Perspectives on Geriatrics by Pioneers in Aging: Reflections of a Clinical Pharmacist

Joseph T. Hanlon PharmD, MS, BCGP, AGSF

Disclosures

J Am Geriatr Soc. 2021;69(4):896-899. 

In This Article

Mid-career

After 6 years, I moved across town to the Duke Center for Aging led by Dr. Harvey J. Cohen, MD.[14] He was the one who saw something in me that I did not and encouraged me to pursue research. He closely worked with me and arranged for two wonderful PhDs to serve as my research mentors: Drs. Morris Weinberger and Gerda Fillenbaum.[15,16] Dr. Weinberger is a sociologist health services research interventionist who was Co-PI on my first NIA funded R01 (AG08380) entitled "Pharmacy Interventions for Polypharmacy in the Elderly". He worked with me and my close colleague Ken Schmader, MD to develop the primary outcome for that randomized controlled trial: the Medication Appropriateness Index (MAI).[17,18] The MAI consists of 10 questions that allow three rating choices: "A" being appropriate, "B" being marginally appropriate, and "C" being inappropriate. To provide clarity for evaluators and improve reliability, the MAI has general instructions for use, and specific definitions of each criterion, instructions on how to answer each of the 10 questions, and specific examples of "A," "B," and "C"s.[17,18] In addition, the MAI uses weights and has numerous appendices as references to help evaluators to accurately answer questions.[17,18] We showed in one of the first deprescribing trials that a clinical pharmacist's activity in a general medicine clinic improved the quality of prescribing by nearly 25% in older outpatients with polypharmacy.[19] The MAI is still used widely around the world as a research measure of prescribing quality.[17,18]

Dr. Fillenbaum is a psychologist who developed international measures of functional and cognitive status and was Co-PI on my second R01 (HS07819) entitled "Cognitive Impairment and Medication Appropriateness." We demonstrated the negative impact of benzodiazepines, and high dose NSAIDs on cognitive function in community dwelling older adults.[20,21] The results from the first study helped influence the inclusion of all benzodiazepines, regardless of half-life, into the explicit criteria for potentially inappropriate medications to avoid both in the United States and Europe.[22,23] With the help of these mentors, I also co-mentored seven geriatric pharmacy fellows supported by the University of North Carolina (UNC), Glaxo Pharmaceutical Company, and a Duke Aging Center T32 grant.

After 11 years at the Duke Aging Center, I moved to the University of Minnesota College of Pharmacy to take an Endowed Professorship. During my 6 years there, I was Co-PI on two R01s (AG15432 and AG14158). The first was entitled "Suboptimal Drug Use and Health Outcomes in the Elderly" from which Dr. Fillenbaum and I found that specific types of inappropriate prescribing (i.e., drug–drug and drug–disease interactions) were associated with functional status decline.[24] It is notable that explicit criteria for both drug–drug and drug disease interactions are now considered in Medicare Part C and D Star Ratings. The second grant was entitled "Impact of Geriatric Care on Drug-Related Problems" from which Dr. Schmader and I found that inpatient geriatric team care improved suboptimal prescribing whereas outpatient geriatric team care reduced the risk of serious adverse drug reactions by 35% in frail older patients.[25] The results from this trial have helped justify clinical pharmacist run "Polypharmacy Clinics" in the Veterans Health Administration. During this time, Dr. Schmader and I became co-editors of the American Journal of Geriatric Pharmacotherapy which was in print for a decade. I also through the support of my endowment mentored two geriatric pharmacy fellows.

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