GeriPal - A Geriatrics and Palliative Medicine Podcast

We dive deep into bone health, osteopenia, osteoporosis, and fracture prevention in older adults in this week's episode of the GeriPal podcast. Joining us are experts Dr. Doug Bauer and Dr. Stan Birge to break down a wide range of critical topics, including:
Defining the terms: Clearing up the differences between osteoporosis, osteopenia, and low bone mass.

Bone Mineral Density (BMD) testing: The evolving role of BMD screening in both men and women.

Bone health and frailty: How skeletal health intersects with overall physical vulnerability, with discussion on Stan's paper "Osteoporotic fractures: A brain or bone disease?"

Screening strategies: Evidence-based approaches to identifying low bone mass, including a look at Dr. Bauer's recent JAMA Internal Medicine article, "Screening for Osteoporosis in Older Men—Getting Closer to Yes."

Non-pharmacologic management: Practical lifestyle, exercise, and nutritional strategies to support bone strength.

Bisphosphonate deep dive: Navigating complex decisions around oral vs. IV administration, timing "drug holidays," and evaluating efficacy in men.

Reconsidering denosumab: Why it should rarely serve as first-line therapy.

Treating osteopenia: Insights from the landmark 2018 NEJM study examining zoledronate treatment in older adults with osteopenia.

Vitamin D controversies: Sorting through the debate over supplementation, featuring a discussion of Dr. Birge's JAGS article, "Vitamin D: What's the Proper Dose?", AGS last position statement on Vitamin D, and a study on Vitamin D and dementia.

So join us to brush up on bone health, learn a little about the controversies in the field, and hear Alex sing a little Pete Seeger.

How do we spread the gospel of geriatrics? How do we convince trainees, our fellow clinicians, older adults, and caregivers - heck, everyone - that a geriatrics' knowledge and skills are essential?  One way is to reach these audiences via traditional avenues, such as journals and books.  Another is to reach them through social media.
In today's podcast we are delighted to welcome Rafael Tenorio, Ellie Fishbein, Patty Lee, Samantha Ing, and Stephanie Rogers - geriatricians all - who each have carved out a substantial social media presence.  Our guests today range from smaller audience influencers to influencers with viral episodes targeting the lay public that reach millions and millions.
We did a similar prior episode focused on palliative care influencers. Rafael, who Eric and I met in Sao Paulo, Brazil, co-founded GeriClass, short and long form geriatrics lessons in Portuguese.  Ellie created GeriatricsinRealLife, is on TikTok most prominently, though also Instagram, and was featured in a JAMA News story about a growing movement to prepare all physicians to care for older adults.  Patty and Sam started the VeriGeri podcast, focused on trainees from medical students to fellows, available on Spotify and Apple. Stephanie writes at AgeWellWithDrSteph, and is on all platforms, including Instagram, Shorts, and Substack.
We discuss:
How did they get into this?

Why do they do it?  What is their goal

Who is your target audience, and has it changed?

How do you reconcile your social media work with the pushback against social media?

What advice do you have for anyone hoping to join the cause?

Who are the other Geriatrics influencers not on today's podcast? 

Geriatricians: Anna Chodos WordsOnAging, Kelly Cheung KellyTakesMedicine, Anita Chandra itsdoctoranita, Erika Noonan erikanoonan, Pavitri Dwivedi thegerigal, Elena Mucci doctor.elenamucci

Gerontologists: Kerry Burnight the_gerontologist, Sara Margolin drsaramargolin

Geriatric NP

Geriatric pharmacists: The Deprescribing Pharmacist geriatrx, Your Geriatric Pharmacist the caregiverpharmacist 

Enjoy!
-Alex Smith

Delirium is probably the single most common issue I see in clinical practice as a palliative care consultant for our hospital's very geriatric population.  I would say that only about half the time we are consulted has the team consulting us recognized that the patient has delirium. I would guess that about 25% of the time there is an obvious culprit or set of culprits that lead to resolution of the delirium, e.g. for one recent patient, sedating meds used for behavioral issues in a patient with dementia.
In today's podcast we focus primarily on the long term effects of delirium on cognition.  There's a major debate in the field as to whether delirium itself is the cause of accelerated cognitive decline, or does delirium merely unmask underlying vulnerability and frailty.  We try not to get confused (see what I did there) as we puzzle out this mystery: hospitalization is associated with worsening cognition, but does rehospitalization explain the worsening cognition observed in older adults with post-operative delirium?
Our guests Tammie Hshieh, Ed Marcantonio, and Thiago Avelino-Silva are experts in delirium research and address:
What is delirium, is it "brain failure" as Ed wrote in the NEJM in 2017?

What are the mechanisms of delirium?

Are debates over which delirium screening tool is best in the hospital productive or counter-productive? Get ready for a fantastic breakfast cereal analogy

What did Tammy and colleagues find when studying the 5 year course of post-operative delirium and impact on cognition, did rehospitalizations as a marker of frailty explain the cognitive decline (the unmasking hypothesis)?  Article in JAMA Internal Medicine

The answer is no, and Thiago's commentary and explanation helps explain why this is important, and demonstrates that delirium itself predisposes to future cognitive decline. He also helps us understand transient vs enduring impacts of delirium.

What evidence do we have about the relationships between frailty and delirium?

What can clinicians do about delirium and do interventions have any impact? Ed's classic trial published in JAGS found that proactive geriatrics consultation in hip-fracture reduced delirium by over one-third. 

The CMS Age Friendly Health System measure and delirium assessment

And I get to play "Where is my mind?" The Pixies were highly influential on Nirvana, one of my favorite bands from high school, and if you listen to the original you can hear it in the sharp contrasts in volume and tone between verse and chorus. Also, Fight Club.
-Alex Smith

In 2019, the American College of Surgeons launched the Geriatric Surgery Verification (GSV) Program to provide evidence-based standards hospitals could adopt to optimize surgical care for older adults. As a surgical resident, I didn't think much about what that meant until I rotated through a GSV-verified hospital and gained firsthand experience. The structure built into the EMR prompted me to go beyond the usual risks and benefits of surgery and prioritize what matters most to patients, including what they hope surgery will accomplish, before booking an operation. It ultimately changed how I think about and practice caring for older adults as I continue my training.
On this week's episode, we sat down with surgeons Dr. Emily Finlayson and Dr. Aaron Baggs, and geriatrician Dr. Ali Torbati to discuss how the GSV Program came to be, what it takes for a hospital system to earn verification, and how it's shaping the way surgeons and multidisciplinary teams care for older adult patients.
Today's topics included:
What is the history of the ACS GSV Program? Why should hospital systems participate?

How do you successfully implement a GSV Program?

What are the levels of verification, including the new Age-Friendly level?

How does GSV align with the CMS Age Friendly Hospital Measures?

How has care for older adults changed after GSV implementation?

This episode builds on a previous GeriPal podcast on the Pre-Operative Geri Assessment with Drs. Vicky Tang and Houman Javedan:
https://geripal.org/pre-operative-geri-assessment-vicky-tang-and-houman-javedan/
Learn more about GSV through the links below:
ACS Geriatric Surgery Verification Program: https://www.facs.org/quality-programs/accreditation-and-verification/geriatric-surgery-verification/

GSV Program Standards, including the Age-Friendly level: https://www.facs.org/quality-programs/accreditation-and-verification/geriatric-surgery-verification/standards/

Making a Financial Case for the Geriatric Surgery Verification: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11191881/

 
Rachel Borthwell

Can we prevent age-related cognitive decline, and perhaps even head off Alzheimer's disease and related dementias before they start?
Pharmaceutical companies are spending billions searching for a magic bullet pill to answer that question. But what if the solution requires more than a single drug? What if real prevention demands a multi-domain approach that combines targeted diet, exercise, social engagement, and vascular risk factor management among other things?
On today's episode, we explore multi-domain interventions for cognitive risk reduction with two leading experts:
Laura D. Baker, PhD, Co-PI and first author of the US POINTER study.

Ellen Binder, MD, Co-PI and senior author of the rrAD Trial.

The key multi-component trials discussed in this episode include:
FINGER Trial (Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability

SMARRT Trial (Systematic Multi-Domain Alzheimer's Risk Reduction Trial -> Check out our previous GeriPal episode on SMARRT

US POINTER Study (US Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk)

rrAD Trial (Risk Reduction for Alzheimer's Disease)

My key takeaway from this conversation? We now have compelling evidence that actively modifying lifestyle risk factors can preserve, and even improve brain health as we age. That makes this episode's song choice all the more fitting: "Get On Your Feet."