In today’s podcast we talk with Eric Wong, geriatrician-researcher from Toronto, and Thiago Silva, geriatrician-researcher from Brazil, about the comprehensive geriatrics assessment. We spend the first 30 minutes (at least) discussing what, exactly is the comprehensive geriatric assessment, including:

• What domains of assessment are essential/mandatory components of the comprehensive geriatrics assessment?

• Who performs it? Is a multidisciplinary team required? Can a geriatrician perform it alone? Can non-geriatricians perform it?

• Who is the comprehensive geriatrics assessment for? Who is most likely to benefit? Eric Widera suggests not as much benefit for very sick and very healthy older adults, more benefit in the vast middle.

• Why do the comprehensive geriatrics assessment? What are the interventions that it leads to (we cover this more conceptually, rather than naming all possible interventions)

• How does the comprehensive geriatrics assessment relate to the 4Ms (or 5 Ms)?

• How long does it take to conduct a comprehensive geriatrics assessment?

• What’s the evidence (BMJ meta analysis) for the comprehensive geriatrics assessment?

• What are the outcomes we hope for from the comprehensive geriatrics assessment?

That final point, about outcomes, bring’s us to Eric Wong’s study, published in JAGS, which evaluates the cost effectiveness of the comprehensive geriatrics assessment performed by a geriatrician across settings (e.g. acute care, rehab, community clinics).

As an aside, as the editor at JAGS who managed this manuscript, I will say that we don’t ordinarily publish cost effectiveness studies at JAGS, as the methods are opaque to our clinical audience (e.g. raise your hand if you understand what ‘CGA provided in the combination of acute care and rehab was non-dominated’ means).

We published this article because its bottom line is of great interest to geriatricians. In Eric’s study, geriatricians performing CGA were more cost effective than usual care in Every. Single. Setting.

And of course cost effectiveness is only one small piece of the argument for why we do the comprehensive geriatrics assessment in the first place (no patient in the history of the world has ever asked for a test or treatment because it’s cost effective for the health care system).

I’ll close with a couple of “mic drop” excerpts from Thiago’s accompanying editorial:

Finally, it is instructive to compare the cost-effectiveness of geriatric services and CGAs with other interventions. A recent analysis of lecanemab for early-stage Alzheimer's disease found that gaining one QALY would cost approximately $287,000 (USD). In contrast, Wong et al. estimated that adding community-based CGA would cost about $1203 (CAD) per quality-adjusted life month (QALM) (equating to roughly $10,105 (USD) per QALY, using $1 USD = $0.7 CAD), making geriatrician-led CGA nearly 30 times more cost-effective. Put simply, for each dollar spent to improve quality of life for a year through CGA, one would need to spend almost $30 to achieve the same benefit with lecanemab.

Ultimately, the question is not whether geriatricians represent a worthwhile investment (they are) but how healthcare systems can ensure that every older adult requiring specialized, comprehensive care can access it. Wong et al.'s modeling study provides a valuable contribution by showing that geriatricians placed in acute and rehabilitation settings offer the most cost-effective deployment given current workforce limitations. Despite some caveats, the overarching message remains clear: geriatric expertise not only enhances care quality but can also align with health-economic objectives, especially in high-acuity environments. However, we cannot allow an inadequate geriatric workforce to become a permanent constraint, forcing painful decisions about which older adults and which settings will miss out on optimal geriatric care. Instead, we should continue to strive to increase the number of geriatricians through robust training programs and payment model reform to ensure that cost-effective care can be provided for this large and growing vulnerable population.

-Alex Smith

On a prior podcast we talked with Todd Semla and Mike Steinman about the update to the AGS Beers Criteria of potentially inappropriate medications in older adults (Todd and Mike co-chair the AGS Beers Criteria Panel). One of the questions that came up was - well if we should probably think twice or avoid that medication, what should we do instead?

Today we talk with Todd and Mike about their new recommendations of alternative treatments to the AGS Beers Criteria, published recently in JAGS, and also presented at the 2025 AGS conference in Chicago (and available on demand online).

We had a lot of fun at the start of the podcast talking about the appropriate analogy for how clinicians should use the AGS Beers Criteria. In our last podcast, the analogy was a stop sign. You should come to a stop before you prescribe or refill a medication on the Beers list, look around at alternatives, and consider how to proceed. You might in the end decide to proceed, as there are certainly situations in which it does make sense to start or continue a medication on the Beers list.

Today’s analogy had somewhat higher stakes, involving a driver, a pothole in the road, and a cyclist on the side who you’d hit if you swerved. Really upping the anti!!!

The podcast is framed around a case Eric crafted of a patient with most of the medications and conditions on the Beers list. We used this as a springboard to discuss the following issues (with links to prior GeriPal podcasts):

• Insomnia (Doxepin is an alternative, trazodone and melatonin are not?!?)

• Diabetes management

• PPI for GERD

• Treatments for pain, including NSAIDS, COX2, and gabapentinoids

• Cannabis

• Deprescribing,org - terrific Canadian website (no tariff to use)

And I hope that the prescribing landscape is indeed getting better (thanks to Kai on guitar)!

-Alex Smith

Health care trainees rotate through a variety of different settings. ICUs, hospital wards, and outpatient clinics. If they're lucky, they might even spend time in a nursing home. But on today’s podcast, we’re adding one more setting to that list: your local art museum.

In this thought-provoking episode, we explore how art museum teaching is being integrated into the education of medical professionals—and why it's making a profound difference. Our guests, Amy Klein, Laura Morrison, and Gordon Wood, share their journey of integrating art into medical training, along with practical strategies you can use if you're inspired to do the same.

You'll also hear how engaging with museum-based medical education can help health care professionals deepen empathy and emotional awareness, practice the skill of multiple perspective-taking, and grow more comfortable with ambiguity and uncertainty.

Resources mentioned in the podcast include:

• A story about one medical student's experience with a day in the museum using multiple museum-based education exercices

• A Journal Article published in the Journal of Palliative Medicine titled “Museum-Based Education: A Novel Educational Approach for Hospice and Palliative Medicine Training Programs”

• A journal article on “Twelve Tips for Starting a Collaboration with an Art Museum.”

• A handout from the 2025 AAHPM/HPNA preconference gives examples of museum-based education exercises and resources for further training.

• Alex’s summary of some prompts we discussed for the “Personal Responses Tour”, which is a reflective exercise where participants choose artwork based on a personal prompt, then share with a small group. The prompts include:

• • Find a work of art that reminds you of a patient

  • Find a work of art that reflects a challenging clinical situation

  • Find a work that speaks to an experience you have had in your palliative medicine training that taught you about the impact of bias or racism

  • Find a work that connects to the path you took into palliative care or geriatrics

  • Find a piece that makes you think about community

  • Find a piece that reflects your idea of what a “good death” is

Lastly, stay on the “look out for” the 2026 Art Museum-Based Education preconferences session at the AAHPM/HPNA annual meeting on March 4, 2026 in San Diego!