And when you do deprescribe and their symptoms come back, we can use rescue meds instead. The simple stuff like aluminum hydroxide aka Maalox can neutralize stomach acid because it's a base.

S: Right and i also love reaching for the H2 blockers, the famotidine , the ranitidine and i get the patients all psyched up because i tell them its a different mechanism and they get all excited about it

M: You all unlocked so many good strategies during the episode! It's all coming back to me!

S: Same here. It's so humbling how much you forget and need to re-remember. And that is wrap for today! If you found this episode helpful, please share with your team and colleagues and give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us!

S: Alright take care!

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5 Pearls on The Geriatric Assessment | Core IM Podcast

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The Curbsiders - An Internal Medicine Podcast

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Audio

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Transcript available via YouTube

Become a mini geriatrician in our new Geriatrics series!

Geriatricize your knowledge of caring for older adults with unintentional weight loss! You'll round out your history taking and weight gain plan by harnessing the age-friendly "5Ms". We're joined by Dr. Eva Szymanski (@eva_szy), expert geriatrician at Penn Medicine.
Claim CME for this episode at curbsiders.vcuhealth.org

Intro

Rapid fire questions

Case

Defining Unintentional Weight Loss

Applying the Geriatric 5Ms Framework

Diagnostic Work-Up

Addressing Ageism in Medical Decisions

Defining Geriatric Syndromes

Weight Loss Treatments

Outro

!

1. Use the Geriatrics 5Ms to manage unintentional weight loss (and other chronic diseases/geriatric syndromes).

2. The Geriatrics 5Ms are Multicomplexity, Mind, Mobility, Medications, and what Matters Most.

3. Dealing with uncertainty and complexity in geriatric syndromes is challenging- know that you are not alone and this is important work!

Show Segments

Unintentional Weight Loss Pearls

Definitions

Unintentional Weight Loss

>5% weight loss (unintentionally) in 6-12 months (in normal aging people might lose 0.2-0.4 lbs per year).

Cachexia

Loss of skeletal muscle due to chronic underlying disease (eg COPD, cancer).

Sarcopenia

Loss of muscle mass and strength.

Failure to Thrive/Frailty

Global syndrome of decline in which physical frailty is present (sarcopenia and unintentional weight loss are often present), and there is impairment in ADLs and/or neuropsychiatric function (eg dementia or depression).

Geriatric Syndromes

Multifactorial clinical conditions that are common in older adults- these can't be explained by an impairment in just one organ system. Other examples: recurrent falls, delirium, urinary incontinence. Apply the 5Ms to eval and treat (see below)!

The Geriatric 5Ms

The Geriatric 5Ms are a great way to approach any condition in older adults ( Health in Aging Tip Sheet, Holliday et al 2022)! (Note: don't get confused, some sources like the IHI/John A. Hartford Foundation call this the "4Ms" which doesn't include multicomplexity). Check out how Leah Witt, MD and Amber Lanae Martirosov, PharmD applied them to the care of COPD (#408 COPD in Older Adults).

Multimorbidity/Multicomplexity

Consider comorbidities and organic causes of weight loss. For example, do they have advancing or severe COPD or heart failure? Do they have an undiagnosed new disease like cancer or a malabsorptive condition?

Make sure to review neglected symptoms that can affect eating such as visual deficits, smell or taste impairment, and dental issues.

Mind/mentation

Focus on mood symptoms/depression and cognitive impairment/dementia. Depression may reduce interest in eating. Dementia can cause dysphagia, behavioral issues with eating like food pocketing, wandering (increasing energy expenditure), and impaired ability to purchase or prepare food. Mild/moderate cognitive impairment can also contribute to weight loss, particularly if they have a neuropsychiatric symptom like apathy or paranoia (eg the person worries the food is poisoned).

Mobility

Consider activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs: are they able to feed themselves? IADLs: are they able to shop and/or prepare food (or arrange for shopping and food preparation independently)? If there are deficits, do they have adequate caregiving or social support? What is their physical function and activity level- are they more sedentary and losing muscle mass?

Medications

Go through the medications (including over the counter meds) with a fine-toothed comb! Medications can cause impairments in taste, appetite, dry mouth, nausea, etc- all of which can contribute to weight loss ( Gaddey and Holder 2021). Examples of meds to look out for include antibiotics, propranolol and allopurinol (which can cause altered taste or smell), anticholinergics and antihistamines (which can cause dry mouth), and metformin, anticonvulsants, and SSRIs (which can cause anorexia). Also explore substance use that could affect appetite (eg alcohol or tobacco).

What Matters

Learn about the patient's day to day life- what brings them joy and value in their life? Are they socially isolated? Are there financial or physical barriers to purchasing food?

Unintentional Work Loss Work-up

Guide your work-up by the 5Ms, history, and physical exam.

Labs

Start with the basics: CBC (looking for anemia that might signal an occult GI malignancy or bone marrow issue), complete metabolic panel (with particular attention to liver and renal function as well as glucose), TSH (to assess thyroid function) and vitamin B12. If they haven't been screened for HIV or HCV this should be done. Consider if A1c, ferritin, or ESR/CRP would help you, but do not order in every situation. Beware of the hail mary prostate specific antigen PSA- this is not very useful in this context.

Imaging

Some sources suggest starting with a chest x-ray or abdominal ultrasound depending on symptoms ( Gaddey and Holder 2021). Dr. Szymanski suggests doing a chart review to see if they have had recent imaging that helps to rule out conditions/need for additional imaging, but she typically pursues cross-sectional imaging (eg CT chest and/or abd/pelvis) if she decides imaging is needed (expert opinion). Whole body CT scanning for unintentional weight loss has been shown to have a diagnostic yield of 33.5% for organic etiologies ( Goh et al. 2018).

Cancer evaluation?

Making sure a patient is "up to date" with cancer screenings isn't totally appropriate in an unintentional weight loss work-up, because at this point the tests are diagnostic, not for screening (since the patient is symptomatic). Carefully chart review historic data which may uncover colonic polyps or lung nodules that were never followed up on and could guide next steps.

Beware of ageism!

Ageism can impact the health of older adults, and is compounded by structural racism ( Sun et al 2023). This can contribute to disease underdiagnosis (eg being dismissive because someone is a certain age) AND overdiagnosis (eg being overly aggressive in diagnostics in a person who is frail and chronically ill, and does not wish for aggressive interventions). Age is just a number- it is important to assess physiologic age and fitness and use that information in concert with a patient's goals and values to drive evaluation and treatment.

Treating Unintentional Weight Loss

Counseling the patient and caregiver

When unintentional weight loss is present, patients and caregivers are often worried about malignancy. They can be reassured that a negative initial workup is usually reassuring against malignancy (and non-malignant organic causes). Watchful waiting is appropriate in this situation (with an agile response/change in management if things get worse) ( Bosch et al. 2017). Explain the multifactorial nature of unintentional weight loss, the intended evaluation (guided by "What Matters") and what the future might hold.

Patient/caregiver resources are so valuable- the Alzheimer's Association has advice for people with cognitive impairment/dementia as does the Family Caregiver Alliance.

Medications

Treat underlying causes such as depression, with appropriate medications. Mirtazipine can help stimulate appetite and cause weight gain in those who have depression, but there is little evidence that it should be prescribed outside of depression management.

What about appetite stimulants (eg megestrol acetate and dronabinol)? It is an American Geriatrics Society Choosing Wisely recommendation to avoid using these in older adults, because of rampant side effects ( Choosing Wisely, Health in Aging resource, Garcia et al 2013).

High-calorie supplements and dietary recommendations

The American Geriatrics Society also recommends against high-calorie supplements ( Choosing Wisely, Health in Aging resource), but Dr. Szymanski suggests that these may have a role in select patients (expert opinion). They have been shown to help people to gain weight but it isn't clear if this translates to real outcomes like mortality. It is important to stress to patients that eating "real food" is best, and if supplements are suppressing appetite at mealtime, that is counter productive. Use supplements in between meals. Supplements can also be very expensive- note Carnation Instant Breakfast is cheaper than Boost or Ensure (courtesy of Dr. Josh Uy's dot phrase!) ( Milne et al 2009).

Liberalize the diet completely- add oil, butter, peanut butter, etc to add extra calories where they can. Undo the messages they have received their whole lives to "watch their diet"- she suggests telling them "if you feel like ice cream, eat the ice cream".

You can also encourage patients to play around with food texture, spice/taste, temperature and smell.

Social recommendations

Social connection and social eating is an important recommendation. Explore if the patient needs help with feeding, affording food, physically obtaining groceries and/or making meals, and recommend appropriate social programs/caregiving resources.

What about a feeding tube?

Anxiety and worry over weight loss is often an emotionally charged discussion that includes uncertainty, grieving, etc. Enteral feeds in advanced-staged dementia is not recommended and can cause harms (eg hospitalizations, bed sores) and does not improve mortality. It is important to provide alternatives to a feeding tube instead of saying there is nothing we can do (eg we are going to do careful 1:1 hand-feeding) ( Choosing Wisely, Health in Aging resource, Finucane et al 1999, Palecek et al 2010).

Steal a dot phrase!
1. Taste-Salty, sweet, bitter, sour, spicy 2. Temperature-Hot or cold 3. Texture-Crunchy, soft, chewy, liquid 4. Smell (for taste issues) Make sure your mouth is clean to improve taste Make sure your mouth is moist Eat with others Puree the foods to make chewing easier To increase calories 1. No restriction on diet: No limits on salt, sugar, fat, or carb restriction. Eat anything you want: Bacon, sausage, bread, ice cream, candy, cookies, cheese etc. 2. Increase the calories in your food by adding: Heavy cream, cheese, sugar, oil, avocado, full fat yogurt 3. Buy Carnation Instant Breakfast instead of Boost or Ensure because it is cheaper. Drink them between meals, not with meals.
Courtesy of Dr. Josh Uy, import this into your EMR for your patient instructions:

1. Geriatric 5Ms pocket card

2. GeriKit app - a resource for comprehensive geriatric assessments which is related to 5Ms

3. Alzheimer's Association Food & Eating

4. American Geriatrics Society work at the intersection of structural racism & ageism

To stimulate your appetite try changing the variety in your food. Specifically change the
Listeners will develop a framework to evaluate and treat unintentional weight loss in older adults.
Links

Goal

1. Define unintentional weight loss as a geriatric syndrome, and differentiate it from related concepts of anorexia, sarcopenia, cachexia, and failure to thrive.

2. Use the Geriatric 5Ms framework as a tool to develop an unintentional weight loss differential diagnosis list and create individualized management plans.

3. Review the evaluation of unintentional weight loss including history, examination, and laboratory testing.

4. Develop multi-modal treatment strategies that address the multifactorial processes driving unintentional weight loss as a geriatric syndrome.

Learning objectives

After listening to this episode listeners will...

Disclosures

Dr. Szymanski reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

The production of this episode was supported by the Penn Geriatrics AGE-SMART Geriatric Workforce Enhancement Grant. This podcast content is solely the responsibility of the authors and does not necessarily represent the official views of the Health Resources and Services Administration or the U.S. Department of Health and Human Services.

Citation

Witt LJ, Miller R, Szymanski E, Williams PN, Watto MF. "#467 Unintentional Weight Loss". The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date Jan 20, 2025.

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#467 Unintentional Weight Loss with Dr. Eva Szymanski - The Curbsiders

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Transcript available via YouTube Become a mini geriatrician in our new Geriatrics series! Geriatricize your knowledge of caring for older adults with unintentional weight loss! You'll round out your history taking and weight gain plan by harnessing the age-friendly "5Ms". We're joined by Dr. Eva Szymanski (@eva_szy), expert geriatrician at Penn Medicine.

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All Fast Facts All Quizzes

Geriatric Fast Facts are accessible, concise, and clinically actionable 1-2 page reports on Geriatric topics applicable across medical specialties. Fast Facts are interdisciplinary, spanning the progression of medical education.

Recent Fast Facts

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All Fast Facts All Quizzes Geriatric Fast Facts are accessible, concise, and clinically actionable 1-2 page reports on Geriatric topics applicable across medical specialties. Fast Facts are interdisciplinary, spanning the progression of medical education. Recent Fast Facts

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A “living will” supplement for various stages of dementia

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Tools to help patients identify what matters most in their healthcare

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Patient Priorities Care is an age-friendly approach to health care that champions what matters most: your health priorities.

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Resource: Mini-cog for Dementia Screening

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Resource: Mini-cog for Dementia Screening

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Quick dementia screening test. Recent cochrane review describes sensitivity 0.76 and specificity 0.73 based on one study with low bias in its methodology.

Reference: Seitz DP, Chan CC, Newton HT, Gill SS, Herrmann N, Smailagic N, Nikolaou V, Fage BA. Mini-Cog for the detection of dementia within a primary care setting. Cochrane Database Syst Rev. 2021 Jul 14;7(7):CD011415. doi: 10.1002/14651858.CD011415.pub3

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Website: ePrognosis "time to benefit" tool

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Website: ePrognosis "time to benefit" tool

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see how long it will take for a medication or intervention to provide benefit

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Time to benefit is the time between the intervention (usually a test or treatment) and its benefit.

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Resource: Philadelphia Corporation for Aging

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Resource: Philadelphia Corporation for Aging

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Philadelphia's Area Agency on Aging. Can provide many home and community-based services for older adults

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PCA's Senior Strut: A Health Event in the Park, presented by PA Health & Wellness

2023 PCA Regional Conference on Aging

PCA to host Listening Sessions on Pennsylvania's Master Plan for Older Adults

New LGBTQ+ Advisory Council seeks to enhance lives

PCA Services

Our Annual Impact

2,568 Older Philadelphians received insurance and benefits counseling through the PA MEDI Program

34,000 Hours of legal services received by Older Philadelphians through PCA-supported programs

Getting Started with PCA Services

Not sure where to start? Learn more about our process and the services that may be available to you or a loved one.

Learn More

Getting Started with PCA Services

Ageism awareness: Changing negative stereotypes

Ageism - how we think, feel and act -toward others based upon age is often fraught with prejudice or discrimination toward older people.
Read More

Yoga improves mental, physical balance

When it comes to total body health, incorporating the practice of yoga into your life can help improve strength, balance, and flexibility.
Read More

Basic Brisket with Root Vegetables

Brisket is a popular Ashkenazi Jewish dish of braised beef, traditionally accompanied by kugel, latkes, and/or matzo ball soup. It is commonly served for Jewish holidays.
Read More

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Home - Philadelphia Corporation For Aging (PCA)

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The Phiadelphia Corporation for Aging (PCA) works to improve the quality of life for older Philadelphians and those with disabilities.

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Quick screen for delirium. Systematic analysis notes sensitivity 82% (95% confidence interval [CI]: 69%–91%) and specificity 99% (95% CI: 87%–100%)

Reference: Shi Q, Warren L, Saposnik G, Macdermid JC. Confusion assessment method: a systematic review and meta-analysis of diagnostic accuracy. Neuropsychiatr Dis Treat. 2013;9:1359-70. doi: 10.2147/NDT.S49520.

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Patient-centered initiative to help communicate what matters to your doctor

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It is extremely important that every adult completes the seven tasks of life review. As the result most people are able to achieve a measure of peace that comes from deep reflection about key life experiences, and the important relationships they have cultivated.

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It is extremely important that every adult completes the seven tasks of life review. As the result most people are able to achieve a measure of peace that comes from deep reflection about key life experiences, and the important relationships they have cultivated.

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Helps connect older adults to community services

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New Eldercare Locator Brochure!

Volunteering is a great way to help others but it's also good for you. Studies show that volunteering can help reduce depression, lessen chronic pain and give your brain a boost. And there's no better time than now to explore the volunteer opportunities available in your community, ( ...read more)

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New Eldercare Locator Brochure! Volunteering is a great way to help others but it's also good for you. Studies show that volunteering can help reduce depression, lessen chronic pain and give your brain a boost.

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Many of the medications that we commonly prescribe have anticholinergic properties. In patients over 65 years of age these can cause adverse events, such as confusion, dizziness and falls. These have been shown to increase patient mortality.

You can use this calculator to work out the Anticholinergic Burden for your patients; a score of 3+ is associated with an increased cognitive impairment and mortality.

Whilst there are multiple different scoring systems, the German Anticholinergic Burden score and the Anticholinergic Cognitive Burden Scale have been demonstrated to show most validity and reliability. Therefore, we have used a combination of these 2 scales when creating the ACB calculator. When discrepancies arose, we opted to include the higher value in the interest of safety.

Find more information on Anticholinergic Burden or help choosing medicines to reduce anticholinergic burden

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A tool for finding the ACB Score of commonly prescribed medicines, and for calculating the Anticholinergic Burden for your patient

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can be completed in an average of 90 seconds!

Reference: Kuzmik A, et al. Pilot Testing of the UB-CAM Delirium Screening App. Innov Aging. 2021 Dec 17;5(Suppl 1):977. doi: 10.1093/geroni/igab046.3515. PMCID: PMC8681914.

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‎The Ultra-Brief CAM (UB-CAM) is a two-step protocol that combines UB-2 items (Fick et. al., 2015;2018) and 3D-CAM (Marcantonio, et. al., 2014) items to identify the presence of delirium. Delirium is an acute, reversible confusion that is preventable and treatable. Delirium occurs in more than 25% o…

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" back · www.benzo.org.uk "

Index · Contents · Introduction · Chapter I · Chapter II · Withdrawal Schedules · Chapter III
Medical Disclaimer · Order A Printed Copy · Professor Ashton's Main Page
The Ashton Manual in other languages · Supplement, April 2011

Index · Contents · Introduction · Chapter I · Chapter II · Withdrawal Schedules · Chapter III
Medical Disclaimer · Order A Printed Copy · Prof Ashton's Main Page · Supplement, April 2011

© Copyright 1999-2013, Professor C H Ashton, Institute of Neuroscience,
Newcastle University, Newcastle upon Tyne, NE4 5PL, England, UK

© Ray Nimmo · 2013

" back · top · www.benzo.org.uk " ·

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benzo.org.uk : Benzodiazepines: How They Work & How to Withdraw, Prof C H Ashton DM, FRCP, 2002

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" back · www.benzo.org.uk " Index · Contents · Introduction · Chapter I · Chapter II · Withdrawal Schedules · Chapter III Medical Disclaimer · Order A Printed Copy · Professor Ashton's Main Page The Ashton Manual in other languages · Supplement, April 2011 Index · Contents · Introduction ·

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Patient-friendly guides for how to think about and discuss ACP topics

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Our free Conversation Guides can help you have conversations with the important people in your life about your - or their - wishes for care through the end of life. Get started!

All the Guides are available to download and print at home for free. Click on the title or image of the Guide to download.

I want to...
Frequently Asked Questions
Note: Before filling in a Conversation Guide, save it to your desktop. Otherwise, anything you type will not be saved.
Other related conversation resources and translations Other related proxy resources and translations Other related health care team resources and translations Other related Workbook resources Other related dementia resources and translations Other related pediatric resources and translations

Can I edit the Conversation Guides to meet my unique needs or situation? Yes. Under our Creative Commons licenses, you can edit the Conversation Guides to better suit you or your community. Get started by following our instructions for customizing the Conversation Guides.

How much do Conversation Guides cost? All the Guides are available to download and print at home for free.

Are there other options for printing if I want multiple guides? Yes.Get started by following our instructions for printing the Conversation Guides or visit our online marketplace to purchase Conversation Guides in bulk

How do I add my own logo and contact information to the Conversation Guides? There are two ways of adding your own logo:

1. Follow instructions for getting started with customizing the Conversation Guides

2. If you prefer to order customized guides in bulk, visit our online marketplace to customize your Conversation Guides.

How do I print or view a Conversation Guide in a larger font? Follow our instructions for larger font

Where can I find other language translations of the Conversation Guides? We released new and improved Conversation Guides in 2021. Spanish and Chinese translations are available for the newer Guides. Additional language translations are available under each guide above, but please note these are older versions of the Conversation Guides. If you know someone willing to volunteer to translate, email us at conversationproject@ihi.org

Thanks to the Cambia Health Foundation for its support creating these Conversation Guides

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Helping people get started by sharing their wishes for care through the end of life.

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The National Resource Center on LGBTQ+ Aging is the country’s first and only technical assistance resource center aimed at improving the quality of services and supports offered to lesbian, gay, bisexual and transgender (LGBTQ+) older adults. Established in 2010 through a federal grant from the U.S. Department of Health and Human Services, the National Resource Center on LGBTQ+ Aging provides training, technical assistance and educational resources to aging providers, LGBTQ+ organizations and LGBTQ+ older adults. The center is led by SAGE in partnership with 10 leading organizations from around the country.

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Patient-facing resource to plan for major life events, such as hospitalization, cognitive impairment, and falls

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Each section on Plan Your Lifespan ® will cover an advanced life event that may increasingly happen to people as they age. The life events that are presented include:

Hospitalizations: Learn what resources are available and how to connect with local in-home services should you need help after a hospitalization. Find out what rehabilitation options are available to you and choose where you would like to receive care should you ever need it.

Falls: Learn practical steps you can take to help prevent falls and make your home safer.

Memory Loss: Find out what your care options are should you ever experience memory loss and share your long-term goals with loved ones.

Also find information on how to communicate with others and finding ways to afford your plans and preferences.

This valuable information is known by doctors, nurses, and social workers, but often is not passed onto older adults.

By having the real-life choices people have to make regarding these advanced life events and critical information shared with you, you will be given the tools to help you make your choices and share them with those most important to you.

You will have the option to pick what you would like in case any of these events happen. If you would like a copy of your choices or would like to share them with others, a Summary can be printed at any time.

If you would like to receive a copy by email, you can choose to enter your email.

You will have the option of sending a copy of your summary to a loved one.

All of your choices are confidential. Your email address will not be shared or distributed.

If you Sign Up, your information will be saved for you to return at any time. If you Continue As A Guest, you can access the site but your information will not be saved. If you change your mind and wish to save it, click sign-in at any time.

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Helping you plan for health events such as hospitalizations, falls, and memory loss that may happen as people get older. This planning differs from end of life care and wills.

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Technically need to be certified to administer the MoCA. Click "apply here" near the bottom of the page

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The one-hour Training & Certification module was conceived to maintain MoCA's superior validity and was designed for busy medical professionals. Care providers and researchers of all backgrounds will gain applicable knowledge of neuroanatomy and the cognitive domains that MoCA assesses. You will become more confident in administering MoCA and explaining results to patients and families.