GeriPal - A Geriatrics and Palliative Medicine Podcast

Today we're delighted to talk with Anne Walling, Neil Wenger, and Rebecca Sudore about a pragmatic implementation trial aimed at increasing advance care planning for primary care patients with serious illness in University of California clinics, published in Annals of Internal Medicine. Seriously ill primary care patients were identified using structured data fields (meaning routinely captured without needing to read the chart or use natural language processing).
This study focused on patients without a completed advance directive or POLST form. This was a 3 arm trial that tested a nudge in the patient portal and a mailed advanced directive vs. the nudge plus a link to PrepareForYourCare vs. the nudge plus PrepareForYourCare plus a navigator reminding patients to talk with their doctor and bring any completed advance directives or POLST forms to the PCP visit.
In brief, the study found that at 2 years there were higher rates of advance directive or POLST in the electronic health record (about 20%) in the arm with the nudge plus PrepareForYourCare plus the navigator compared to the other 2 arms (around 13%). Rates of advance care planning discussions with primary care providers were similarly higher in the 3rd arm. Health care utilization, however, did not differ between arms.  Please see links to articles describing the intervention in detail and incorporation of stakeholder perspectives.
I'm going to cut to the pushback to this article right up front: 
The study's primary outcomes were advanced directives or completion of POLST forms - haven't we moved beyond thinking completion of forms should be the primary outcome of advance care planning research?

There was no control condition. Observed increases in advance directive or POLST in the electronic health record may have occurred without any intervention.  People with serious illness get sicker with time and the sicker they are the more likely they are to engage in advance care planning, without any intervention. This is particularly true as the study occurred during the hight of the Covid pandemic, when there was a global effort to increase advance care planning. How much did these interventions contribute on top of that rise that might have occurred without intervention? 

Observed documentation - 13-20% - was low.  Is it worth the effort of getting buy-in to automate these EHR nudges and spend FTE to hire a navigator? Particularly as health systems, who pushed for focusing on seriously ill patients because they are the most expensive/highest utilizers, did not get what they wanted, i.e. no difference in utilization of acute healthcare services between arms?

Our guests provide a strong defense and additional context, which you can and should listen to on the podcast. And I have to point out, setting aside the advance care planning aspect, the method of identifying upstream primary care patients with serious illness is a major contribution to the field in and of itself.  Pioneers in the field, led by Amy Kelley, have been working to identify the seriously ill population for over a decade.
And a fun fact about All You Need is Love - the verses are in 7/4 time!
-Alex Smith

In 2025, the Centers for Medicare and Medicaid Services (CMS) began requiring hospitals participating in the Hospital Inpatient Quality Reporting (IQR) program to report on a new "Age-Friendly Hospital Measure."  The hope is that, by attesting to this measure, hospitals will develop evidence-based processes to improve care for older adults in hospital settings.
On this week's podcast, we explore this new measure with Sheri Ling, CMS's Deputy Chief Medical Officer serving in the Center for Clinical Standards and Quality (CCSQ). We've also invited some returning guests from our past Age Friendly Health Systems podcast, Julia Adler-Milstein and Stephanie Rogers, to discuss how they are thinking about this new measure and how we should operationalize it.
We go over everything you will want to know about the new measure, including:
How does this CMS measure differ from both Age-Friendly Health Systems and the 4Ms movement we've been hearing about for years (and that we did the podcast on in 2020 here)

Why is CMS finally making "Age-Friendly" a formal, structural requirement for hospitals now?

What is an attestation measure vs outcome measure, and why is this one an attestation measure?

A deeper dive into the 5 domains to the measure (Eliciting Patient Goals, Medication Management, Frailty Screening, Social Determinants of Health, and Leadership/Governance.

Lastly, here are some great resources if you want to help get this started at your hospital:
A report by JAHF, Julia and others on how to think about different dimensions of measure performance

Health Affairs Scholar paper on related the 4Ms to the 5 domains

Two CMS resources with detailed information on how to meet and report on the five domains of this measure:

Age-Friendly Hospital Specifications (July 2025)

Age-Friendly Hospital Measure Attestation Guide

A few weeks ago, I was skimming this NEJM paper for UCSF's Division of Geriatrics Journal club on de-prescribing anti-hypertensive medications for older adults in nursing homes. Seemed to make a world of sense. The study found no difference between the deprescribing arm and the usual care arm in mortality, the primary study outcome. I thought, great! So we can deprescribe anti-hypertensives without changing mortality, that must be what the authors concluded.
I was shocked, therefore, to read in the first paragraph of the discussion that the deprescribing arm did not achieve the hypothesized 25% reduction in mortality.  What?!?  Why would deprescribing be associated with reduced mortality? That's not the main reason or even the first reason I think of for deprescribing.  Reducing side effects that impair quality of life, sure. Less pill burden, of course.  But prolonged life?  Seemed a stretch.
Today we hear from the first author of this study, Athanase Benetos, an esteemed geriatrician-researcher from France.  For context, we also interviewed Mike Steinman, co-chair of the Beers criteria and co-lead of the US Deprescribing Research Network.
We learned about:
Why the hypothesis of reduced mortality in deprescribing was justified, based on natural decreases in blood pressure with aging, and the Partridge study, an observational study that found higher risks of mortality associated with using multiple anti-hypertensive and low blood pressure.

Why mortality was chosen as the primary outcome.

Is a negative superiority study the same as what they might have found in a non-inferiority study? (stay with us)

Variation in outcome by frailty status

How to place this study in context with other research, such as the Danton study mentioned on a recent podcast about deprescribing near the end of life. Dantos was a study of deprescribing for nursing home residents with dementia that was stopped early due to safety concerns. Other studies for context include Sprint, Optimize, and an observational study by Bocheng Jing (UCSF statistician in our group).

At the end, we ask our guests to put it together. With all that we know at this point, what's a clinician to do? To deprescribe or not to deprescribe?
And, zoot alors! I get to sing Hymne A L'amour in French! Athanase recounts the moving story of how Edith Piaf sang this song the night she learned the man she loved, Marcel Cerdan, died in a plane crash.
-Alex Smith

It's an era of breakthroughs in Alzheimer's research, yet for many clinicians, it's also a time of profound uncertainty. We are currently navigating competing definitions of the disease, multiple new biomarkers coming on market seemingly every week, and the clinical rollout of new amyloid antibodies.
How do we translate this rapid-fire science into daily practice? On this week's GeriPal podcast, we sit down with dementia experts Halima Amjad, Barak Gaster, and Heather Whitson. We dive deep into:
The evolving definitions of Alzheimer's disease.  Does someone have Alzheimer's disease if you have only an abnormal biomarker as defined by the Alzheimer's Association, or is amyloid pathology necessary but not sufficient to define Alzheimer's as per the International Working Group (IWG) recommendations?

Where do blood-based biomarkers for Alzheimer's fit into the diagnostic workup, and should they be used at all in primary care?  FYI - here is my take on that question in a recent JAMA IM article titled "The Limited Role of Alzheimer's Disease Blood-Based Biomarkers in Primary Care."

What's the role of amyloid antibodies in the care of individuals with Alzheimer's disease, including who to use them on?


We covered a lot and discussed some of these resources that you can do a deeper dive on:
Blood-based biomarker resources

JAMA article on Blood-Based Biomarkers for Alzheimer's Disease: Preventing Unintended Consequences 

Alzheimer's Dementia article on Blood-based biomarkers for detecting Alzheimer's disease pathology in cognitively impaired individuals within specialized care settings: A systematic review and meta-analysis

JAMA IM article on The Limited Role of Alzheimer Disease Blood-Based Biomarkers in Primary Care

Appropriate use recommendations for amyloid antibodies

Donanemab: Appropriate use recommendations 

Lecanemab: Appropriate Use Recommendations

Primary Care Resources

Cognition in Primary Care program

A JAGS article on "Large Health System Quality Improvement Intervention Providing Training and Tools to Improve Detection of Cognitive Impairment in Primary Care"

Other resources

AGS's new online curriculum for Alzheimer's Disease


By Eric Widera

Today we're doing something different. Today, dear listeners, you get two podcasts for the price of one! (OK, our podcasts are both free, but you get the idea).
We're joined today by Chris Comeaux, host of TCN Talks, a podcast about leadership, strategy, innovation, and the future of serious illness care, and author of The Anatomy of Leadership. We are also joined by TCN Talks' frequent guest host Cordt Kassner, CEO of Hospice Analytics, which provides in depth data on hospice quality, utilization, and access, and publisher of Hospice and Palliative Care Today, a daily email about the hottest stories and news in the field.
This is an "ask us anything" style podcast in which we get to ask each other questions.  Our discussions focus on concerning trends in hospice, Ira Byock's white paper, concerning trends in hospice, certificate of need, danger of losing a generation of junior researchers and hope in the form of ASCENT, various measures of hospice quality including Cordt's National Hospice Locator, which ranks all area hospice by quality, unlike CMS's Hospice Care Compare, which only has star ratings for about 30% of hospices.
Hospice and palliative care are going through a tough growth period, and sometimes being real with your friends and colleagues in your field means tough love. Love hurts.  And no, I'm not attempting the Nazareth version!
-Alex Smith