Volume 18, Issue 2, Spring 2006
New Findings
Exercise linked to later onset of dementia
Regular exercise is associated with a delay in the onset of dementia and Alzheimer's disease, according to a Group Health Cooperative/University of Washington study that appeared in the Jan. 17 issue of Annals of Internal Medicine.
The study—the most definitive investigation of exercise and dementia to date—also found that the more frail a person is, the more he or she may benefit from exercise.
"Even those elderly people who did modest amounts of gentle exercise, such as walking for 15 minutes three times a week, appeared to benefit," says Eric B. Larson, MD, MPH, director of Group Health Center for Health Studies and the lead investigator for the study.
"Based on these findings, we can advise older people to 'use it even after you start to lose it,' because exercise may slow the progression of age-related problems in thinking," said Larson.
The study followed 1,740 Group Health members, aged 65 and older, over a six-year period. The researchers contacted the participants every two years to assess factors potentially affecting dementia, including exercise frequency, cognitive function, physical function, symptoms of depression, and lifestyle characteristics. After six years, 158 participants had developed dementia and 107 of those with dementia had been diagnosed with Alzheimer's disease. People who exercised three or more times a week had a 30 percent to 40 percent lower risk for developing dementia compared with those who exercised fewer than three times per week.
Larson's study was designed to be more definitive than previous research into exercise and dementia—the results of which have been mixed. In this study, Larson's team used test scores to ensure that all participants had a minimum level of function at the time the study began. Doing so eliminated participants who might already be developing Alzheimer's disease, but not showing overt signs of the disease—a factor that would make it difficult to determine the true effects of exercise over the duration of the study.
Larson believes that exercise may improve brain function by boosting blood flow to areas of the brain used for memory. "Earlier research has shown that poor blood flow can damage these parts of the brain," he explained. "So one theory is that exercise may prevent damage and might even help repair these areas by increasing blood flow."
Larson advises older people that it's never too late to begin exercising. "Even if you're 75 and have never exercised before, you can still benefit by starting to exercise now."
Simply walking or swimming for 15 minutes three times a week may be enough, added Larson. And programs such as the "EnhanceFitness" classes that Group Health offers to its Medicare Advantage members can be especially helpful because they are designed with attention to senior safety issues, such as avoiding falls.
"As our population ages, strategies are needed to reduce the risks and delay the onset of dementing disorders such as Alzheimer's disease," Larson said. "These findings indicate that programs that encourage elderly people to exercise should be part of those strategies."
The National Institute of Aging funded the study. Other researchers contributing to the study were:
- Li Wang, MS, Veterans Affairs Puget Sound Health Care System, Seattle
- Wayne C. McCormick, MD, MPH, Harborview Medical Center, Seattle
- James D. Bowen, MD, Department of Neurology; Paul K. Crane, MD, MPH, Department of Internal Medicine; Walter Kukull, PhD, Department of Epidemiology; and Linda Teri, PhD, deTornay Center on Healthy Aging—all at the University of Washington, Seattle
Yoga is more effective than conventional exercise for low back pain, study finds
Yoga appears to be more effective for low back pain than conventional exercise or getting a self-care book, according to a first-of-its kind study conducted by researchers at Group Health Center for Health Studies and published in the December 20 issue of Annals of Internal Medicine.
The study involved 101 adults with low back pain who were randomly assigned to one of three groups.
- One group attended 12 weekly, 75-minute classes to learn yoga and practiced at home.
- A second group attended 12 weekly, 75-minute sessions of aerobic, strengthening, and stretching exercise, plus home practice.
- A third group received a self-care book on back pain.
After 12 weeks, the patients in the yoga group were better able to do daily activities involving the back than were the patients in the exercise or education groups. After 26 weeks, the patients in the yoga group had better back-related function and less pain. Also, fewer people in the yoga group used pain relievers.
"Most people have experienced back pain at some point in their lives," explained Karen Sherman, PhD, a Group Health researcher and the lead author of the study. "Sometimes the pain goes away in a few days, but sometimes it lasts for weeks. And unfortunately, the treatments offered by modern Western medicine are only modestly effective."
Current treatments for low back pain include pain relievers—such as nonsteroidal anti-inflammatory drugs (NSAIDs), painkillers, and muscle relaxants—and exercise.
"Although exercise is one of the few proven treatments for chronic low back pain, its effects are often small and we haven't known whether one form is better than another," Sherman added. "So we designed a study to evaluate the effectiveness and safety of a gentle program of yoga for people with this condition."
While it's estimated that about one million people currently practice some form of yoga for relief of back pain, questions about yoga's value for this condition have persisted. Sherman's study, which is the largest randomized controlled trial to date, helps to prove its effectiveness.
The yoga students in Sherman's study learned 17 poses from viniyoga, a style that's easy to learn and typically allows poses to be adapted for use by various body types.
People interested in learning yoga for relief of low back pain should choose an instructor who is experienced working with students who have this condition, Sherman recommended.
Her study was funded by a grant from the National Center for Complementary and Alternative Medicine, which is part of the National Institutes of Health. Other researchers on the study were:
- Group Health's Daniel C. Cherkin, PhD; Janet Erro, RN; and Diana Miglioretti, PhD;
- University of Washington Professor of Medicine Richard A. Deyo
Suicide risk does not increase when adults start using antidepressants, study finds
The risk of serious suicide attempts or death by suicide generally decreases in the weeks after patients start taking antidepressant medication, according to a new study led by Group Health Cooperative researchers and published in the January issue of The American Journal of Psychiatry. The study also found that the risk of suicidal behavior after starting 10 newer antidepressant medications is less than the risk posed by older medications.
These findings challenge a 2004 advisory by the U.S. Food and Drug Administration (FDA), which warned that suicidal behavior might emerge after treatment with the newer antidepressant drugs has begun.
"Our findings show that, fortunately, suicide attempts and death by suicide are rare following the initiation of antidepressants," says Greg Simon, MD, MPH, a Group Health psychiatrist and the lead researcher on the study. "The period right after people start taking antidepressant medication is not a period of increased risk. In fact, risk after starting medication is lower than before."
This study is the first published analysis to compare the risk of suicide attempts before treatment to the risks following treatment. It is based on computerized medical and pharmacy records for more than 65,000 patients who filled prescriptions for antidepressants from 1992 to 2003. Deaths by suicide were determined from death certificates and suicide attempts were identified from hospital discharge data.
Group Health researchers found that the number of suicide attempts fell by 60 percent in adults during the month after antidepressant treatment began, and declined further in the following five months. Among the 65,103 patients taking antidepressants, there were 31 completed suicides in the six months following the antidepressant prescription. That rate was not higher in the one month after the prescription than in subsequent months. The study also found that newer antidepressants were associated with a faster decline in rates of suicidal behavior than older drugs.
Adolescents in the study had more suicide attempts than adults. The researchers found that the rate for the first six months of antidepressant treatment was 314 attempts per 100,000 in teens and 78 attempts per 100,000 in adults. As with adults, the rate was highest in the month before treatment and declined by about 60 percent after treatment began.
Given recent public concern over a possible link between suicide and antidepressants, Simon says he fears people may mistakenly believe that suicidal behavior is common after taking antidepressant medications. That misperception could lead to fewer people with depression being treated with medications proven to be effective in battling depression, he adds.
"There may be subgroups of people who become more agitated or suicidal after taking these drugs, and those people should seek help from a doctor or therapist right away if that happens," says Simon. "But our study showed that on average, the risk of suicide actually goes down after people start taking the antidepressant."
Simon agrees with the FDA's recommendations that doctors carefully monitor people taking antidepressants. "Keeping a close watch on patients after they begin taking these drugs is a good idea—although not because these medicines are especially risky or dangerous," he says. "Patients need to be monitored to ensure they're getting the right medication in the amount that can help them feel better."
The National Institute of Mental Health funded Simon's study. Other researchers on the study were:
- James Savarino, PhD, and Belinda Operskalski, MPH, of Group Health Center for Health Studies
- Philip S. Wang, MD, of Harvard Medical School's Department of Health Care Policy
Group Health research finds no help from ibuprofen, acetaminophen
A red splotch forms where most preschoolers get their fifth, and last, shot of the acellular diphtheria-tetanus-pertussis (DTaP) vaccine, and it can last a few days. Neither of two common over-the-counter drugs—ibuprofen (Advil) and acetaminophen (Tylenol)—help prevent this side effect, according to a Group Health Cooperative study appearing in the March issue of Pediatrics.
In about 1 in 5 children, this "local reaction" measures at least 4 inches, spreading over the whole upper arm (or thigh) in about 1 in 100. But it is seldom serious and usually does not hurt.
"Often children don't notice they have it," said Lisa A. Jackson, MD, MPH, a senior investigator at Group Health Center for Health Studies and the study's lead investigator. "But it can concern parents, leading to medical visits or even needless antibiotic treatment, so we'd like to make it rarer."
Jackson and Group Health colleagues observed 372 children from 4 to 6 years old who were due for their fifth DTaP dose after getting 4 doses of this vaccine since age 2 months. Four in 10 children were randomly assigned to receive ibuprofen; 4 in 10, acetaminophen; and 2 in 10, placebo (providers and families were "blind" to who got what).
The medication was given preventively 3 times: at 2 hours before, and 6 and 12 hours after, the vaccination. About a third of each group had local reactions at least 2 inches wide. The placebo and treatment groups did not differ significantly in their proportions of children whose reactions lasted at least 3 days or whose vaccinated limb swelled by about 1 inch or more.
Acetaminophen is commonly given to help prevent post-vaccine fever in babies, who are more likely than toddlers or preschoolers to have fever after vaccination.
"Acetaminophen is an effective anti-pyretic (fever reducer)," Jackson explained. "But it isn't an anti-inflammatory (inflammation reducer)." So even though acetaminophen is commonly given to older children for their later immunizations, Jackson was not surprised that her study showed it failed to prevent preschoolers' local reactions, which are likely caused by inflammation.
What Jackson did not expect is that the anti-inflammatory drug ibuprofen would prove similarly ineffective at preventing these local reactions. "We certainly thought that ibuprofen, through its anti-inflammatory effect, might make the local reactions less common or severe," she said. "We all want to decrease discomfort in children, so we were disappointed not to show a prevention effect for ibuprofen; but on the other hand we got a fairly definitive answer, and that's why we do research."
Possible explanations? Maybe a different kind of inflammation, which ibuprofen doesn't interrupt, causes the local reaction, Jackson said. Or perhaps taking any anti-inflammatory drug by mouth doesn't get enough active ingredients to the site of the vaccination—and reaction. Future approaches include evaluating more dilute DTaP vaccines. "These vaccines with a lower antigen content may be just as effective, but may be associated with fewer reactions, in 4 to 6 year olds," she said.
Sanofi-Aventis Group, which manufactures the Tripedia DTaP vaccine, funded the study. Other researchers contributing to the study were:
- Maya Dunstan, RN; Patty Starkovich, RN; Onchee Yu, MS; Jennifer C. Nelson, PhD; Thom Rees, MHA; and Ann Zavitkovsky, MPH—all of CHS (Nelson, like Jackson, has a joint appointment at the University of Washington)
- Group Health pediatrician John Dunn, MD, MPH
Research Highlights
Menopausal hormone formulations may differ in cardiovascular risk but not efficacy
One menopausal hormone formulation—esterified estrogens (EE)—may carry smaller cardiovascular risks than another—conjugated equine estrogen (CEE)—even though they're considered clinically interchangeable and biologically equivalent, according to a study by Rozenn N. Lemaitre, PhD, MPH, of the University of Washington's Cardiovascular Health Research Unit. Other authors include CHS Senior Investigator Bruce M. Psaty, MD, PhD, CHS Affiliate Investigator Susan R. Heckbert, MD, PhD, and CHS Director Eric B. Larson, MD, MPH. The findings, which appeared in the February 27, 2006 issue of the Archives of Internal Medicine, are based on a study of about 7,000 women who had gone through menopause and were members of Group Health Cooperative.
Children in outpatient pediatric settings are at risk for receiving a medication dosing error
A study published in the December 2005 issue of the Journal of Pediatrics was featured in the March 3, 2006 edition of the Agency for Healthcare Research and Quality (AHRQ)'s Patient Safety E-Newsletter. The study's authors included Robert L. Davis, MD, MPH, now a medical epidemiologist at the Centers for Disease Control and Prevention (CDC) but a CHS investigator for years previously. The research, based on data from nearly 2,000 children in three health plans including Group Health Cooperative, showed that nearly 15 percent of children in ambulatory pediatric settings were dispensed medications that could have resulted in a potential overdose (8 percent) or underdose (7 percent). The researchers found most potential overdoses with analgesics (especially oxycodone), and most potential underdoses with antiepileptics.
A year of enhanced depression treatment model not sufficient to improve diabetes self-management
Diabetes self-management did not improve among patients receiving care using an enhanced depression treatment model during a 12-month period, according to a study by Group Health physician and CHS Affiliate Investigator Elizabeth Lin, MD, MPH. The study appeared in the January/February issue of the Annals of Family Medicine. The thinking was that in patients with both depression and diabetes, treating the underlying depression would lead to better management of their diabetes. "Research needs to assess whether self-care interventions tailored for specific conditions, in addition to enhanced depression care, can achieve better diabetes and depression outcomes," wrote Lin and her colleagues, including CHS affiliate investigator Paul Ciechanowski, MDCM, MPH, of the University of Washington and CHS scientists Carolyn Rutter, PhD; Greg E. Simon, MD, MPH; Evette J. Ludman, PhD; Michael Von Korff, ScD; and Malia Oliver.
Studies tend to overstate influenza vaccine effectiveness in elderly
Studies of influenza vaccine effectiveness in elderly people substantially overestimate vaccine benefits, according to a Group Health study published December 21, 2005 in the International Journal of Epidemiology. The study by CHS Senior Investigator Lisa Jackson, MD, MPH, and colleagues suggests that the association between vaccination and a lower risk of death may be because relatively healthy seniors—that is, those already less at risk from dying—are more likely to get vaccinated. The research does not indicate that there is no benefit in vaccinating the elderly, just that the differences in health between seniors receiving and not receiving the vaccine make it difficult or impossible to tell what benefit is being derived from the vaccine. The researchers studied 73,527 people aged 65 and over during an eight-year period.
Hormone therapy raises breast cancer screening false-positives
Women using hormone therapy at the time of breast cancer screening are more likely to have a false-positive recall compared to non-users, according to a Group Health study published in the January 2006 issue of Medical Care. This is likely because hormone therapy has been found to increase breast density, and mammograms are less accurate in denser breasts. Led by CHS assistant investigator Denise Boudreau, PhD, the study found that that the link between hormone therapy and a false-positive recall varied by age. There was no increase observed among women aged 40-49 and the largest increases were seen among women aged 60 and older. The increase in false positive recall among the HT users was limited to additional imaging and ultrasound and not invasive procedures. Other researchers on the study included CHS' Diana Buist, PhD; Carolyn Rutter, PhD; Paul Fishman, PhD; Kevin Beverly, MA; and former CHS investigator Stephen Taplin, MD, MPH, now at the National Cancer Institute.
Team care model for depression treatment is cost-effective in older adults
A team care model for treating depression in older adults is more cost-effective than standard treatment according to a University of Washington/Group Health study that appeared in the December 5, 2005 issue of Archives of General Psychiatry. Cost effectiveness is defined in the study as the health advantages patients receive from medical care in relation to the cost of that care. The team approach that was examined—called the IMPACT model—features a nurse, social worker, or psychologist serving as a depression case manager working with the primary care physician and a consulting psychiatrist to care for depressed patients in primary care clinics. "For the same price as usual care, the IMPACT model provided an additional 107 depression-free days," said Wayne Katon, MD, a UW professor of psychiatry, CHS affiliate investigator, and lead author of the study. CHS affiliate investigator Elizabeth Lin, MD, MPH, was the lead Group Health researcher on the study.
Staff News
Sarah Greene assumes new responsibilities
Sarah Greene, MPH, has assumed new responsibilities at CHS, effective February 1. Her new position is designed to help enrich the Center's intellectual environment and maximize opportunities for collaboration across the HMO Research Network (HMORN). Among her specific tasks will be arranging faculty seminars, identifying faculty training needs, and building bridges between collaborators and institutions. This role capitalizes on her breadth and depth of experience with the Cancer Research Network, the Coordinated Clinical Studies Network, and HMORN. She will continue in her research associate role at half time.
William Foege will deliver 7th Annual Birnbaum Lecture
On Thursday, October 5, 2006, at 11:30 a.m., guest speaker William H. Foege, MD, MPH, senior medical advisor to the Bill & Melinda Gates Foundation's Global Health Program, senior fellow in health policy at the Carter Center, and presidential distinguished professor at Emory University's Rollins School of Public Health in Atlanta, will deliver the 7th Annual Birnbaum Lecture in Seattle. Foege also directed the Carter Center and the Centers for Disease Control and Prevention (CDC) after leading the CDC's Smallpox Eradication Program. Foege has championed many issues. Child survival and development, injury prevention, population health, preventive medicine, and public health leadership, particularly in the developing world, are his special interests.
Dan Cherkin serving on Puget Sound Health Alliance Back Pain Clinical Improvement Team
CHS Associate Director Dan Cherkin, PhD, was recently appointed to serve on the Puget Sound Health Alliance Back Pain Clinical Improvement Team. The Alliance is a regional partnership of employers, health care professionals, hospitals, health plans, unions, patients, and others working to improve quality and reduce the cost of health in five counties. The back pain team will review the research on best practices, select clinical guidelines for care and health promotion programs, advise the Alliance on aligning financial and quality improvement incentives, and recommend nationally vetted, standardized performance measures.
Robert Davis moves to CDC
Senior Investigator Robert L. Davis, MD, MPH, left his position at Group Health Center for Health Studies on January 23 to work for the Centers for Disease Control and Prevention (CDC) as director of its Immunization Safety Office (ISO). An acknowledged leader in the field, Davis brings a wealth of experience from his research at Group Health, the HMO Research Network, academia, and community health. In his new position, he will lead the ISO as it evolves to take advantage of emerging capabilities in genomics and information technology. Davis has indicated a willingness and a desire to stay affiliated with CHS faculty and the process for allowing that to happen is now underway.
Leslie Spangler accepts women's health fellowship
Epidemiologist Leslie Spangler, PhD, recently began a two-year post-doctoral women's health fellowship at CHS. Funded by a $50,000 grant from the Group Health Community Foundation, Spangler's research at CHS will focus on women's midlife health, osteoporosis, and menopause. Spangler's dissertation work focused on biomechanical factors as predictors for failure of hip fracture repair. She served as a representative to the Defense Women's Health Research Program while working as a public health officer in the U.S. Air Force. As a senior health analyst with the U.S. Government Accountability Office, she investigated health issues related to emergency medical services, childhood vaccine supplies, and uncompensated hospital care costs.
Elizabeth Phelan joins CHS affiliates
CHS has added Elizabeth Phelan, MD, MS, to its roster of affiliate investigators, the research scientists employed by other institutions who have long-term collaborative relationships with the Center. Phelan is an assistant professor of medicine at the University of Washington, specializing in gerontology and geriatric medicine. She has worked with CHS faculty on several studies related to care of seniors. She has received research awards in geriatrics including the prestigious Beeson Fellowship, which she devoted to studying quality of care for seniors at Group Health. She is also is an important support to Group Health's emerging Senior Care Program under the leadership of Marty Levine, MD.
Continuing to welcome Arlene Jackson
We continue to welcome Arlene Jackson, MPH, who joined the Center as senior manager of grant and contract administration (GCA) on December 1, 2005. Arlene brings a wealth of experience to the Center, having worked previously at Fred Hutchinson Cancer Research Center as a grant and contract administrator and project manager in the Clinical Research Division.