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Seattle, WA, United States

Group Health Research Institute

Seattle, WA, United States
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News Article | November 21, 2016

ANN ARBOR, Mich. -- In a hopeful sign for the health of the nation's brains, the percentage of American seniors with dementia is dropping, a new study finds. The downward trend has emerged despite something else the study shows: a rising tide of three factors that are thought to raise dementia risk by interfering with brain blood flow, namely diabetes, high blood pressure and obesity. Those with the most years of education had the lowest chances of developing dementia, according to the findings published in JAMA Internal Medicine by a team from the University of Michigan. This may help explain the larger trend, because today's seniors are more likely to have at least a high school diploma than those in the same age range a decade ago. With the largest generation in American history now entering the prime years for dementia onset, the new results add to a growing number of recent studies in the United States and other countries that suggest a downward trend in dementia prevalence. These findings may help policy-makers and economic forecasters adjust their predictions for the total impact of Alzheimer's disease and other conditions. "Our results, based on in-depth interviews with seniors and their caregivers, add to a growing body of evidence that this decline in dementia risk is a real phenomenon, and that the expected future growth in the burden of dementia may not be as extensive as once thought," says lead author Kenneth Langa, M.D., Ph.D., a professor in the U-M Medical School, Institute for Social Research and School of Public Health, and a research investigator at the VA Ann Arbor Healthcare System. "A change in the overall dementia forecast can have a major economic impact," he adds. "But it does nothing to lessen the impact that each case has on patients and caregivers. This is still going to be a top priority issue for families, and for health policy, now and in the coming decades." Langa and colleagues used data and cognitive test results from ISR's long-term Health and Retirement Study to evaluate trends from 2000 to 2012 among a nationally representative sample of more than 21,000 people age 65 or over. In all, 11.6 percent of those interviewed in 2000 met the criteria for dementia, while in 2012, only 8.8 percent did. Over that time, the average number of years of education a senior had rose by nearly an entire year, from 12 to 13. "It does seem that the investments this country made in education after the Second World War are paying off now in better brain health among older adults," says David R. Weir, Ph.D., senior author of the paper and director of the Health and Retirement Study. "But the number of older adults is growing so rapidly that the overall burden of dementia is still going up." Even as these new results come out, the Health and Retirement Study team is in the middle of another large study of dementia in the U.S. that will help refine the techniques for better understanding who has dementia in the American population, and allow them to be used in other countries around the world where HRS "sister studies" are also collecting data. Langa, who is the Sturgis Professor of Internal Medicine and a member of the U-M Institute for Healthcare Policy and Innovation, notes that the differences in dementia risk according to education level mark an important health disparity now, and likely into the future. "More Baby Boomers have completed some higher education than any previous generation, but the trend toward more education appears to be leveling off in the U.S. And there are clear disparities in educational attainment according to wealth and ethnicity," he says. "These differences in education and wealth may actually be creating disparities in brain health and, by extension, the likelihood of being able to work and be independent in our older years." Years of formal education was the only marker tracked among the study participants. But, says Langa, it is likely that the other ways that people challenge and use their brains throughout life--reading, social interactions, what occupation they have, and how long they work -- may also have an impact on dementia risk in later life. All of these pursuits can help build up a person's "cognitive reserve" of brain pathways that can survive the assault of the physical factors that lead to dementia. Researchers hope to learn much more about the cognitive reserve concept with new funding from recent federal initiatives that aim to increase dementia-related research and discovery. Continued focus on reducing cardiovascular risk -- through increased physical activity and controlling hypertension and diabetes in younger and middle-aged people -- may also help reduce future dementia rates. Growing evidence has shown that dementia in older adults is usually due to multiple causes, including Alzheimer's disease, which is characterized by a buildup of abnormal proteins in the brain, as well as vascular dementia, which results from brain tissue not receiving enough blood due to blockages and leaks in the brain's blood vessels. For those who do develop dementia, Langa notes, the challenge for America going forward will be to address the need for long-term care at home and in institutions, in the face of smaller families with fewer members to act as caregivers. Even if the slide in dementia incidence continues, the Baby Boom generation's sheer size will mean challenges for those who fund care or provide it. In addition to Langa and Weir, the study's authors are Eric B. Larson, M.D., M.P.H. of the Group Health Research Institute, Eileen M. Crimmins, Ph.D. of the University of Southern California, and University of Michigan researchers Jessica D. Faul, Ph.D., Deborah A. Levine, M.D., M.P.H., and Mohammed Kabeto, M.S. The study was funded by the National Institute on Aging of the National Institutes of Health (AG00974, AG040278, AG053760, AG024824)

von Korff M.,Group Health Research Institute | Kolodny A.,Maimonides Medical Center | Deyo R.A.,Oregon Health And Science University | Chou R.,Oregon Health And Science University
Annals of Internal Medicine | Year: 2011

In the past 20 years, primary care physicians have greatly increasedprescribing of long-term opioid therapy. However, the rise in opioidprescribing has outpaced the evidence regarding this practice. Increasedopioid availability has been accompanied by an epidemic ofopioid abuse and overdose. The rate of opioid addiction amongpatients receiving long-term opioid therapy remains unclear, butresearch suggests that opioid misuse is not rare. Recent studiesreport increased risks for serious adverse events, including fractures,cardiovascular events, and bowel obstruction, although further researchon medical risks is needed. New data indicate that opioidrelatedrisks may increase with dose. From a societal perspective,higher-dose regimens account for the majority of opioids dispensed,so cautious dosing may reduce both diversion potential and patientrisks for adverse effects. Limiting long-term opioid therapy to patientsfor whom it provides decisive benefits could also reduce risks.Given the warning signs and knowledge gaps, greater caution andselectivity are needed in prescribing long-term opioid therapy. Untilstronger evidence becomes available, clinicians should err on theside of caution when considering this treatment. © 2011 American College of Physicians.

News Article | March 23, 2016

People with chronic low back pain may benefit from meditating, a new study finds. The practice may reduce pain and make it easier for patients to carry out their daily activities, according to the findings.. In the study, a group of people with chronic low back pain participated in an eight-week program called mindfulness-based stress reduction, which involved using meditation to increase their awareness of the present moment, and their acceptance of difficult thoughts and feelings, including their pain. About six months after the start of the study, the people who participated in the meditation program were more likely to experience at least a 30 percent improvement in their ability to carry out daily activities, compared with the people who received only standard treatments for low back pain, such as medication. Those in the mindfulness meditation group were also more likely to report meaningful improvements in how much their back pain bothered them, compared with those in the standard treatment group, the study found. The findings remained similar a year after the start of the study. The study suggests that mindfulness-based stress reduction (MBSR) "may be an effective treatment option for patients with chronic low back pain," the researchers said. [7 Reasons You Should Meditate] "We are excited about these results, because chronic low back pain is such a common problem and can be disabling and difficult to treat," said study leader Daniel Cherkin, a senior investigator at Group Health Research Institute, a nonprofit health care organization in Seattle. Along with previous studies, "I believe that there is enough evidence…to say that MBSR is a reasonable treatment option," for patients to start now, Cherkin told Live Science. "It is relatively safe and may improve people's life beyond just back pain," Cherkin said. However, Cherkin noted that like all treatments for back pain, MBSR may not work for everyone. And more research is needed to see how long the effects last — the researchers were not able to look at the effects of MSRB beyond a year. The new study involved 342 adults ages 20 to 70 who had low back pain that wasn't attributable to another condition. On average, participants had experienced moderate back pain (rated as 6 out of 10 on a pain scale) for seven years, and said they had pain most days. About three-quarters of participants said they had used pain medication at least once in the past week to treat their back pain. The researchers randomly assigned participants to one of three groups: One group received MBSR in addition to their usual treatment; another received cognitive behavioral therapy (or CBT, a type of talk therapy that is already recommended for people with low back pain) in addition to their usual treatment; and the third group that received only their usual treatment. The participants answered questions about how their back pain limited their everyday activities (such as whether it prevented them from going to work, or standing for long periods of time), and how much their back pain bothered them. After 26 weeks (18 weeks after the MBSR and CBT treatments had finished), about 60 percent of participants in both the MBSR group and the CBT group had experienced meaningful improvements on the survey of everyday activities, compared with just 44 percent in the usual care group. In addition, about 44 percent of participants in the MBSR group and the CBT group experienced meaningful improvements in their bothersomeness ratings, compared with just 27 percent in the usual-care group. The results "indicate a considerable number of patients experienced clinically important relief of pain and disability," in the MBSR and CBT groups, Dr. Madhav Goyal and Jennifer Haythornthwaite, of Johns Hopkins University School of Medicine, wrote in an editorial accompanying the study. The editorial noted that the study was not able to determine whether the improvements seen in patients in the MSBR and CBT groups were due to so-called "nonspecific effects," such as participating in a group activity, or paying attention to an instructor. While this may be important to distinguish for academic purposes "for patients, it really may not matter if the intervention helps their condition," Goyal and Haythornthwaite said.

Phelan E.A.,University of Washington | Borson S.,University of Washington | Grothaus L.,Group Health Research Institute | Balch S.,Group Health Research Institute | Larson E.B.,Group Health Research Institute
JAMA - Journal of the American Medical Association | Year: 2012

Context: Dementia is associated with increased rates and often poorer outcomes of hospitalization, including worsening cognitive status. New evidence is needed to determine whether some admissions of persons with dementia might be potentially preventable. Objective: To determine whether dementia onset is associated with higher rates of or different reasons for hospitalization, particularly for ambulatory care-sensitive conditions (ACSCs), for which proactive outpatient care might prevent the need for a hospital stay. Design, Setting, and Participants: Retrospective analysis of hospitalizations among 3019 participants in Adult Changes in Thought (ACT), a longitudinal cohort study of adults aged 65 years or older enrolled in an integrated health care system. All participants had no dementia at baseline and those who had a dementia diagnosis during biennial screening contributed nondementia hospitalizations until diagnosis. Automated data were used to identify all hospitalizations of all participants from time of enrollment in ACT until death, disenrollment from the health plan, or end of follow-up, whichever came first. The study period spanned February 1, 1994, to December 31, 2007. Main OutcomeMeasures: Hospital admission rates for patients with and without dementia, for all causes, by type of admission, and for ACSCs. Results: Four hundred ninety-four individuals eventually developed dementia and 427 (86%) of these persons were admitted at least once; 2525 remained free of dementia and 1478 (59%) of those were admitted at least once. The unadjusted all-cause admission rate in the dementia group was 419 admissions per 1000 person-years vs 200 admissions per 1000 person-years in the dementia-free group. After adjustment for age, sex, and other potential confounders, the ratio of admission rates for all-cause admissions was 1.41 (95% confidence interval [CI], 1.23-1.61; P<.001), while for ACSCs, the adjusted ratio of admission rates was 1.78 (95% CI, 1.38-2.31; P<.001). Adjusted admission rates classified by body system were significantly higher in the dementia group for most categories. Adjusted admission rates for all types of ACSCs, including bacterial pneumonia, congestive heart failure, dehydration, duodenal ulcer, and urinary tract infection, were significantly higher among those with dementia. Conclusion: Among our cohort aged 65 years or older, incident dementia was significantly associated with increased risk of hospitalization, including hospitalization for ACSCs. ©2012 American Medical Association. All rights reserved.

Von Korff M.R.,Group Health Research Institute
Best Practice and Research: Clinical Rheumatology | Year: 2013

Increased opioid prescribing for back pain and other chronic musculoskeletal pain conditions has been accompanied by dramatic increases in prescription-opioid addiction and fatal overdose. Opioid-related risks appear to increase with dose. Although short-term randomised trials of opioids for chronic pain have found modest analgesic benefits (a one-third reduction in pain intensity on average), the long-term safety and effectiveness of opioids for chronic musculoskeletal pain remains unknown. Given the lack of large, long-term randomised trials, recent epidemiologic data suggest the need for caution when considering long-term use of opioids to manage chronic musculoskeletal pain, particularly at higher dosage levels. Principles for achieving more selective and cautious use of opioids for chronic musculoskeletal pain are proposed. © 2013 Elsevier Ltd. All rights reserved.

Jackson M.L.,Group Health Research Institute | Nelson J.C.,Group Health Research Institute | Nelson J.C.,University of Washington
Vaccine | Year: 2013

Objective: The test-negative design has emerged in recent years as the preferred method for estimating influenza vaccine effectiveness (VE) in observational studies. However, the methodologic basis of this design has not been formally developed. Methods: In this paper we develop the rationale and underlying assumptions of the test-negative study. Under the test-negative design for influenza VE, study subjects are all persons who seek care for an acute respiratory illness (ARI). All subjects are tested for influenza infection. Influenza VE is estimated from the ratio of the odds of vaccination among subjects testing positive for influenza to the odds of vaccination among subjects testing negative. Results: With the assumptions that (a) the distribution of non-influenza causes of ARI does not vary by influenza vaccination status, and (b) VE does not vary by health care-seeking behavior, the VE estimate from the sample can generalized to the full source population that gave rise to the study sample. Based on our derivation of this design, we show that test-negative studies of influenza VE can produce biased VE estimates if they include persons seeking care for ARI when influenza is not circulating or do not adjust for calendar time. Conclusions: The test-negative design is less susceptible to bias due to misclassification of infection and to confounding by health care-seeking behavior, relative to traditional case-control or cohort studies. The cost of the test-negative design is the additional, difficult-to-test assumptions that incidence of non-influenza respiratory infections is similar between vaccinated and unvaccinated groups within any stratum of care-seeking behavior, and that influenza VE does not vary across care-seeking strata. © 2013 Elsevier Ltd.

LeResche L.,University of Washington | LeResche L.,Group Health Research Institute
Clinical Orthopaedics and Related Research | Year: 2011

Background: Prevalence rates of most musculoskeletal pain conditions are higher among women than men. Reasons for these prevalence disparities likely include sex differences in basic pain mechanisms and gender differences in psychosocial factors. Questions/purposes: The purposes of this review were to (1) identify reasons for differences in pain prevalence between men and women, (2) assess whether musculoskeletal pain conditions are differently treated in men and women, and (3) identify reasons for sex/gender disparities in pain treatment. Methods: A MEDLINE search was conducted using the terms "pain" or "musculoskeletal pain" and "gender differences" or "sex differences" with "health care," "health services," and "physician, attitude." Articles judged relevant were selected for inclusion. Where Are We Now? Higher pain prevalence in women is consistently observed but not well understood. The relative contributions of sex differences in pain mechanisms and gender differences in psychosocial factors (eg, coping, social roles) to explaining differences in prevalence are not yet clear. Gender disparities in the amount of healthcare use for pain may be partially explained by the experience of higher-intensity pain in women. Pain intensity also seems to be a major factor influencing treatment, especially the prescription of medications for acute pain. However, clinicians' gender stereotypes, as well as the clinician's own gender, appear to influence diagnostic and treatment decisions for more persistent pain problems. Where Do We Need To Go? The ultimate goal is optimal pain control for each individual, with gender being one difference between individuals. How Do We Get There? Further research is needed to address all three major purposes, with particular attention to whether gender-specific pain treatment may sometimes be warranted. © 2011 The Association of Bone and Joint Surgeons®.

Arterburn D.E.,Group Health Research Institute | Courcoulas A.P.,University of Pittsburgh
BMJ (Online) | Year: 2014

This review summarizes recent evidence related to the safety, efficacy, and metabolic outcomes of bariatric surgery to guide clinical decision making. Several short term randomized controlled trials have demonstrated the effectiveness of bariatric procedures for inducing weight loss and initial remission of type 2 diabetes. Observational studies have linked bariatric procedures with long term improvements in body weight, type 2 diabetes, survival, cardiovascular events, incident cancer, and quality of life. Perioperative mortality for the average patient is low but varies greatly across subgroups. The incidence of major complications after surgery also varies widely, and emerging data show that some procedures are associated with a greater risk of substance misuse disorders, suicide, and nutritional deficiencies. More research is needed to enable long term outcomes to be compared across various procedures and subpopulations, and to identify those most likely to benefit from surgical intervention. Given uncertainties about the balance between the risks and benefits of bariatric surgery in the long term, the decision to undergo surgery should be based on a high quality shared decision making process.

Simon G.E.,Group Health Research Institute | Perlis R.H.,Massachusetts General Hospital
American Journal of Psychiatry | Year: 2010

Objective: Response to specific depression treatments varies widely among individuals. Understanding and predicting that variation could have great benefits for people living with depression. Method: The authors describe a conceptual model for identifying and evaluating evidence relevant to personalizing treatment for depression. They review evidence related to three specific treatment decisions: choice between antidepressant medication and psychotherapy, selection of a specific antidepressant medication, and selection of a specific psychotherapy. They then discuss potential explanations for negative findings as well as implications for research and clinical practice. Results: Many previous studies have examined general predictors of outcome, but few have examined true moderators (predictors of differential response to alternative treatments). The limited evidence indicates that some specific clinical characteristics may inform the choice between antidepressant medication and psychotherapy and the choice of specific antidepressant medication. Research to date does not identify any biologic or genetic predictors of sufficient clinical utility to inform the choice between medication and psychotherapy, the selection of specific medication, or the selection of a specific psychotherapy. Conclusions: While individuals vary widely in response to specific depression treatments, the variability remains largely unpredictable. Future research should focus on identifying true moderator effects and should consider how response to treatments varies across episodes. At this time, our inability to match patients with treatments implies that systematic follow-up assessment and adjustment of treatment are more important than initial treatment selection.

Larson E.B.,Group Health Research Institute
International Psychogeriatrics | Year: 2010

Worldwide, lifespan is lengthening. Concomitantly, late-life dementias are increasingly common, challenging both personal and public health internationally. After age 65, rates of dementia tend to double every five years in developed countries and every seven in developing ones. The late-life dementias, particularly Alzheimer's disease, have profound effects on aging individuals and their caregivers. Multidisciplinary research has explored the potential for various approaches to prevent or delay the onset of late-life dementias. Outlining that research, including our team's Adult Changes in Thought and Kame studies, this review concludes that delaying the onset of these dementias appears feasible, although absolute prevention may not be. Today, the most promising methods appear to include controlling vascular risk factors like hypertension and engaging in physical exercise - and possibly mental exercise. If people can delay the onset of dementias, they can lead more fulfilling lives for longer, spending less time suffering from dementia and letting their families spend less time coping with the disease. It is possible that trends toward more knowledge-based societies, where cognitive health is so vital, may increasingly exert evolutionary pressure favoring larger and healthier brains - and a "compression of cognitive morbidity" - well into old age. Public health's great triumph, increased lifespan, should give more of the world's people the reward of many years of dementia-free life. Rather than the personal difficulties and public health burdens of many years of functional impairment, dependency, and suffering with dementia, some interventions may delay the onset of Alzheimer's disease and other dementias. © International Psychogeriatric Association 2010.

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