Falls are very common among older adults but often go unreported or untreated by healthcare providers. There may be lots of reasons behind this. Patients may feel like falls are just part of normal aging. Providers may feel a sense of nihilism, that there just isn't anything they can do to decrease the risk of falling. On this week's podcast, we try to blow up this nihilism with our guest Sarah Berry.

Sarah is a geriatrician at Hebrew SeniorLife in Boston where she does research on falls, fractures, and osteoporosis in older adults. We pepper Sarah with questions ranging from:

• Why should we care about falls?

• What are ways we should screen for falls?

• What are evidence based interventions to decrease the risk of falls?

• What about Vitamin D and falls???

• How should we assess for fracture risk?

• What are some evidence-based ways to decrease fracture risk?

• When should we prescribe vs deprescribe bisphosphonate therapy? How does life expectancy fit in with all of this?

If you want to do a deeper dive into some of the articles we discuss, take a look at the following:

• An awesome JAMA review by Sarah on fall risk assessment and prevention in community-dwelling adults.

• The Fracture Risk Assessment in Long term care (FRAiL) website

• James Deardorff’s JAMA IM article on “Time to Benefit of Bisphosphonate Therapy for the Prevention of Fractures Among Postmenopausal Women With Osteoporosis

• Sarah’s article on “Controversies in Osteoporosis Treatment of Nursing Home Residents”, which includes this helpful flow chart on starting/stopping osteoporosis drugs in nursing homes

We recently published a podcast on palliative care for kidney failure, focusing on conservative kidney management. Today we’re going to focus upstream on the decision to initiate dialysis vs conservative kidney management.

As background, we discuss Manju Kurella Tamura’s landmark NEJM paper that found, contrary to expectations, that function declines precipitously for nursing home residents who initiate dialysis. If the purpose of initiating dialysis is improving function - our complex, frail, older patients are likely to be disappointed.

We also briefly mention Susan Wong’s terrific studies that found a disconnect between older adults with renal failure’s expressed values, focused on comfort, and their advance care planning and end-of-life care received, which focused on life extension; and another study that found quality of life was sustained until late in the illness course.

One final briefly mentioned piece of background: John Oliver’s hilarious and disturbing takedown of the for profit dialysis industry, focused on DaVita.

And the main topic of today is a paper in Annals of Internal Medicine, Maria first author, that addressed the tradeoffs between initiating dialysis vs continued medical/supportive management. Turns out, in summary people who initiate dialysis have mildly longer lives, but spend more time in facilities, away from home. We also discuss (without trying to get too wonky!) immortal time bias and target emulation trials. Do target trials differ from randomized trials and “ordinary” observational studies, or do they differ?!? Eric is skeptical.

Bottom line: if faced with the decision to initiate dialysis, waiting is generally better. Let it be (hint hint).

-Additional link to study with heatmaps of specific locations (hospital, nursing home, home) after initiating dialysis.

-@AlexSmithMD

In March 2020, we launched our first podcast on COVID-19. Over the past four years, we’ve seen many changes—some positive, some negative. While many of us are eager to move past COVID (myself included), it’s clear that COVID is here to stay.

This week, we sit down with infectious disease experts Peter Chin-Hong and Lona Mody to discuss living with COVID-19. Our conversation covers:

• The current state of COVID

• Evidence for COVID boosters, who should get them, and preferences between Novavax and mRNA vaccines

• COVID treatments like Molnupiravir and Paxlovid

• Differences in COVID impact on nursing home residents and those with serious illnesses

We wrap up with a “magic wand” question. My wish was for better randomized evidence for vaccines and treatments, though I worry this might not be feasible. In the meantime, there’s significant room to improve vaccine uptake among high-risk groups, particularly nursing home residents. Currently, only 1 in 5 nursing home residents in the US have received the COVID booster, compared to over 50% in the UK.

By: Eric Widera