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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."

In 1987, lovastatin became the first FDA-approved statin in the United States. Four decades later, statins are among the most frequently prescribed medications nationwide, with atorvastatin topping the overall list. Now, updated guidelines have expanded statin eligibility to cover nearly every older adult. On today's episode, we are joined by experts Tim Anderson, Rita Redberg, and Mike Rich to discuss when to start, and when to stop, statin therapy in older adults. Topics we talk about on starting and stopping statins in older adults include: Updates and changes for statin use in older adults in the new 2026 Guideline on the Management of Dyslipidemia including: The transition to the new PREVENT (Predicting Risk of Cardiovascular Disease EVENTs) equations. Raising the target age for 10-year ASCVD risk estimation from 75 to 79. Lowering ASCVD risk threshold categories: Low ( Clinical Implications of these new guidlines:  A new study led by Tim Anderson reveals that over 93% of adults aged 70–79 now meet the criteria for primary prevention statins. Does the STAREE trial change anything?  The STAREE trial showed a 30% reduction in major cardiovascular events with atorvastatin in older adults, yet found no significant improvement in disability-free survival or all-cause mortality.  Statin Discontinuation Trials: Should we change our practice now that the SAGA/SITE trial showed stopping statins in older adults who have been on them for more than a year had no impact on mortality, quality of life, cognitive function, functional status, symptom burden, and adverse events. Lastly, while we didnt talk about it, this is another great RCT on statin discontinuation in individuals nearing the end of life, finding no significant difference in 60-day mortality or 1-year cardiovascular event risk between statin discontinuation and continuation.

When you think of palliative care pharmacotherapy, you probably think about the tried-and-true mainstays of our field like morphine, haloperidol, and senna. But the landscape of palliative symptom management is rapidly evolving, with hot new drug classes and rediscovered old-school opioids (and not just buprenorphine!) On today's episode of the GeriPal Podcast, we sit down with three expert palliative care clinical pharmacists, Max Stevenson, Alex McPherson, and Nisha Iyer, to talk about 5 hot new drugs (or rediscovered): Suzetrigine: It works for bunions (at least as well as opioids, maybe?), but can it work in palliative care?  My take-home point here is that its not ready for prime time, but you may have a different take after listening. Levorphanol: The forgotten opioid that looks a lot like methadone but more NMDA.  Should we bring it back to the living?  Maybe if it were cheaper (why does an old drug cost this much?) Tapentadol: Basically a better version of tramadol (aka Tamadont) that combines mu-opioid agonism with norepinephrine reuptake inhibition. Expensive but our guests varied in the potential benefit here. Dual Orexin Receptor Antagonists (DORAs): Rerouting sleep management away from sedating Z-drugs and benzodiazepines to these new agents seems reasonable (again if cost was no concern) given that they appear safer (check out this JAGS article on DORAs and the risk of falls) GLP-1 Receptor Agonists: Wait, GLP1's in palliative care (not just stopping it when we get consults for weight loss)? There may be a couple reasons to consider… Also check out some of these podcasts that we talked about in this episode: Gabapentinoids – Gabapentin and Pregabalin: Tasce Bongiovanni, Donovan Maust and Nisha Iyer Tramadon't: a podcast with David Juurlink about the dangers of Tramadol Buprenorphine Use in Serious Illness: A Podcast with Katie Fitzgerald Jones, Zachary Sager and Janet Ho All the Questions You Had About Opioids But Were Afraid To Ask: A Podcast with Mary Lynn McPherson

Love the story Judy Solerno tells at the start of this podcast. The story is about how John Snow, the father of modern epidemiology, mapped out cases of Cholera in London in the year 1854.  He was able to identify a concentration of cases near a neighborhood water pump.  Simply removing the handle from the pump halted the outbreak.  This is one of the earliest recorded uses of maps for public health purposes. Our guests today, Judy Salerno (President Emeritus of the New York Academy of Medicine) and Lindsay Goldman (CEO of Grantmakers in Aging) have done some wonderful work creating detailed, in-depth, interactive maps of aging in New York City. Go to IMAGENNYC and try it yourself. Today we talk about: How the whole country became familiar with these sort of maps during Covid The case for using these maps for health needs of older adults, outside of the use cases in infections like Cholera and Covid Our "favorite" density maps of resources, services, and amenities, including: benches, crosswalks, tree canopy, heat vulnerability, among others. Use cases for these maps in public health and planning, grantmaking/philanthropy, and politics/policy advocacy. Judy's work creating similar maps for Sao Paulo Brazil (will add link here when website is up). How others can replicate this process in their home cities or counties And I get to sing Tapestry, by Carol King, which Judy chose in honor of two recently deceased giants of feminism, Dolly Parton and Gloria Steinem.  My wife Cindy plays piano on the audio only podcast. -Alex Smith

Just in time for respiratory virus season, this episode of the podcast breaks down essential vaccine guidance for older adults. From flu, COVID-19, and RSV to an added bonus deep dive into shingles, we cover everything you need to know to protect older adults this season. Our expert guests include: Kenneth Schmader, MD: A geriatrician and vaccine researcher who helped develop the zoster vaccine. Ken serves on the Working Groups for the Herpes Zoster, Influenza, COVID-19, RSV and General Adult Immunization Guidelines for the US Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP). Sharon Brangman, MD: a geriatrician extraordinaire whom we've had in the past for her work in Alzheimer's, and whom we've now asked to talk about her work with the AGS Older Adults Vaccine Initiative. We covered a lot of topics, including: Who needs which vaccine at what age: Clear guidelines for COVID-19, RSV, flu, and shingles vaccines. Optimal seasonal timing: What the optimal timing during the year to receive the schedule their shots? Vaccine selection: How to choose between options, including standard-dose, high-dose, and new mRNA flu vaccines? Does the shingles vaccine really prevent dementia? Listen now and explore the links below for more resources. Eric Resources: AGS Vaccine Initiative Website.  They have a variety of resources including: Get the Basics: Essential Vaccines for Older Adults Learn More: What You Need to Know About COVID-19 Vaccines for Older Adults (Age 65+) Ask The Expert: The Flu Vaccine Learn More: What You Need to Know About the Shingles Vaccine Get the Basics: RSV Vaccines for Older Adults (60+) CDC Adult Immunization Schedule The Nature study we discussed on the effect of herpes zoster vaccination on dementia

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: Aruna's article in JAGS titled "One Size Fits None: Developing a Person-Centered Approach to Weight Management in Older Adults" John's Annal's article on the "Effect of Incretin-Based and Nonpharmacologic Weight Loss on Body Composition: A Systematic Review" John's article on the "Unintended risks of sarcopenic obesity during weight-loss interventions in older people" in Nature Med.   An article titled "The Effects of Incretin Mimetic Therapies on Muscle and Bone Health in Older Adults" A systematic review of the effect of weight loss on muscle-based indices An article on "Treating Sarcopenic Obesity in the Era of Incretin Therapies: Perspectives and Challenges" Shen's article describing "The Optimal Health Weight and Lifestyle (OHWL) Clinic" Shen's article titled "A Geriatrician's Approach to Managing the Complex Older Adult with Obesity" Another JAGs article on "Older Adults with Obesity: The Need for a 4Ms Age-Friendly Approach to Care" 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