Todd Semla, Pharm D.

Department of Veterans Affairs

“I always liked working with older people. Older people always have interesting stories to tell."

A Clinical Pharmacy Specialist with the Department of Veterans Affairs, an expert on drug treatment for older adults, and an associate professor in the Feinberg School of Medicine at Northwestern University, Todd Semla, PharmD, developed an interest in geriatrics for many of the same reasons he was drawn to clinical pharmacy. Both fields were complex and challenging. And they offered opportunities to dramatically improve people's lives.

"When I started high school, I was actually thinking about becoming a chef," recalls Dr. Semla, who inherited a love of cooking from his mother and grandmother and an appreciation of the value of work that's of service to others from both parents.

"During my sophomore year, though, someone from the St. Louis College of Pharmacy came to my school's Career Day and talked about this new field called "clinical pharmacy" where you work with patients to help make medication therapy decisions and monitor drug treatment," Dr. Semla continues. "It wasn't just dispensing medicine. There was an emphasis on pharmacology and drug therapy. There was a lot involved, a lot to learn. And that got me really interested."

At the time, the late 1970s, clinical pharmacists worked primarily in hospitals but were beginning to branch out into ambulatory settings, starting with family practice resident training clinics. "At one rural clinic in Iowa where I worked as a clinical pharmacist early in my career, we provided continuity care because the residents would change every six weeks," he explains. "We would monitor each patient's response to drug therapy and make adjustments as outlined in the treatment plan." Clinical pharmacists now run anticoagulation, diabetes, lipid management clinics, and general medicine ambulatory care clinics as well.

After earning his bachelor's degree in pharmacy at the University of Iowa College of Pharmacy in May of 1981, Dr. Semla enrolled in the school's master's program in clinical/hospital pharmacy. During the intervening summer, he worked at the University of Iowa Psychopathic Hospital, where he interviewed former psychiatric patients. It was an experience that fostered an enduring interest in psychiatry, psychopharmacology, and pharmacotherapy for dementia and depression in late life. "My very first clerkship in pharmacy school was in psychiatry," he recalls. "My professors were great teachers and the experience re-emphasized the biological basis for mental illness, which interested me."

Dr. Semla got interested in geriatrics during his final year in pharmacy school, during a clerkship in geriatrics that introduced him to nursing home and ambulatory care geriatric practices. While completing his master's degree and, later, his PharmD, at the university, he both worked as a clinical pharmacist and joined a research team conducting a three-site study funded by the National Institute on Aging. Dubbed the Established Population for Epidemiology Studies of the Elderly (EPESE), it was a longitudinal study of different groups of older adults in the US, including a group living just outside Iowa City. Among other things, the study examined medication use among older people. After earning his doctorate in 1985, he completed an American Society of Health-System Pharmacists' fellowship in geriatric pharmacotherapy.

"I always liked working with older people and bond with them," says Dr. Semla, a former president of the American Geriatrics Society. "Older people always have interesting stories to tell. In some ways it's more of a social call for them than for younger people, who usually want to get in and out quickly."

The complexity of working with older patients—who tend to have multiple health problems and take multiple medications—makes geriatric pharmacotherapy as rewarding as it is demanding, he explains.

"If you have a 40-year old patient with one or two health problems, like diabetes and high lipids, you can follow the therapeutic guidelines (for prescribing) and he's going to go on with his life," he says. "If you have a patient who's in her 80s and has, say, diabetes, arthritis, high blood pressure, high lipids and maybe glaucoma, along with functional limitations, it's very different," he explains. "You have to consider a wide array of things when determining the goals of therapy and how to proceed. Your primary goal may be just to keep her living at home and as independent as possible. To accomplish that, you have to take into account factors such as whether she lives alone; the health of her caregiver, if she has one; her financial resources and whether she has anyone to help her get her medications. There are all sorts of medical and psychosocial issues that come into play. Coming up with a personalized plan can significantly impact her quality of life, which is rewarding.

"You do this work as part of a team," that includes physicians, nurses, social workers, and others, he adds. "And working with a team makes caring for older patients even more enjoyable because you always learn new things and see different perspectives by interacting with providers in other disciplines."

When managing drug therapy for older adults with multiple health problems, recognizing and addressing drug side effects and interactions is another ongoing challenge, Dr. Semla says.

"You always have to be very comprehensive—you can't change one thing and not think about others," he says. "You also always have to watch for drug-induced illnesses. Is the person having memory problems because he's depressed or is it because of a medication side effect?"

Adding to the complexity, drugs may have unanticipated side effects in older people because older adults are underrepresented in drug trials. At the same time, practice guidelines that may be appropriate for younger adults aren't always the best fit for older adults.

In the classroom, Dr. Semla emphasizes the importance of taking multiple factors into account while working with older patients. His first teaching job was as a clinical assistant professor in the department of pharmacy practice in the College of Pharmacy at the University of Illinois at Chicago. He later became a clinical assistant professor of pharmacy practice in medicine in the Section of Geriatric Medicine at the college, a post he held for 15 years. He is currently an associate professor in the Departments of Medicine and Clinical Psychiatry and Behavioral Sciences at Northwestern University's Fienberg School of Medicine.

"I've always enjoyed teaching geriatric pharmacotherapy because it's important to me to impress on students that you can't just take the same approach," regardless of a patient's age, he says. "It's important to open their eyes to the challenges they're going to see when they're out there taking care of patients. It's also important to teach students about the disease syndromes that are relatively unique to geriatrics, such as urinary incontinence and dementia."

Dr. Semla has published scores of papers on Alzheimer's disease, depression, psychiatric symptoms, antipsychotic drug therapy, drug related problems, and optimal drug therapy in older people. He has also been the lead editor of 11 editions of the Geriatric Dosage Handbook, and an editor of every issue of the American Geriatrics Society's Geriatrics at Your Fingertips, among other texts.

Since 2003, has been a member of the US Department of Veterans Affairs Pharmacy Benefits Management & Strategic Healthcare Group. Though part of the VA's Central Office in Washington, DC, most of the group has offices in Hines, Illinois. The healthcare group writes in-depth reviews of research concerning new and existing medications that the VA uses to decide which drugs to include in its national formulary.

"It's very academically and intellectually satisfying; you get to read and write all day and you have a lot of time to get into a particular topic in depth," says Dr. Semla, who reviews drugs for psychiatric conditions, dementia, osteoporosis and other age-associated health problems, and is working with other VA offices to develop drug databases applicable to older adults in long-term care. "My background in geriatrics and psychiatry complements the expertise of my colleagues."

Identifying interventions that improve prescribing for older people, he says, is the most pressing concern in geriatric pharmacology today.

"One of the biggest limitations we face is that we have so little information about how drugs—new drugs in particular—affect older people because drug trails usually include people from younger populations," he emphasizes. "There's a lot of work that needs to be done in this area. It's important work."

Dr. Semla and his wife, Susan, who has a Ph.D. in Pharmaceutical Sciences and has worked for Abbott Laboratories for more than 20 years, live in Evanston, Illinois with their three children. "We like to say that 'life is full' around our house," he says. "So Susan and I don't talk about work."