Difficulty managing money is often one of the earliest signs of Alzheimer's disease and related dementias, frequently appearing years before an official diagnosis. This loss of financial capacity leaves individuals vulnerable to costly mistakes and exploitation, threatening the financial security and quality of life of entire families.

In this episode, we sit down with Dr. Lauren Hersch Nicholas, Dr. Duke Han, and Dr. Jason Karlawish to examine the intersection of cognitive decline, financial decision-making, and patient protection. We covered a lot of topics, including these key ones:

• The Financial Prodrome: Dr. Nicholas shares her health economics research showing that missed payments and credit score drops can appear up to six years before a dementia diagnosis—causing major wealth loss long before healthcare providers catch the issue, especially in lower-income communities.

• Brain Function & Social Buffers: Dr. Han discusses new neuroimaging research on how cognitive decline impairs financial judgment and explains how strong social connections can serve as a critical protective buffer.

• Clinical & Policy Solutions: Dr. Karlawish outlines the medical, policy, and financial-sector interventions needed to safeguard vulnerable patients.

For a deeper dive on some of the articles we discussed, check out these references:

• My first JAMA paper on Finances in the Older Patient With Cognitive Impairment

• Lauren's plant money podcast on how your bank account might predict dementia

• Lauren's article on Management of Financial Assets by Older Adults With and Without Dementia or Other Cognitive Impairments

• Jason's editorial on the Importance of Asking Older Adults Whether They Are Having Difficulty Managing Finances.

• Jason's article on Desktop Medicine and the Practice of Wealth Care

• Duke's article on Financial exploitation vulnerability and social connectedness in middle-aged and older adults without dementia https://www.tandfonline.com/doi/full/10.1080/13607863.2025.2475331

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:

1. Aruna's article in JAGS titled "One Size Fits None: Developing a Person-Centered Approach to Weight Management in Older Adults"

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

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

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

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

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

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

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

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

10. 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

Who's better at delivering palliative care to patients with liver disease: palliative care specialists, or hepatologists who have received liver disease-specific palliative care training?

That's the question we take a deep dive into on this week's podcast by breaking down the PAL-LIVER trial, published this year in JAMA Internal Medicine. We've invited three of the trial's authors, Manisha Verma, Chris Woodrell, and Marie Bakitas, to discuss this cluster-randomized clinical trial spanning 19 U.S. medical centers.

We'll discuss:

• Why was this trial done?

• Do we really need to run a separate palliative care trial for every single organ disease?

• What kind of specialized palliative care training did the hepatologists receive?

• What exactly is meant by the finding that hepatologists were not statistically superior, but were shown to be statistically non-inferior?

Lastly, we discuss whether these results change anyone's practice, and whether healthcare systems should decide which type of palliative care model to fund (primary vs. specialty.)

—-

References we discussed

• Developing palliative care interventions in liver disease using formative and summative qualitative evaluation. Hepatology 2026

• Palliative Care for Advanced Liver Disease: Hepatology and Palliative Care Specialists Experiences. J Pain Symptom Manage 2026

Emergency Podcast! Our guests Sean Morrison, Ken Covinsky, and Stacy Fischer believe that you should care deeply about the proposed shakeup at the National Institutes of Health. Major proposed rules changes at the Office of Management and Budget, would affect a huge range of government grants, from Headstart to Transportation to the National Science Foundation, as well as the National Institutes of Health (NIH), the subject of today's podcast.

You dear listeners should all care. You should care because you care for older adults, or you're a researcher who studies palliative care, or you're a chaplain who visited with the family of a patient who died today. You should care because these rule changes are so sweeping that they would remove standard components of the scientific review process and instead put them in the hands of political appointees.

You should care because if rules like this were in place in the 1980s, we might not have developed treatments to stop the HIV/AIDS epidemic. You should care because if these rules go into effect we will not be able to work with researchers in other countries studying outbreaks of Ebola or Hauntavirus. You should care because these rules silence federal research into groups of people we care for daily.

And if you're not a researcher, your voice is even more important here. As Sean says, researchers who protest these proposed rule changes might come across as self-serving. Clinicians who are not researchers - who can say that these rules will negatively impact the science that improves care of older adults living with chronic conditions and their families - your voices may resonate even more.

What can you do? Most of these rule changes are open for public comment here until July 13, 2026. Every comment will be read and requires a response. It's ok to respond anonymously. Personalized stories matter more than form responses. Tips:

1. 1: Say (or just describe to keep anonymous) who you are and why you are qualified to comment. Telling the story of how patients and families you care for or study is enough. Get your partner and parents to respond too. Simply being a concerned citizen is perfectly fine.

2. 2: List the exact provision #s that concern you, and explain what they would do. You do not need to quote the rule directly. Just explain what you understand it to mean in plain terms.

   1. Political Appointees Take Control of Grant Awards (§200.205);

   2. Peer Review Is No Longer Binding (§200.205(d));

   3. Active Grants Can Be Terminated at Any Time, for Any Reason (§200.340);

   4. DEI, Gender Research, and Related Topics Banned as Grant Conditions (§200.300);

   5. Prohibition on International Scientific Collaboration (§200.220);

   6. Conference Attendance Now Requires Express Agency Pre-Approval (§200.432);

   7. Publication Costs and Open Access Fees Presumptively Unallowable (§200.461)

3. 3: Explain the concrete harm. What would happen to your patients and their families if this provision takes effect?

4. 4: Closing: State clearly what you want OMB to do. This can be as simple as: "I urge OMB to withdraw these specific provisions: §200.340, §200.202, §200.205." or "I urge OMB not to finalize this rule."

Submit your comment in opposition here: The deadline is July 13, 2026. You can also email your congressperson or senator.

Times they are a changin'.

Today's podcast is a natural follow up to our podcasts on Slow Codes and Unilateral DNR orders.Today we talk about a new study about how clinicians talk about potentially non-beneficial life-prolonging treatments, published in JAMA Network Open. Do they adhere to society guidelines, which allow as permissible approaches only shared decision-making and following institutional policy. Or do they take alternative approaches, like not offering interventions, not mentioning interventions, or simply stating a plan to limit interventions? Turns out doctors are using these alternative approaches frequently.

Our guests are Jason Batten, Liz Dzeng, and Teva Brender, all clinicians, all of whom have been thinking about and wrestling with the ethical reasoning behind these approaches. We all admit to using these approaches. Are the alternative approaches wicked games (song hint), and our response should be to stop these behaviors, beginning with ourselves? After all, if you ask patients or surrogates, they're likely to say they want all the options and may not universally welcome recommendations. Or, as with slow codes, does the fact that these alternative approaches are in common use suggest that the guidelines should be revised? You listen and decide!

-Alex Smith

Additional links:

Dzeng 2023 JAMA IM: The larger ethnographic study from which data was drawn with data drawn from high- medium- and low-intensity hospitals. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2806959

Brender 2025 JAMA NO: Factors that exacerbate or mitigate moral distress related to potentially non-beneficial treatments.https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2835316

Dzeng 2015 JAMA IM: Study illustrating that more senior physicians feel more comfortable not offering or recommending against futile CPR. Relevant quote: "Experienced physicians at all sites generally were comfortable engaging in best interest decision making and, when clinically appropriate, not offering or making explicit recommendations against offering resuscitation." https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2212265

Weiss Goitiandia AJOB 2025: Reasons why some clinicians would hesitate to go to the ethics committee / futility process for these discussions: https://www.tandfonline.com/doi/10.1080/15265161.2025.2457734?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Axelrod AJOB 2025: Discusses some of the systemic consequences of using physiologic futility as a standard and how it might contribute to a healthcare system that imposes aggressive treatments on vulnerable patients. https://www.tandfonline.com/doi/full/10.1080/15265161.2025.2530715#d1e152

Today we revisit a topic we last discussed in a 2020 podcast with Laura Mosqueda: elder mistreatment. Our guests today are geriatricians Carrie Rubenstein and Julia Hiner, and Tony Rosen, an emergency medicine doctor. They talk about where we are now, in 2026, with elder mistreatment, including:

• Terminology: elder mistreatment vs. abuse and neglect

• The need to incorporate prevention and solutions into how we talk about mistreatment

• This is not rocket science. Studying elder mistreatment is much harder than rocket science.

• Highlighting the reasons they focus on elder mistreatment, including inspiring words for why this led them to geriatrics and aging research

• Should we screen for elder mistreatment? The US Preventive Services Task Force doesn't see enough evidence to recommend screening. Our guests may differ…

• Which clinicians should assess for elder mistreatment? Hospitalists? ED docs? Primary care providers? Tony published a study in JAGS showing older adults who experienced elder mistreatment were as likely to visit primary care as those who did not, also great accompanying editorial by Mara Rosenberg and Lena Makaroun gets a shout out.

• Early evidence that supporting caregivers can reduce elder mistreatment (in one small study of the COACH intervention, rates of mistreatment were reduced to zero)

• Borrowing from pediatrics: many/most hospitals and emergency departments can call a Child Protective Services Team. Tony is piloting a parallel team for older adults - the Vulnerable Elders Protection Team (see JAGS paper).

• We talk about key members of interdisciplinary teams across sites, systems, and counties. Social workers get a big shout out.

• A one year fellowship in capacity assessment and elder mistreatment at UT Houston, directed by Julia.

• An Elder Abuse Curriculum for Medical Residents and Geriatric Medicine Fellows

• https://pmc.ncbi.nlm.nih.gov/articles/PMC10842324/

Kudos to my son Renn for recording 5 overlapping cello parts on Eleanor Rigby!

-Alex Smith