Pharmacotherapy

Professor of Medicine Joe Hanlon PharmD MS directs the NIH Geriatric Pharmacotherapy Center of Excellence, which was launched with funding from an NIH K07. Dr. Hanlon is also a key contributor to the renowned “Beers List,” which is used by researchers, clinicians, and the federal government (e.g. CMS, NQF, HEDIS). The Center’s goals are two-fold: 1) to conduct systematic evaluations of drug use and medications recommended for older people; 2) to support a fellowship training program in geriatric pharmacotherapy. The Pharmacotherapy Center-supported fellows have established a history of research excellence.

Selected publications of recent fellows include:

Marcum ZA, Perera S, Thorpe JM, Switzer GE, Castle NG, Strotmeyer ES, Simonsick EM, Ayonayon HN, Phillips CL, Rubin S, Zucker-Levin AR, Bauer DC, Shorr RI, Kang Y, Gray SL, Hanlon JT; Health ABC Study. Antidepressant Use and Recurrent Falls in Community-Dwelling Older Adults: Findings From the Health ABC  Study. Ann Pharmacother. 2016 Jul;50(7):525-33. doi: 10.1177/1060028016644466. Epub 2016 Apr 11. PMID: 27066988; PMCID: PMC4892949.

Few studies have compared the risk of recurrent falls across various antidepressant agents-using detailed dosage and duration data-among community-dwelling older adults, including those who have a history of a fall/fracture. The objective of this study is to examine the association of antidepressant use with recurrent falls, including among those with a history of falls/fractures, in community-dwelling elders.

Marcum ZA, Wirtz HS, Pettinger M, LaCroix AZ, Carnahan R, Cauley JA, Bea JW, Gray SL. Anticholinergic medication use and falls in postmenopausal women: findings from the women’s health initiative cohort study. BMC Geriatr. 2016 Apr 2;16:76. PMID: 27038789; PMCID: PMC4818856.

Results from studies assessing the association between anticholinergic use and falls are mixed, and prior studies are limited in their ability to control for important potential confounders. Thus, we sought to examine the association between anticholinergic medication use, including over-the-counter medications, and recurrent falls in community-dwelling older women. Our findings reinforce judicious use of anticholinergic medications in older women. Public health efforts should emphasize educating older women regarding the risk of using over-the-counter anticholinergics, such as first-generation antihistamines.

Marcum ZA, Kisak A, Visoiu A, Resnick N. Medication Discrepancies and Shared Decision-Making. J Am Geriatr Soc. 2016 Mar;64(3):653-4. PMID: 27000344.

Older adults often find medication instructions confusing and frustrating after hospital discharge, putting them at high risk of potentially dangerous medication discrepancies or errors.  To address this problem, older adults were followed within 7 days of hospital discharge from the geriatric service of MWH to identify the root causes of common medication discrepancies. Shared decision-making concepts were used with participants and caregivers to better understand the medication information needed—and desired—when leaving the hospital. Overall, the goal was to better understand the frequency and causes of medication discrepancies during the transition from hospital to home.

Naples JG, Hanlon JT, Schmader KE, Semla TP. Recent Literature on Medication Errors and Adverse Drug Events in Older Adults. J Am Geriatr Soc. 2016 Feb;64(2):401-8. Epub 2016 Jan 25. Review.  PMID: 26804210; PMCID: PMC4760841.

Medication errors and adverse drug events are common in older adults, but locating literature addressing these issues is often challenging. The objective of this article is to summarize recent studies addressing medication errors and adverse drug events in a single location to improve accessibility for individuals working with older adults. A comprehensive literature search for studies published in 2014 was conducted, and 51 potential articles were identified. After critical review, 17 studies were selected for inclusion based on innovation; rigorous observational or experimental study designs; and use of reliable, valid measures. Four articles characterizing potentially inappropriate prescribing and interventions to optimize medication regimens were annotated and critiqued in detail. The authors hope that health policy-makers and clinicians find this information helpful in improving the quality of care for older adults.

Marcum ZA, Kisak A, Visoiu A, Resnick N. Medication Reconciliation: Will the Real Medication List Please Stand Up? J Am Geriatr Soc. 2015 Dec;63(12):2639-2641. PMID: 26691709; PMCID: PMC4814208.

Medication reconciliation is defined by The Joint Commission as “a process of obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient.”1 Medication reconciliation on admission to the hospital is an essential step to prevent downstream medication discrepancies and adverse drug events.2 At Magee-Womens Hospital (MWH) of UPMC, nurses document initial medication lists as soon as possible upon admission as one part of the admission process. Pharmacists are not routinely or systematically involved in admission medication reconciliation at MWH; however, prior research has shown tremendous promise for pharmacist-led medication reconciliation.3-6Thus, using a pharmacist-led quality improvement process, we sought to describe the prevalence of medication clarifications (i.e., initial differences between outpatient medication list and first-documented list that require clarification to be reconciled) and medication discrepancies (i.e., unexplained differences between outpatient medication list and inpatient list present after 24 hours); and to describe the potential severity of detected medication clarifications and discrepancies.

Marcum ZA, Perera S, Newman AB, Thorpe JM, Switzer GE, Gray SL, Simonsick EM,  Shorr RI, Bauer DC, Castle NG, Studenski SA, Hanlon JT; Health ABC Study. Antihypertensive Use and Recurrent Falls in Community-Dwelling Older Adults: Findings From the Health ABC Study. J Gerontol A Biol Sci Med Sci. 2015 Dec;70(12):1562-8. Epub 2015 Aug 11.  PMID: 26265732; PMCID: PMC4643613.

Despite wide-spread use of antihypertensives in older adults, the literature is unclear about their association with incident recurrent falls over time. Controlling for potential demographic, health status/behavior and access to care confounders, we found no increase in risk of recurrent falls in antihypertensive users compared to nonusers (adjusted odds ratio [AOR] = 1.13; 95% CI = 0.88-1.46), or those taking higher SDDs or for longer durations. Only those using a loop diuretic were found to have a modest increased risk of recurrent falls (AOR = 1.50; 95% CI = 1.11-2.03).  In conclusion, antihypertensive use overall was not statistically significantly associated with recurrent falls after adjusting for important confounders. Loop diuretic use may be associated with recurrent falls and needs further study.

Hanlon JT, Semla TP, Schmader KE. Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures. J Am Geriatr Soc. 2015 Dec;63(12):e8-e18. Epub 2015 Oct 8.  PMID: 26447889; PMCID: PMC4890629.

The National Committee for Quality Assurance (NCQA) and the Pharmacy Quality Alliance (PQA) use the American Geriatrics Society (AGS) Beers Criteria to designate the quality measure Use of High-Risk Medications in the Elderly (HRM). The Centers for Medicare and Medicaid Services (CMS) use the HRM measure to monitor and evaluate the quality of care provided to Medicare beneficiaries. NCQA additionally uses the AGS Beers Criteria to designate the quality measure Potentially Harmful Drug-Disease Interactions in the Elderly. Medications included in these measures may be harmful to elderly adults and negatively affect a healthcare plan’s quality ratings. Prescribers, pharmacists, patients, and healthcare plans may benefit from evidence-based alternative medication treatments to avoid these problems. Therefore the goal of this work was to develop a list of alternative medications to those included in the two measures. The authors conducted a comprehensive literature review from 2000 to 2015 and a search of their personal files. From the evidence, they prepared a list of drug-therapy alternatives with supporting references. A reference list of nonpharmacological approaches was also provided when appropriate. NCQA, PQA, the 2015 AGS Beers Criteria panel, and the Executive Committee of the AGS reviewed the drug therapy alternatives and nonpharmacological approaches. Recommendations by these groups were incorporated into the final list of alternatives. The final product of drug-therapy alternatives to medications included in the two quality measures and some nonpharmacological resources will be useful to health professionals, consumers, payers, and health systems that care for older adults.

Naples JG, Marcum ZA, Perera S, Gray SL, Newman AB, Simonsick EM, Yaffe K, Shorr RI, Hanlon JT; Health, Aging and Body Composition Study. Concordance Between Anticholinergic Burden Scales. J Am Geriatr Soc. 2015 Oct;63(10):2120-4. PMID: 26480974; PMCID: PMC4617193.

The goal was to evaluate concordance of five commonly used anticholinergic scales. Any anticholinergic use in rank order was 51% for the ACB, 43% for the ADS, 29% for the DBI-ACh, 23% for the ARS, and 16% for the SAMS. Kappa statistics for all pairwise u comparisons ranged from 0.33 to 0.68. Similarly, concordance as measured using weighted kappa statistics ranged from 0.54 to 0.70 for the three scales not incorporating dosage (ADS, ARS, ACB). Spearman rank correlation between the DBI-ACh and SAMS was 0.50.Only low to moderate concordance was found between the five anticholinergic scales. Future research is needed to examine how these differences in measurement affect their predictive validity with respect to clinically relevant outcomes, such as cognitive impairment.

Culley CM, Perera S, Marcum ZA, Kane-Gill SL, Handler SM. Using a Clinical Surveillance System to Detect Drug-Associated Hypoglycemia in Nursing Home Residents. J Am Geriatr Soc. 2015 Oct;63(10):2125-9. Epub 2015 Oct 12.  PMID: 26456318; PMCID: PMC4778416.

The goal was to determine whether a clinical surveillance system could be used to detect drug-associated hypoglycemia events and determine their incidence in nursing home (NH) residents.
Hypoglycemia can be detected using a clinical surveillance system. This evaluation found a high incidence of drug-associated hypoglycemia in a general NH population. Future studies are needed to determine the potential benefits of use of a surveillance system in real-time detection and management of hypoglycemia in NHs.

Lo-Ciganic WH, Donohue JM, Thorpe JM, Perera S, Thorpe CT, Marcum ZA, Gellad WF. Using machine learning to examine medication adherence thresholds and risk of hospitalization. Med Care. 2015 Aug;53(8):720-8. doi: 10.1097/MLR.0000000000000394.  PMID: 26147866; PMCID: PMC4503478.

Quality improvement efforts are frequently tied to patients achieving ≥80% medication adherence. However, there is little empirical evidence that this threshold optimally predicts important health outcomes. The study found that adherence thresholds most discriminating of hospitalization risk were not uniformly 80%. Machine-learning approaches may be valuable to identify appropriate patient-specific adherence thresholds for measuring quality of care and targeting nonadherent patients for intervention.

Marcum ZA, Gurwitz JH, Colón-Emeric C, Hanlon JT. Pills and ills: methodological problems in pharmacological research. J Am Geriatr Soc. 2015 Apr;63(4):829-30. PMID: 25900504; PMCID: PMC4408882.

Medications are the most frequently used form of therapy employed in the care of older adults. Unfortunately, the frequent exclusion of these patients from premarketing clinical trials of new medications has limited our knowledge regarding the safety and efficacy of individual medications in our aging population. Moreover, the most common chronic condition that older adults experience is multimorbidity, with two of every three older adults having multiple chronic conditions. Multiple chronic conditions account for 66% of the country’s overall health expenditures and more than 95% of Medicare expenditures. Therefore, it is critical to understand the risks and benefits of medications in the presence of multimorbidity.

Marcum ZA, Sevick MA, Handler SM. Medication nonadherence: a diagnosable and  treatable medical condition. JAMA. 2013 May 22;309(20):2105-6. PMID: 23695479; PMCID: PMC3976600.

Medication nonadherence is widely recognized as a common and costly problem.1 Approximately 30% to 50% of US adults are not adherent to long-term medications leading to an estimated $100 billion in preventable costs annually.1 The barriers to medication adherence are similar to other complex health behaviors, such as weight loss, which have multiple contributing factors. Despite the widespread prevalence and cost of medication nonadherence, it is undetected and undertreated in a significant proportion of adults across care settings. According to the World Health Organization, “increasing the effectiveness of adherence interventions may have far greater impact on the health of the population than any improvement in specific medical treatments.” How can adherence be improved? We propose that the first step is to view medication nonadherence as a diagnosable and treatable medical condition.

Peron EP, Zheng Y, Perera S, Newman AB, Resnick NM, Shorr RI, Bauer DC, Simonsick EM, Gray SL, Hanlon JT, Ruby CM; Health, Aging, and Body Composition (Health ABC) Study. Antihypertensive drug class use and differential risk of urinary incontinence in community-dwelling older women. J Gerontol A Biol Sci Med Sci. 2012 Dec;67(12):1373-8. Epub 2012 Sep 12.  PMID: 22972942; PMCID: PMC3636671.

Medication use is a potentially reversible cause of urinary incontinence (UI). The objective of this longitudinal cohort study was to evaluate whether self-reported UI in community-dwelling older women is associated with the use of different classes of antihypertensive agents.  In community-dwelling older women, peripheral alpha blocker use was associated with UI, and the odds nearly doubled when used with loop diuretics.

Marcum ZA, Hanlon JT. Commentary on the new American Geriatric Society Beers criteria for potentially inappropriate medication use in older adults. Am J Geriatr Pharmacother. 2012 Apr;10(2):151-9. PMID: 22483163; PMCID: PMC3381503.

Recently, the American Geriatrics Society (AGS) Beers criteria were unveiled as a measure of potentially inappropriate medication use in older adults. We thought that it would be timely and relevant to comment on this updated quality measure for medication use. Of note, a recent systematic review summarized the current literature on the more than a dozen measures of potentially inappropriate prescribing in older adults and reported that the Beers criteria and the Screening Tool of Older Persons’ Prescriptions (STOPP) criteria were some of the most commonly used measures. With that in mind, in this commentary, we discuss some of the history of the Beers criteria as well as briefly describe the process of updating the criteria, highlighting some of the key changes made. Then, we compare and contrast the new criteria with the STOPP criteria from Europe. Finally, we briefly comment on some future directions for the Beers criteria as an explicit measure of potentially inappropriate medication use in older adults.