2008 Hartford Outcomes Award Winners
Sarah D. Berry, MD, MPH
“Medications as Acute Precipitants of Falls in the Nursing Home Setting”
Hebrew Rehabilitation Center, Institute for Aging Research (Boston, MA)
Sarah D. Berry is an Instructor of Medicine in the Division of Gerontology at Harvard Medical School. She finished an Internal Medicine residency at the University of Utah, and a geriatrics fellowship at Beth Israel Deaconess Medical Center in Boston, MA. After her clinical fellowship she received a Masters in Public Health through Harvard University, and pursued research training as a fellow at Beth Israel Deaconess Medical Center/ Hebrew Rehabilitation Center. Her research interests include osteoporosis and fracture related outcomes in the elderly. As a Hartford scholar, she plans to extend her current research to study acute risk factors for falls. Specifically she will look at the temporal effect of medication changes on the acute risk of falls in nursing home residents using a case-crossover study design. Information from this study could be used to develop more effective fall prevention strategies in the nursing home setting.
Name: Sarah D. Berry
Title: Medications as Acute Falls Precipitants in the Nursing Home Setting Background
In the nursing home setting, medications are a common risk factor for falls, yet little is known about the temporal relationship between medications and falls.
Objective: Determine the acute effect of medication administration or medication changes (increasing or starting a new medication) on the risk of falls. Determine if there is an interaction between functional status and medication administration or medication changes.
Methods: We propose a case-crossover study of 400 nursing home residents with a fall to examine the acute effects of medication use on the risk of falls. Falls, defined as unintentionally coming to rest on a lower surface, will be ascertained through a computerized falls-database, and will be confirmed through nursing records. Medication exposure will be determined from a retrospective review of medication logs during the 1- week preceding the fall. Ambulatory status will be determined from the ADL selfperformance scale of the Minimum Data Set closest to and preceding the fall. The effect of medication administration or medication changes on falls will be determined from the ratio of the frequency of medication exposure during hazard periods compared to the frequency of the same medication exposure during control periods using the Mantel- Haenzel equation for each class of medications separately. Stratified analyses will be performed on significant predictors based on ambulatory status.
Anticipated Results: Antidepressants, antipsychotics, benzodiazepines, other sedative hypnotics, diuretics, dementia medications, and hypoglycemic agents will be associated with an acute increased risk of falling between 1-12 hours following administration and/or within 1-week of medication changes. The acute effects of medication administration and medication changes will be greater among ambulatory nursing home residents compared with non-ambulatory residents.
Conclusion: Future falls prevention strategies in the nursing home setting should consider the acute effects of medication use on the risk of falls in their design.
Holly M. Holmes, MD
“Utility of Medications for Patients with Cancer in Hospice Care”
University of Texas, M.D. Anderson Cancer Center (Houston, TX)
Holly M. Holmes, MD is an Assistant Professor of Medicine at the University of Texas M. D. Anderson Cancer Center in the Department of General Internal Medicine, Ambulatory Treatment, and Emergency Care. She completed her clinical training in internal medicine and geriatrics at the University of Chicago, as well as research training in the University of Chicago’s Clinical Research Training Program. Dr. Holmes’ research interest centers on optimal prescribing for frail older adults with multiple comorbidities. Her initial work will focus on end-of-life populations. Specifically, the Hartford Award will allow her to study the use of medications for comorbidities in patients with cancer enrolling in hospice care.
Name: Holly M. Holmes, M.D.
Title of Proposed Research: Utility of Medications for Patients with Cancer in Hospice Care
Background: Limited studies have identified commonly used medications in patients with cancer in hospice, but little attention has been given to medications other than those for symptoms. There are no criteria that help to identify which therapies are no longer necessary or beneficial and may result in undue burdens to the patient. Establishing which medications for asymptomatic conditions are useful at the end of life could result in a substantial number of medications to target for discontinuation in hospice patients.
Methods: The first aim of this proposal is to characterize the current state of medication use in patients with cancer in hospice, identifying the most commonly used symptom medications and non-symptom medications, and evaluating the change in medication use throughout a patient’s hospice length of stay. Symptom medications are defined as those used for immediate benefit to control symptoms or acute diseases resulting in symptoms. Non-symptom medications are defined as those used for long-term benefit to control or prevent a chronic asymptomatic disease. Aim 1 will be accomplished with a retrospective analysis of a large database of hospice patients, comprising about 30% of the hospice population in the United States. The second aim of this proposal is to explore relevant data from clinical trials to quantify likelihood of benefits and risks of the most commonly prescribed non-symptom medications for patients with cancer in hospice, generating decision models for the use of these non-symptom medicines in hospice.
Long-term Objectives: The objective of this work is to create criteria for better medication use in patients with cancer enrolling in hospice care, in order to improve quality of life and reduce burdens at the end of life. The knowledge gained from this research will enable future prospective studies that evaluate the impact of improving medication use in hospice patients on quality of life.
Sei J. Lee, MD, MAS
“Glycemic Control and Health Outcomes in Frail, Dependent Elders”
University of California, San Francisco (San Francisco, CA)
Sei J. Lee, MD, MAS is an Assistant Professor of Medicine in the Division of Geriatrics at the San Francisco VA Medical Center and the University of California, San Francisco. He completed his clinical training in internal medicine and geriatrics at UCSF, along with research training focusing on healthcare quality improvement through the VA Quality Scholars Fellowship. As a Hartford Geriatrics Health Outcomes Research Scholar, Dr. Lee will study the association between glycemic control and mortality, functional decline and geriatric syndromes in a frail, dependent elderly population. He will also determine whether guideline-driven intensification of glycemic control has altered the rates of these outcomes. His long term research goal is to improve the care of older Americans through the application of prognostic information and quality measurement.
Stephen Thielke, MD, MA
“The Effects of Pain on Health and Quality of Life in Older Adults”
University of Washington (Seattle, WA)
Stephen Thielke, MD, MA is an Instructor in the University of Washington Department of Psychiatry and Behavioral Sciences. He completed residency of Psychiatry and a fellowship in Geriatric Psychiatry at the University of Washington. He is currently a research fellow in an NRSA T32 Geriatric Mental Health Services Research Fellowship in Seattle, and is completing an MS degree in Health Services. His research focuses on the role of pain and pain medications in the physical and mental health of older adults. He is analyzing large longitudinal databases in order to model the relationships between physical health, pain, depression, and analgesic medications. He will construct predictive models to ascertain the effects of different interventions for painful conditions and mental health diagnoses, and will use these findings to develop and test targeted interventions for pain in primary care settings.
Name: Stephen Thielke, MD
Title: The Effects of Pain on Health and Quality of Life in Older Adults
Chronic pain is common in older adults, and causes significant suffering and disability. Recent research has suggested that common painful conditions are associated with greater declines in physical health than are other chronic medical diagnoses such as diabetes or congestive heart failure. There is also evidence that painful diagnoses are associated with higher healthcare costs. I aim to investigate the effects of pain on health outcomes, quality of life, and health care utilization and costs using four large existing longitudinal datasets: the Medicare Current Beneficiary Survey, Arkansas Medicaid, HealthCore, and the Medicare Health Support Program. Each of these captures a different sociodemographic group, and provides a slightly different set of measures of pain and outcomes. Using these datasets, I will categorize patients according to pain diagnoses and use of analgesic medications. I will then conduct analyses to determine how pain-related diagnoses are associated with (1) health outcomes, (2) quality of life, (3) mental health, and (4) costs and use of medical services. I will stratify the analyses by age and sociodemographic variables in order to model the effects of pain during aging and across different populations. I will include mental health diagnoses in the models in order to understand the relationship between pain and psychiatric comorbidity. Using these results, I will identify populations showing the most significant pain-related adverse health outcomes and identify opportunities for improving care for older adults with pain.
Alexia Torke, MD, MS
“A Prospective , Observational Study of Surrogate Decision Making for Hospitalized Older Adults”
Indiana University (Indianapolis, IN)
Alexia Torke, MD, MS is an Assistant Professor of Medicine in the Department of General Medicine and Geriatrics, Research Scientist with the Indiana University Center for Aging Research and the Regenstrief Institute, and Associate Director of the Fairbanks Fellowship in Medical Ethics. She completed her residency in Primary Care-Internal Medicine at Emory University and was a clinician-educator at Emory for five years. During that time, she developed and taught curricula on end of life communication and conducted prior research addressing end of life decision making for hospitalized adults. Dr. Torke then completed a fellowship in primary care health services research and ethics at the University of Chicago, where she also received a Masters in Science for Clinical Professionals. Dr. Torke’s clinical practice is located in the Indiana University Center for Senior Health and focuses on the primary care of older adults. Her research focuses on ethical aspects of medical decision making for older adults, including surrogate decision making for patients with dementia and other forms of cognitive impairment. Her long term goal is to improve the process and outcomes of decision making for older adults who cannot make their own medical decisions.
Four recipients, selected by an academic advisory board composed of distinguished academic geriatricians, will receive a $200,000 grant over a two-year period to perform studies in outcomes research addressing clinical strategies, innovative outcomes measures and quality of life. Research findings are presented at the American Geriatrics Society Annual Scientific Meeting at the conclusion of the recipient’s grant. Dr. Sarah Berry is receiving one year of funding. Congratulations!