GeriPal - A Geriatrics and Palliative Medicine Podcast

GLP-1 receptor agonists (the "Ozempics of the world") have been a truly revolutionary pharmacological advance in modern medicine. In randomized controlled trials (RCTs), these agents have been shown to do much more than just reduce weight, including significantly reducing cardiovascular events, lowering all-cause mortality in patients with type 2 diabetes, and even slowing the progression of chronic kidney disease.
But as we see their use rapidly expand among older adults, we have to ask: at what cost?
In geriatrics, weight loss is rarely simple. In older bodies, GLP1s carry increased risks, including accelerated muscle loss, functional decline, and possibly decreased bone density. So are we just trading weight loss for frailty?
To help us untangle this complex web, we sit down with three expert geriatricians in obesity: Dr. John Batsis, Dr. Shen Dewar, and Dr. Aruna Josyula.
What We Discuss in This Episode:
How age-related changes alter the distribution of fat and muscle, even when body weight stays exactly the same.

What are sarcopenia (muscle loss) and sarcopenic obesity, and why are they so dangerous for independence?

A discussion on what happens to fat, muscle, and bone during standard weight loss versus weight loss accelerated by GLP-1s.

Whether GLP-1-induced muscle loss a direct biological side effect from suppressed muscle protein synthesis, or is it simply the indirect result of a massive caloric deficit and dropping protein intake?

A broad, geriatric-focused approach to weight, including a vital review of common medications that might actually be causing weight gain in the first place.

Practical, actionable strategies to protect muscle mass and function when prescribing GLP1s

A discussion of red flags in older adults, where we should have major hesitation before ever writing a prescription for a GLP-1

We cover this and more in the podcast. There is a forthcoming article in JAGS that addresses this topic, and we will add the link here once published.  If you want to take a deeper dive, take a look at some of the following references we discuss:
Aruna's article in JAGS titled "One Size Fits None: Developing a Person-Centered Approach to Weight Management in Older Adults"

John's Annal's article on the "Effect of Incretin-Based and Nonpharmacologic Weight Loss on Body Composition: A Systematic Review"

John's article on the "Unintended risks of sarcopenic obesity during weight-loss interventions in older people" in Nature Med.  

An article titled "The Effects of Incretin Mimetic Therapies on Muscle and Bone Health in Older Adults"

A systematic review of the effect of weight loss on muscle-based indices

An article on "Treating Sarcopenic Obesity in the Era of Incretin Therapies: Perspectives and Challenges"

Shen's article describing "The Optimal Health Weight and Lifestyle (OHWL) Clinic"

Shen's article titled "A Geriatrician's Approach to Managing the Complex Older Adult with Obesity"

Another JAGs article on "Older Adults with Obesity: The Need for a 4Ms Age-Friendly Approach to Care"

Lastly, CMS's information on the GLP1 bridge program

As Diane Meier remarks to start today's podcast, palliative care has come a long way from the days when we were the "brink of death" consult. We're seeing patients earlier and earlier in the course of illness.  In fact, the evidence base for specialist palliative care is arguably stronger in the outpatient setting than the inpatient setting.
In some ways, as Eric remarked, we are a victim of our own success. We've pushed on the boundaries of seeing patients earlier in the course of illness, we've demonstrated remarkable value to our colleagues and health systems: now they want us to see more and more patients, with conditions we would not have previously considered core to palliative care practice.
Our guests modeled respectful disagreement, and we were somewhat surprised that there was more agreement than we expected.  I'm sure you will all have strong feelings about the opinions expressed, please let us know!
In addition to Diane Meier, we welcome back Bob Arnold and Justin Sanders to talk through these issues, including:
We agree specialist palliative care is for people with "serious illness" - but what constitutes "serious illness"

Is a limited prognosis part of the definition of serious illness?  We discuss the Center to Advance Palliative Care definition of palliative care and Amy Kelley's oft-cited definition of serious illness.  

Many patients with conditions that overlap with palliative care would benefit from our help, e.g. chronic pain, opioid use disorder, mental illness. Our health system is not meeting their needs.  Should palliative care see them, in the absence of a clear life-limiting illness?

How limited a prognosis should we consider here - months, years…decades?

We have a tremendous workforce shortage.  There are not enough specialist palliative care providers to see all patients with advanced cancer, much less the many other conditions whose guidelines now say should include palliative care.  The reality does not match the mission.  Does that change our mission? 

Should local workforce issues dictate who should see palliative care? See this article by Pelleg in which clinicians at Mt Sinai agreed that patients with serious illness and high risk of mortality should be prioritized, explicitly excluding patients with chronic pain or psychosocial distress in the absence of serious illness.

What is the role for Patient Reported Outcomes (PROs)? e.g. patients regularly reporting pain or other symptoms and an escalation in symptoms triggering a palliative care intervention. 

How is the definition of who should see palliative care expanding in Canada, and is there a linkage to who is eligible for medical aid in dying in Canada.  Justin makes a good plug for the McGill National Palliative Care Grand Rounds Programme

What is our vision for where palliative care should be 10 years from now? Population health specialists, or healing patients one visit at a time? To be sure, these are not mutually exclusive.

How long should palliative care fellowship be - should we expand it to 3 years so palliative care specialists can care for people with a wider range of conditions?  

What is Precision Palliative Care? Diane mentions this article by Ramy Sedhom on a couple of occasions.  

Should palliative care see patients with sickle cell disease? How about survivorship clinics? How about very elderly patients with multiple mild chronic conditions (e.g. mild heart failure, mild COPD, mild cognitive impairment, arthritis, diabetes, hypertension)?

And much more!

Please listen to the audio only version of Stand by Me - my son Renn added an upright base, snap, and triangle parts - it's much better than the live version for YouTube that I accidentally started in a much too high key!

Up until just a couple years ago, an 85-year-old patient presenting with gradual, amnestic memory loss was almost automatically presumed to have Alzheimer's disease. However, new biomakers and the recognition of conditions like Limbic-predominant age-related TDP-43 encephalopathy (LATE) are reshaping our understanding of cognitive decline in older adults. It's looking more clear that pure Alzheimers dementia is rare in older adults, and co-occurring pathologies that may include Alzheimer's, LATE, Lewy Body, and vascular neuropatholigies, are the rule rather than the exception. 
In this episode of the GeriPal Podcast, we sit down with Sterling Johnson and Nate Chin from the University of Wisconsin. Sterling is a clinical neuropsychologist and researcher who leads the CLARiTI study, which is attempting to uncover the intersecting causes of dementia.  Nate is the medical director and Clinical Core Co-Leader for the Wisconsin Alzheimer's Disease Research Center (ADRC), the host of the Dementia Matters podcast, and author of a new book When Memory Fades.  
We tackle the real-world complexity of mixed dementia and its major diagnostic and clinical treatment dilemmas. We also go in deep to discuss LATE, from what it is, to how it presents, to whether it should change how we think about using newly approved disease-modifying therapies when a patient has confirmed amyloid positivity alongside suspected LATE.

Can simple, evidence-based video decision aids—paired with structured clinician training—improve Advance Care Planning (ACP) documentation and goal-concordant care? That's the question we pose in this week's podcast with Dr. Joshua Lakin and Dr. Kei Ouchi. We break down the methodologies behind two major clinical trials in which they were involved that implemented this video-enhanced approach.
The first study, published in JGIM, was a multicenter, parallel randomized trial of 598 seriously ill older adults in emergency departments (EDs). It tested whether watching a 5-minute video and having a short, 10-minute structured clinical conversation during acute ED visits could establish longitudinal care preferences. The researchers found that this intervention not only increased ACP documentation at 3 months (45.6% vs. 31.3%), but also significantly increased goal-concordant care in a subset of study participants who died in the hospital.
The second study, published in JAMA Network Open, was a multicenter, stepped-wedge trial involving 13,800 older adults with advanced cancer across 29 outpatient oncology clinics. Practices in the trial received patient video tools and VitalTalk clinician training. The bundled intervention led to a statistically significant increase in electronic health record (EHR) ACP documentation (25.3% vs. 20.8% with usual care).
Both studies provide strong evidence that combining video-enhanced ACP with clinician training improves documentation of these discussions. What I loved most, though, is that the JGIM paper offers some of the first evidence that combining these approaches directly helps patients receive care aligned with their true values.

The longevity industry is booming. Influencers are promoting this and that as promoting healthy aging, longevity, and healthspan, and it's hard for us, much less our patients, to make sense of it.  To be sure, we should always start by recommending exercise, nutritious foods, good sleep habits, and meaningful social interaction.  We wanted to go beyond that to talk about the promise and potential and risks/harms of "biohacks."
Today we talk with Mahtab Jafari, PharmD, and John Newman, MD, PhD, and to discuss:
How we clinicians should think about this movement, knowing many of our patients (and ourselves) also prize living as long as we can as healthy as we can, and at the same time acknowledge that a high quality of life, growth, and a meaningful life are possible with support in states of disability or dementia.

How animal models can leading to promising therapeutics but must be tested in humans

What it takes for a drug to obtain approval for longevity or healthspan indications when we cannot realistically wait around 40 years for a result

We ask them to rate the evidence for many treatment on the scale of very promising, meh, or snake oil/avoid, including creatine, metformin, GLP1, SGLT2i, NAD+, testosterone/estrogen, red light therapy, rapamycin, and rodeola rosea.

And I get to sing Wake Me Up by Avicii - an uplifting song with lyrics that could have multiple meanings - makes you think!
-Alex Smith