Publications by authors named "Stephen Thielke"

101 Publications

Digital Technology Differentiates Graphomotor and Information Processing Speed Patterns of Behavior.

J Alzheimers Dis 2021 ;82(1):17-32

Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA.

Background: Coupling digital technology with traditional neuropsychological test performance allows collection of high-precision metrics that can clarify and/or define underlying constructs related to brain and cognition.

Objective: To identify graphomotor and information processing trajectories using a digitally administered version of the Digit Symbol Substitution Test (DSST).

Methods: A subset of Long Life Family Study participants (n = 1,594) completed the DSST. Total time to draw each symbol was divided into 'writing' and non-writing or 'thinking' time. Bayesian clustering grouped participants by change in median time over intervals of eight consecutively drawn symbols across the 90 s test. Clusters were characterized based on sociodemographic characteristics, health and physical function data, APOE genotype, and neuropsychological test scores.

Results: Clustering revealed four 'thinking' time trajectories, with two clusters showing significant changes within the test. Participants in these clusters obtained lower episodic memory scores but were similar in other health and functional characteristics. Clustering of 'writing' time also revealed four performance trajectories where one cluster of participants showed progressively slower writing time. These participants had weaker grip strength, slower gait speed, and greater perceived physical fatigability, but no differences in cognitive test scores.

Conclusion: Digital data identified previously unrecognized patterns of 'writing' and 'thinking' time that cannot be detected without digital technology. These patterns of performance were differentially associated with measures of cognitive and physical function and may constitute specific neurocognitive biomarkers signaling the presence of subtle to mild dysfunction. Such information could inform the selection and timing of in-depth neuropsychological assessments and help target interventions.
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http://dx.doi.org/10.3233/JAD-201119DOI Listing
January 2021

Unexpected Findings During Double-blind Discontinuation of Acetylcholinesterase Inhibitor Medications.

Clin Ther 2021 Jun 12. Epub 2021 Jun 12.

Puget Sound Veterans Affairs Medical Center, Seattle, Washington; The Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington. Electronic address:

Purpose: The long-term effects of acetylcholinesterase inhibitors (AChEIs) used in the treatment of patients with various types of dementia remain unclear, largely due to challenges in the study of their discontinuation. We present several unexpected results from a discontinuation trial that might merit further investigation.

Methods: This double-blind, placebo-controlled study of the discontinuation of AChEI medications was conducted in 62 US veterans. Participants were randomized to receive continued treatment with their medication (sham-taper group) or to treatment discontinuation via tapering (real-taper group), over a period of 6 weeks. The primary end point was the patient's/family caregiver's decision to discontinue the study medication.

Findings: The study was underpowered to detect a significant between-group difference in the primary end point, but examination of the discontinuation process generated several unexpected results: (1) recruitment proved extremely challenging for a variety of reasons, with <5% of potentially eligible participants enrolled; (2) all 3 patients with Parkinson disease-associated dementia showed a worsening of symptoms when they discontinued their AChEI medication, but they showed improvement after they restarted it; (3) changes in symptom-scale scores varied quite broadly across participants, regardless of treatment arm; (4) unusual effects were noted in the sham-taper arm; and (5) the only significant predictor of the decision to discontinue the study medication was a worsening in the caregiver's mood.

Implications: These findings argue for the use of caution in discontinuing AChEIs in patients with Parkinson disease-associated dementia, although there may be potential benefits of a "drug holiday." The findings also urge the consideration of distress on the part of the caregiver while making medication treatment decisions in dementia. Future research must address challenges with recruitment and symptom fluctuations. (Clin Ther. 2021;43:XXX-XXX) © 2021 Elsevier Inc.
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http://dx.doi.org/10.1016/j.clinthera.2021.05.010DOI Listing
June 2021

Ophthalmic conditions associated with dementia risk: The Cardiovascular Health Study.

Alzheimers Dement 2021 Mar 31. Epub 2021 Mar 31.

Department of Epidemiology, University of Washington, Seattle, Washington, USA.

Introduction: Ophthalmic conditions and dementia appear to overlap and may share common pathways, but research has not differentiated dementia subtypes.

Methods: Diagnoses of cataracts, age-related macular degeneration (AMD), diabetic retinopathy (DR), and glaucoma were based on medical histories and International Classification of Diseases, Ninth Revision (ICD-9) codes for 3375 participants from the Cardiovascular Health Study. Dementia, including Alzheimer's disease (AD) and vascular dementia (VaD), was classified using standardized research criteria.

Results: Cataracts were associated with AD (hazard ratio [HR] = 1.34; 95% confidence interval [CI] = 1.01-1.80) and VaD/mixed dementia (HR = 1.41; 95% CI = 1.02-1.95). AMD was associated with AD only (HR = 1.87; 95% CI = 1.13-3.09), whereas DR was associated with VaD/mixed dementia only (HR = 2.63; 95% CI = 1.10-6.27).

Discussion: Differential associations between specific ophthalmic conditions and dementia subtypes may elucidate pathophysiologic pathways. Lack of association between glaucoma and dementia was most surprising from these analyses.
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http://dx.doi.org/10.1002/alz.12313DOI Listing
March 2021

Cannabis Use and Nonfatal Opioid Overdose among Patients Enrolled in Methadone Maintenance Treatment.

Subst Use Misuse 2021 22;56(5):697-703. Epub 2021 Mar 22.

Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.

Background: Some ecological studies found lower rates of opioid overdose in states with liberalized cannabis legislation, but results are mixed, and the association has not been analyzed in individuals. We quantified the association between cannabis use and nonfatal opioid overdose among individuals enrolled in methadone maintenance treatment (MMT) for opioid use disorder (OUD).

Methods: We recruited a convenience sample of individuals enrolled in four MMT clinics in Washington State and southern New England who completed a one-time survey.Descriptive statistics and multivariate logistic regression compared the prevalence and risk of nonfatal opioid overdose in the past 12 months between participants reporting frequent (at least weekly) or infrequent (once or none) cannabis use in the past month.

Results: Of 446 participants, 35% ( = 156) reported frequent cannabis use and 7% ( = 32) reported nonfatal opioid overdose in the past year. The prevalence of nonfatal opioid overdose was 3% among reporters of frequent cannabis use, and 9% among reporters of infrequent/no use ( = 0.02). After imputing missing data and controlling for demographic and clinical factors, the likelihood of self-reported nonfatal opioid overdose in the past year was 71% lower among reporters of frequent cannabis use in the past month (adjusted RR = 0.29, 95% CI 0.10-0.80,  = 0.02).

Conclusions: Among individuals enrolled in MMT, frequent cannabis use in the past month was associated with fewer self-reported nonfatal opioid overdoses in the past year. Methodological limitations caution against causal interpretation of this relationship. Additional studies are needed to understand the prospective impact of co-occurring cannabis on opioid-related outcomes.
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http://dx.doi.org/10.1080/10826084.2021.1892137DOI Listing
June 2021

An Agenda for Addressing Multimorbidity and Racial and Ethnic Disparities in Alzheimer's Disease and Related Dementia.

Am J Alzheimers Dis Other Demen 2020 Jan-Dec;35:1533317520960874

Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.

Advancements in Alzheimer's disease and related dementias (ADRD) research on the U.S. population acknowledge the importance of the high burden of ADRD on segments of the population and yet-to-be characterized risks attributable to the burden of multiple chronic diseases (multimorbidity). These realizations suggest successful strategies in caring for people with ADRD and their caregivers will rely not only on clinical treatments but also on more refined and comprehensive models of ADRD that take its broad effects on the whole-person and the whole of society into consideration. To this end, it is critical to characterize and address the relationship between ADRD and multimorbidity combinations that complicate care and lead to poor outcomes, particularly with regard to racial and ethnic disparities in the occurrence, course, and effects of ADRD. Several research and policy recommendations are presented to address the intersection of ADRD, multimorbidity, and underrepresented populations most at risk for adverse outcomes.
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http://dx.doi.org/10.1177/1533317520960874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7984095PMC
February 2021

An Agenda for Addressing Multimorbidity and Racial and Ethnic Disparities in Alzheimer's Disease and Related Dementia.

Am J Alzheimers Dis Other Demen 2020 Jan-Dec;35:1533317520960874

Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.

Advancements in Alzheimer's disease and related dementias (ADRD) research on the U.S. population acknowledge the importance of the high burden of ADRD on segments of the population and yet-to-be characterized risks attributable to the burden of multiple chronic diseases (multimorbidity). These realizations suggest successful strategies in caring for people with ADRD and their caregivers will rely not only on clinical treatments but also on more refined and comprehensive models of ADRD that take its broad effects on the whole-person and the whole of society into consideration. To this end, it is critical to characterize and address the relationship between ADRD and multimorbidity combinations that complicate care and lead to poor outcomes, particularly with regard to racial and ethnic disparities in the occurrence, course, and effects of ADRD. Several research and policy recommendations are presented to address the intersection of ADRD, multimorbidity, and underrepresented populations most at risk for adverse outcomes.
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http://dx.doi.org/10.1177/1533317520960874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7984095PMC
February 2021

Dual sensory impairment in older adults and risk of dementia from the GEM Study.

Alzheimers Dement (Amst) 2020 7;12(1):e12054. Epub 2020 Jul 7.

Department of Epidemiology University of Washington Seattle Washington USA.

Introduction: Hearing and vision loss are independently associated with dementia, but the impact of dual sensory impairment (DSI) on dementia risk is not well understood.

Methods: Self-reported measures of hearing and vision were taken from 2051 participants at baseline from the Gingko Evaluation of Memory Study. Dementia status was ascertained using standardized criteria. Cox models were used to estimate risk of dementia associated with number of sensory impairments (none, one, or two).

Results: DSI was significantly associated with higher risk of all-cause dementia (hazard ratio [HR] = 1.86; 95% confidence interval [CI] = 1.25-2.76) and Alzheimer's disease (HR = 2.12; 95% CI = 1.34-3.36). Individually only visual impairment was independently associated with an increased risk of all-cause dementia (HR = 1.32; 95% CI = 1.02-1.71).

Discussion: Older adults with DSI are at a significantly increased risk for dementia. Further studies are needed to evaluate whether treatments can modify this risk.
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http://dx.doi.org/10.1002/dad2.12054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340796PMC
July 2020

The price of mental well-being in later life: the role of financial hardship and debt.

Aging Ment Health 2021 Jul 19;25(7):1338-1344. Epub 2020 May 19.

Department of Psychiatry and Behavioral Sciences, University of Washington, Geriatric Research, Education, and Clinical Center, Seattle VA Medical Center, Seattle, WA, USA.

Objective: This study investigated the associations between various financial hardship and debt indicators and mental health status among older adults.

Methods: Using data from the Health and Retirement Study (HRS), we considered the association between different forms of financial hardship and debt of those who were identified as having high levels of depressive symptoms ( = 7678) and anxiety ( = 8079). Financial hardship indicators: difficulty paying bills, food insecurity, and medication need; debt indicators: credit card and medical debt. Associations were tested using multiple logistic regression analyses and are reported as relative risk (RR) ratios and 95% confidence intervals (CIs).

Results: Participants who had difficulty paying bills were more likely to have high levels of depressive symptoms (RR = 2.06, CI = 1.75-2.42,  < 0.001) and anxiety (RR = 1.46, CI = 1.02-2.05,  < 0.001) compared to those who did not have financial difficulty. Similarly, medical debt was associated with depressive symptoms (RR = 1.43, CI = 1.14-1.74,  < 0.01) and anxiety (RR = 1.20, CI = 0.96-1.50,  < 0.01). Credit card debt was not significantly associated with either mental health outcome.

Conclusion: Indicators of financial hardship and medical debt were associated with depressive symptoms and anxiety in a cohort of older adults. In contrast, the influence of credit card debt appeared to be more complex and vary by individual. These findings indicate that doing without meeting personal salient needs has a particularly adverse effect on psychological well-being.
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http://dx.doi.org/10.1080/13607863.2020.1758902DOI Listing
July 2021

Associations Between Activities of Daily Living Independence and Mental Health Status Among Medicare Managed Care Patients.

J Am Geriatr Soc 2020 06 20;68(6):1301-1306. Epub 2020 Mar 20.

University of Washington School of Medicine, Seattle, Washington, USA.

Background/objectives: Although there is a strong cross-sectional association between dependence in activities of daily living (ADLs) and decreased mental health, it is largely unknown how the loss of specific ADLs, or the combination of ADLs, influences mental health outcomes. We examined the effect of ADL independence on mental health among participants in a large survey of Medicare managed care recipients.

Design/setting: Retrospective cohort study.

Participants: A total of 104,716 participants in cohort 17 of the Medicare Health Outcomes Survey, who completed the baseline and follow-up surveys in 2014 and 2016.

Measurements: Linear regression models estimated the effects of loss of ADL independence on change in Mental Component Summary (MCS) score.

Results: In an adjusted model, loss of independence in eating, bathing, dressing, and toileting were associated with three- to four-point declines in MCS, suggesting meaningful worsening. In a model that also included all six ADLs, loss of independence in each ADL was associated with declines in MCS, with the largest effects for eating and bathing. MCS decreased by 1.3 per each additional summative loss of ADL independence (P < .001).

Conclusion: Loss of ADL independence was associated with large declines in mental health, with personal care activities showing the largest effects. Additional research can help to characterize the causes of ADL loss, to explore how older adults cope with it, and to identify ways of maximizing resilience. J Am Geriatr Soc 68:1301-1306, 2020.
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http://dx.doi.org/10.1111/jgs.16423DOI Listing
June 2020

How to Ensure That Teaching Kitchens Are Age-Friendly.

J Nutr Educ Behav 2020 02;52(2):187-194

Division of Gerontology and Geriatric Medicine, Geriatric Research Education and Clinical Center, Puget Sound Veterans Affairs Medical Center and University of Washington, Seattle, WA; Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA.

Health systems and community organizations have increasingly offered nutrition education through teaching kitchens. With an increasing number of older adults (>65 years) accessing these programs, teaching kitchens may consider age-friendly adaptations to their standard curriculum. Based on experiences with implementing Healthy Teaching Kitchens Across Veteran Affairs Health Care System, and by applying the 5M Geriatric Care Framework (Mind, Multicomplexity, Medications, Mobility, What Matters Most), several steps are proposed for teaching kitchens to be able to better accommodate older adults.
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http://dx.doi.org/10.1016/j.jneb.2019.11.003DOI Listing
February 2020

GRECC Connect: Geriatrics Telehealth to Empower Health Care Providers and Improve Management of Older Veterans in Rural Communities.

Fed Pract 2019 Oct;36(10):464-470

is a Research Health Scientist at the Center for Healthcare Organization and Implementation Research and the New England Geriatric Research Education and Clinical Center (GRECC), and is a Program Manager and is Site Director at the New England GRECC, Edith Nourse Rogers Memorial Veterans Hospital in Bedford, Massachusetts. is a Physician at Madison GRECC, William S. Middleton Memorial Veterans Hospital in Wisconsin. is Associate Director (research), J is Deputy Director, and is Associate Director (clinical) at Bronx/NY Harbor GRECC, James J. Peters Veterans Affairs Medical Center in New York. is a Geriatrician and is Associate Director (clinical) at the Birmingham/Atlanta GRECC in Alabama. is a Geriatrician at the Canandaigua VA Medical Center in New York. is Associate Director (clinical) at the Durham GRECC, Durham VA Medical Center in North Carolina. and are Geriatricians at the Miami GRECC, Miami VA Healthcare System in Florida. is Associate Director (clinical) at the San Antonio GRECC, Audie L. Murphy Memorial VA Hospital in Texas. is Associate Director (education & evaluation) at the Little Rock GRECC, Central Arkansas Veterans Healthcare System. is a Research Health Scientist at the Birmingham/Atlanta GRECC, Atlanta VA Medical Center in Decatur, Georgia. is a Geriatrician at the Eastern Colorado GRECC, VA Eastern Colorado Health Care System in Denver. is Associate Director (clinical) at the Pittsburgh GRECC, VA Pittsburgh Healthcare System in Pennsylvania. is Associate Director (education & evaluation) at the Puget Sound GRECC, Puget Sound VA Medical Center in Seattle, Washington.

A telehealth program supports meaningful partnerships between urban geriatric specialists and rural health care providers to facilitate increased access to specialty care.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6837335PMC
October 2019

Healthy Teaching Kitchen Programs: Experiential Nutrition Education Across Veterans Health Administration, 2018.

Am J Public Health 2019 12 17;109(12):1718-1721. Epub 2019 Oct 17.

Marissa Black, Sunny Chen, Katherine Ritchey, and Stephen Thielke are with the Geriatric Research Education and Clinical Center, Puget Sound Veterans Affairs Medical Center, Seattle, WA. Katherine Hoerster is with the Research and Development Service, Puget Sound Veterans Affairs Medical Center, Seattle, WA. Robin LaCroix, Melanya Souza, and Anne Utech are with Nutrition and Food Service, Veterans Health Administration, Department of Veterans Affairs, Washington, DC.

Traditional clinical interventions yield few positive effects on diet. The Healthy Teaching Kitchen (HTK) program implemented by the Veterans Health Administration at sites across the United States delivers interactive nutrition and culinary education, guided instruction, and social opportunities for patients and caregivers. We report HTK outcomes of veterans' self-reported acceptability, self-efficacy for dietary change, and dietary and cooking habits. The HTK program is acceptable and feasible and may empower participants to improve health.
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http://dx.doi.org/10.2105/AJPH.2019.305358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6836789PMC
December 2019

Cost-related delay in filling prescriptions and health care ratings among medicare advantage recipients.

Medicine (Baltimore) 2019 Aug;98(31):e16469

Department of Psychiatry and Behavioral Sciences, University of Washington, Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System.

Despite higher health care needs, older adults often have limited and fixed income. Approximately a quarter of them report not filling or delaying prescription medications due to cost (cost-related prescription delay, CRPD). To ascertain the association between CRPD and satisfaction with health care, secondary analysis of the 2012 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare Advantage Survey was performed.Regression models quantified the association between CRPD and rating of personal doctor, specialist, and overall health care. Models were adjusted for demographic, health-related, and socioeconomic characteristics. 274,996 Medicare Advantage enrollees were mailed the CAHPS survey, of which 101,910 (36.8%) returned a survey that had responses to all the items we analyzed. CRPD was assessed by self-report of delay in filling prescriptions due to cost. Health care ratings were on a 0-10 scale. A score ≤ 5 was considered a poor rating of care.In unadjusted models, CRPD more than doubled the relative risk (RR) for poor ratings of personal doctor (RR 2.34), specialist (RR 2.14), and overall health care (RR 2.40). Adjusting for demographics and health status slightly reduced the RRs to 1.9, but adjusting for low-income subsidy and lack of insurance for medications did not make a difference.CRPD is independently associated with poor ratings of medical care, regardless of health, financial or insurance status. Providers might reduce patients' financial stress and improve patient satisfaction by explicitly discussing prescription cost and incorporating patient priorities when recommending treatments.
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http://dx.doi.org/10.1097/MD.0000000000016469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6708951PMC
August 2019

Detection of probable dementia cases in undiagnosed patients using structured and unstructured electronic health records.

BMC Med Inform Decis Mak 2019 07 9;19(1):128. Epub 2019 Jul 9.

Geriatric Research, Education, and Clinical Center, S182 GRECC, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA.

Background: Dementia is underdiagnosed in both the general population and among Veterans. This underdiagnosis decreases quality of life, reduces opportunities for interventions, and increases health-care costs. New approaches are therefore necessary to facilitate the timely detection of dementia. This study seeks to identify cases of undiagnosed dementia by developing and validating a weakly supervised machine-learning approach that incorporates the analysis of both structured and unstructured electronic health record (EHR) data.

Methods: A topic modeling approach that included latent Dirichlet allocation, stable topic extraction, and random sampling was applied to VHA EHRs. Topic features from unstructured data and features from structured data were compared between Veterans with (n = 1861) and without (n = 9305) ICD-9 dementia codes. A logistic regression model was used to develop dementia prediction scores, and manual reviews were conducted to validate the machine-learning results.

Results: A total of 853 features were identified (290 topics, 174 non-dementia ICD codes, 159 CPT codes, 59 medications, and 171 note types) for the development of logistic regression prediction scores. These scores were validated in a subset of Veterans without ICD-9 dementia codes (n = 120) by experts in dementia who performed manual record reviews and achieved a high level of inter-rater agreement. The manual reviews were used to develop a receiver of characteristic (ROC) curve with different thresholds for case detection, including a threshold of 0.061, which produced an optimal sensitivity (0.825) and specificity (0.832).

Conclusions: Dementia is underdiagnosed, and thus, ICD codes alone cannot serve as a gold standard for diagnosis. However, this study suggests that imperfect data (e.g., ICD codes in combination with other EHR features) can serve as a silver standard to develop a risk model, apply that model to patients without dementia codes, and then select a case-detection threshold. The study is one of the first to utilize both structured and unstructured EHRs to develop risk scores for the diagnosis of dementia.
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http://dx.doi.org/10.1186/s12911-019-0846-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6617952PMC
July 2019

Mental health treatment among older adults with mental illness on parole or probation.

Health Justice 2019 Mar 28;7(1). Epub 2019 Mar 28.

Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA.

Background: The number of older adults on parole and probation is growing at an unprecedented rate, yet little is known about the mental health needs and treatment utilization patterns among this group. The objective of this study is to compare the prevalence of serious or moderate mental illness (SMMI), and the proportion of those with SMMI who receive mental health treatment, among community-dwelling older adults on correctional supervision (parole or probation) vs. not on correctional supervision.

Methods: Design: Cross-sectional analysis of data from the 2008-2014 National Surveys for Drug Use and Health (NSDUH).

Setting: Population-based national survey data.

Participants: Older adults (age ≥ 50) who participated in the NSDUH between 2008 and 2014 (n = 44,624). Participants were categorized according to whether they were on parole or probation during the 12 months prior to survey completion (n = 379) vs. not (n = 44,245).

Measurements: Probable SMMI was defined using a validated measure in the NSDUH. Mental health treatment included any outpatient mental health services or prescriptions over the 12 months prior to survey completion. We compared the prevalence of SMMI, and the proportion of those with SMMI who received any treatment, by correctional status.

Results: Overall, 7% (N = 3266) of participants had SMMI; the prevalence was disproportionately higher among those on parole or probation (21% vs. 7%, p <  0.001). Sixty-two percent of those with SMMI received any mental health treatment, including 81% of those on parole or probation and 61% of those who were not (p <  0.001). This result remained statistically significant after logistic regression accounted for differences in sociodemographics and health.

Conclusions: SMMI is disproportionally prevalent among older adults on parole or probation, and community correctional supervision programs may be facilitating linkages to needed community-based mental health treatment.
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http://dx.doi.org/10.1186/s40352-019-0084-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717990PMC
March 2019

Conditional Permission to Not Resuscitate: A Middle Ground for Resuscitation.

J Am Med Dir Assoc 2019 06 28;20(6):679-682. Epub 2019 Feb 28.

Department of Psychiatry, University of Washington, Seattle, WA; Geriatric Research, Education, and Clinical Center, Puget Sound VA Medical Center, Seattle, WA.

Every decision to perform or withhold cardiopulmonary resuscitation (CPR) has ethical implications that are not always well understood. Value-based decisions with far-reaching consequences are made rapidly, based on incomplete or possibly inaccurate information. For some patients, skilled, timely CPR can restore spontaneous circulation, but for others, success may either be unobtainable or bring serious iatrogenic consequences. Because CPR is an aggressive process yielding mixed results, patients must be informed about the likelihood of its positive and adverse outcomes. In considering whether to accept or refuse it, patients should also be given a realistic set of alternatives. Current protocols limit patients' options by restricting them to a choice between accepting or refusing CPR. Adding a "middle" code, DNAR-X (Do Not Attempt Resuscitation-Except), significantly expands patients' right to control what happens to their bodies by allowing them to stipulate CPR in some circumstances but not in others.
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http://dx.doi.org/10.1016/j.jamda.2019.01.002DOI Listing
June 2019

Scientific Autobiography.

Authors:
Stephen Thielke

Am J Geriatr Psychiatry 2019 02 8;27(2):175-177. Epub 2018 Dec 8.

Department of Psychiatry and Behavioral Sciences, University of Washington; Geriatric Research, Education, and Clinical Center, Puget Sound VA Medical Center. Electronic address:

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http://dx.doi.org/10.1016/j.jagp.2018.12.008DOI Listing
February 2019

Engage for Change: The Imperative to Increase Our Efforts in Geriatric Mental Health Policy.

Am J Geriatr Psychiatry 2019 02 8;27(2):97-99. Epub 2018 Dec 8.

Department of Psychiatry and Behavioral Sciences, University of Washington; Geriatric Research, Education, and Clinical Center, Puget Sound VA Medical Center.

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http://dx.doi.org/10.1016/j.jagp.2018.12.006DOI Listing
February 2019

Genetics of Human Longevity From Incomplete Data: New Findings From the Long Life Family Study.

J Gerontol A Biol Sci Med Sci 2018 10;73(11):1472-1481

Biodemography of Aging Research Unit, Social Science Research Institute, Duke University, Durham, North Carolina.

The special design of the Long Life Family Study provides a unique opportunity to investigate the genetics of human longevity by analyzing data on exceptional lifespans in families. In this article, we performed two series of genome wide association studies of human longevity which differed with respect to whether missing lifespan data were predicted or not predicted. We showed that the use of predicted lifespan is most beneficial when the follow-up period is relatively short. In addition to detection of strong associations of SNPs in APOE, TOMM40, NECTIN2, and APOC1 genes with longevity, we also detected a strong new association with longevity of rs1927465, located between the CYP26A1 and MYOF genes on chromosome 10. The association was confirmed using data from the Health and Retirement Study. We discuss the biological relevance of the detected SNPs to human longevity.
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http://dx.doi.org/10.1093/gerona/gly057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6175028PMC
October 2018

Qualitative research is a fundamental scientific process.

J Clin Epidemiol 2018 10 21;102:129-133. Epub 2018 May 21.

Geriatric Research Education and Clinical Center, Puget Sound VA Medical Center, 1660 S. Columbian Way, Seattle, Washington 98108, USA; Psychiatry and Behavioral Sciences, University of Washington, Seattle, 1959 NE Pacific Avenue, Seattle, Washington 98195, USA.

By framing the investigation of scientific inquiry around Plato's "arch of knowledge", we argue that qualitative inquiry is essential to the scientific process. We propose that because qualitative research applies a systematic and self-critical approach to induction and deduction, it should be considered a fundamental scientific enterprise.
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http://dx.doi.org/10.1016/j.jclinepi.2018.04.024DOI Listing
October 2018

Identifying and categorizing spurious weight data in electronic medical records.

Am J Clin Nutr 2018 03;107(3):420-426

Geriatric Research, Education, and Clinical Center and Research and Development, Puget Sound VA Medical Center, Seattle, WA.

Background: Spurious weights compromise the validity of summary measures, such as averages and trends. Even rare errors in weight records can undermine the utility of electronic medical record (EMR) data.

Objective: We sought to estimate the prevalence of spurious weight values in a large EMR, to ascertain the likely causes, and to develop and test straightforward algorithms for identifying spurious weight data.

Design: Using EMR data from 10,000 randomly selected patients aged ≥65 y in the VA system, we examined the percentage of weight change across various time intervals, from 1 to 3000 d. We examined descriptive results and developed 3 algorithms to categorize degree of weight change over time. On the basis of distributions, we identified cases that were most likely spurious. We manually reviewed these and categorized the type of error.

Results: The data followed the expected distributions. The algorithms reliably identified spurious weight. Approximately 0.8% of all weights in the record appeared to be spurious and ∼1 in 5 patient charts included ≥1 spurious weight value. The most common type of error involved the misentry of a single digit (e.g., 148 for 178).

Conclusions: Spurious weights are common in EMRs. Straightforward algorithms can identify and remove them, and thus enhance the reliability of EMR data.
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http://dx.doi.org/10.1093/ajcn/nqx056DOI Listing
March 2018

Long-Term Cognitive Decline After Newly Diagnosed Heart Failure: Longitudinal Analysis in the CHS (Cardiovascular Health Study).

Circ Heart Fail 2018 03;11(3):e004476

From the Department of Statistics (C.A.H., N.J.B.) and Department of Public Health (E.L.T.), Brigham Young University, Provo, UT; Department of Internal Medicine, Yale School of Medicine, New Haven, CT (S.I.C.); Department of Medicine (J.A.D.) and Department of Population Health (J.A.D.), New York University Langone Medical Center; Cardiovascular Health Research Unit (S.R.H., B.M.P., C.M.S.), Department of Neurology (W.T.L.), Department of Epidemiology (W.T.L., S.R.H., B.M.P., S.D.), Department of Medicine (B.M.P., C.M.S.), Department of Health Services (B.M.P.), Department of Biostatistics (A.M.A.), and Department of Psychiatry and Behavioral Sciences (S.M.T.), University of Washington, Seattle; Kaiser Permanente Washington Health Research Institute, Seattle (S.R.H., B.M.P., S.D.); Department of Medicine, Rutgers New Jersey Medical School, Newark (J.M.G.); Geriatric Research, Education, and Clinical Center, Seattle VA Medical Center, WA (S.M.T.); Department of Medicine, Duke University School of Medicine, Durham, NC (M.G.N.); Department of Neurology, Johns Hopkins University, Baltimore, MD (R.F.G.); and Department of Epidemiology (A.B.N.), Department of Medicine (A.B.N.), and Clinical and Translational Science Institute (A.B.N.), University of Pittsburgh, PA.

Background: Heart failure (HF) is associated with cognitive impairment. However, we know little about the time course of cognitive change after HF diagnosis, the importance of comorbid atrial fibrillation, or the role of ejection fraction. We sought to determine the associations of incident HF with rates of cognitive decline and whether these differed by atrial fibrillation status or reduced versus preserved ejection fraction.

Methods And Results: Participants were 4864 men and women aged ≥65 years without a history of HF and free of clinical stroke in the CHS (Cardiovascular Health Study)-a community-based prospective cohort study in the United States, with cognition assessed annually from 1989/1990 through 1998/1999. We identified 496 participants with incident HF by review of hospital discharge summaries and Medicare claims data, with adjudication according to standard criteria. Global cognitive ability was measured by the Modified Mini-Mental State Examination. In adjusted models, 5-year decline in model-predicted mean Modified Mini-Mental State Examination score was 10.2 points (95% confidence interval, 8.6-11.8) after incident HF diagnosed at 80 years of age, compared with a mean 5-year decline of 5.8 points (95% confidence interval, 5.3-6.2) from 80 to 85 years of age without HF. The association was stronger at older ages than at younger ages, did not vary significantly in the presence versus absence of atrial fibrillation (=0.084), and did not vary significantly by reduced versus preserved ejection fraction (=0.734).

Conclusions: Decline in global cognitive ability tends to be faster after HF diagnosis than without HF. Clinical and public health implications of this finding warrant further attention.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.117.004476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6072263PMC
March 2018

Ethical and Practical Ways in Which MOELI (Medical Orders for End-of-Life Intervention) Advance the Physician Orders for Life-Sustaining Treatment (POLST) Program.

J Am Med Dir Assoc 2018 03 9;19(3):270-272. Epub 2018 Jan 9.

Department of Psychiatry, University of Washington, Seattle, WA.

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http://dx.doi.org/10.1016/j.jamda.2017.12.004DOI Listing
March 2018

Protocol for the Assessment of Patient Capacity to Make End-of-Life Treatment Decisions.

J Am Med Dir Assoc 2018 02 26;19(2):106-109. Epub 2017 Dec 26.

Department of Psychiatry, University of Washington, Seattle, WA.

Patients' right to decide what happens to their bodies, especially around the end of life, is enshrined in legislation across the world, but questions often arise about whether a patient is capable of meaningfully participating in such decisions. Because of uncertainties about capacity, care providers and administrative agencies often must decide whether to honor, or even to elicit, patients' wishes. General decision-making capacity has been well studied, but few clear protocols exist for ascertaining capacity at the end of life. Without clear guidelines about how to assess capacity, medical staff may ignore assessment and operate from invalid assumptions. In the interests of protecting patients' agency, we propose a straightforward protocol for assessing capacity to make decisions about end-of-life interventions.
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http://dx.doi.org/10.1016/j.jamda.2017.11.011DOI Listing
February 2018

A Systematic Review of Practice Guidelines and Recommendations for Discontinuation of Cholinesterase Inhibitors in Dementia.

Am J Geriatr Psychiatry 2018 02 10;26(2):134-147. Epub 2017 Oct 10.

Veterans Affairs HSR&D Houston Center of Innovation, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX; Department of Medicine-Section of Health Services Research, Baylor College of Medicine, Houston, TX; Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, TX. Electronic address:

Cholinesterase inhibitors (ChEIs) are the primary pharmacological treatment for symptom management of Alzheimer disease (AD), but they carry known risks during long-term use, and do not guarantee clinical effects over time. The balance of risks and benefits may warrant discontinuation at different points during the disease course. Indeed, although there is limited scientific study of deprescribing ChEIs, clinicians routinely face practical decisions about whether to continue or stop medications. This review examined published practice recommendations for discontinuation of ChEIs in AD. To characterize the scientific basis for recommendations, we first summarized randomized controlled trials of ChEI discontinuation. We then identified practice guidelines by professional societies and in textbooks and classified them according to 1) whether they made a recommendation about discontinuation, 2) what the recommendation was, and 3) the proposed grounds for discontinuation. There was no consensus in guidelines and textbooks about discontinuation. Most recommended individualized discontinuation decisions, but there was essentially no agreement about what findings or situations would warrant discontinuation, or even about what domains to consider in this process. The only relevant domain identified by most guidelines and textbooks was a lack of response or a loss of effectiveness, both of which can be difficult to ascertain in the course of a progressive condition. Well-designed, long-term studies of discontinuation have not been conducted; such evidence is needed to provide a scientific basis for practice guidelines. It seems reasonable to apply an individualized approach to discontinuation while engaging patients and families in treatment decisions. .
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http://dx.doi.org/10.1016/j.jagp.2017.09.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5817050PMC
February 2018

Older adults rate their mental health better than their general health.

J Public Health Res 2017 Sep 29;6(2):967. Epub 2017 Sep 29.

University of Washington, Seattle, WA.

Background: Self-rated health (SRH) shows strong associations with measures of health and well-being. Increasingly, studies have used self-rated mental health (SRMH) as a predictor of various outcomes, independently or together with SRH. Research has not firmly established if and how these two constructs differ. We sought to characterize the relationship between SRH and SRMH, and to determine how this relationship differed across subgroups defined by sociodemographic and health-related characteristics.

Design And Methods: We analyzed data from the 2012 CAHPS Medicare Advantage Survey. SRH and SRMH ratings were crosstabulated to determine the distribution of responses across response categories. The expected joint probability distribution was computed and compared to the observed distribution. A constructed variable indicated whether SRMH was better, the same, or worse than SRH. We analyzed the distribution of this variable across various subgroups defined by sociodemographic and health-related factors.

Results: A total of 114,905 Medicare Advantage beneficiaries responded to both the SRH and SRMH questions. Both in general and within all subgroups, SRMH was usually rated as better than SRH, and rarely as worse.

Conclusions: Within a large group of Medicare recipients, the overwhelming trend was for recipients to rate their mental health as at least as good as their overall health, regardless of any sociodemographic and health-related factors. This finding of a shifted distribution encourages caution in the analytic use of selfrated mental health, particularly the use of both SRH and SRMH for adjustment. Additional research is needed to help clarify the complex relationship between these variables.

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http://dx.doi.org/10.4081/jphr.2017.967DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5641665PMC
September 2017

Screening Is Not Benign: Comment on "Olfactory Dysfunction Predicts Subsequent Dementia in Older US Adults".

Authors:
Stephen Thielke

J Am Geriatr Soc 2018 01 25;66(1):13-14. Epub 2017 Sep 25.

Geriatric Research, Education and Clinical Center, Puget Sound Veterans Affairs Medical Center, Seattle, WA.

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http://dx.doi.org/10.1111/jgs.15122DOI Listing
January 2018

Pain and fracture-related limitations persist 6 months after a fragility fracture.

Rheumatol Int 2017 Aug 20;37(8):1317-1322. Epub 2017 Jun 20.

Osteoporosis Canada, 1200 Eglinton Avenue East, Suite 500, Toronto, ON, M3C 1H9, Canada.

Our objective was to examine the experience of pain after a fracture beyond the conventional healing duration of 6 months. We conducted a phenomenological study in participants who were deemed high risk for future fracture and recruited through an urban fracture clinic in Toronto, Canada. In-depth interviews were conducted with questions addressing the experience of pain, the status of recovery from the fracture, ways in which the fracture affected one's daily activities, and interactions with health care providers. Two researchers coded the transcripts within the phenomenological perspective to develop a structure of the pain experience, promoting rigour through the use of multiple analysts, searching for negative cases, and supporting claims with direct quotations from participants. We interviewed 21 participants who had sustained fractures of the wrist (n = 4), hip (n = 6), vertebrae (n = 2), and multiple or other locations (n = 9). All patients were ambulatory, had a range of socioeconomic status, and lived in the community. Eleven of the 21 participants reported persistent pain at the site of the fracture. Of the 10 participants who reported no pain, four indicated they had ongoing difficulties with range of motion and specific activities and two others described persistent pain from a previous fracture or reliance on a scooter for mobility. Our study demonstrated that over two-thirds of older adults reported fracture-related pain and/or limitations at, or beyond, 6 months post-fracture. We suggest that health care providers ask questions about post-fracture pain and/or limitations when assessing fracture status beyond 6 months.
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http://dx.doi.org/10.1007/s00296-017-3761-yDOI Listing
August 2017

Standardizing Protection of Patients' Rights From POLST to MOELI (Medical Orders for End-of-Life Intervention).

J Am Med Dir Assoc 2017 09 13;18(9):741-745. Epub 2017 Jun 13.

Department of Psychiatry, University of Washington, Seattle, WA.

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http://dx.doi.org/10.1016/j.jamda.2017.04.022DOI Listing
September 2017

Prospective Disability in Different Combinations of Somatic and Mental Multimorbidity.

J Gerontol A Biol Sci Med Sci 2018 01;73(2):204-210

University of Michigan-Dearborn, Health Policy Studies.

Background: Multimorbidity (multiple co-occurring chronic conditions) may be an important contributor to disability and poor health-related quality of life. The functional consequences of specific combinations of somatic and mental health conditions are unclear.

Methods: Nationally representative prospective cohort study using the National Health and Aging Trends Study data of Medicare beneficiaries. We included 4,017 participants aged 65 years or older interviewed in 2013 and 2014. The primary outcome was prospective activities of daily living (ADL)-instrumental ADL (IADL) index (range = 0-11) assessed in 2014. All other measures were assessed in 2013. Chronic conditions included heart disease, hypertension, stroke, diabetes, arthritis, lung disease, osteoporosis, cancer, depression, and cognitive impairment. Analyses were adjusted for age, sex, education, race/ethnicity, body mass index, and baseline ADL-IADL.

Results: Thirty-four percent of multimorbidity combinations included depression, cognitive impairment, or both. Relative to multimorbidity combinations of exclusively somatic conditions, combinations that included both depression and cognitive impairment were associated with 1.34 times greater ADL-IADL in adjusted models (95% confidence interval [CI]: 1.09, 1.64). Relative to combinations of both depression and cognitive impairment, combinations of cognitive impairment and somatic conditions were associated with 0.84 times lower ADL-IADL in adjusted models (95% CI: 0.74, 0.96); combinations of depression and somatic conditions were associated with 0.72 times lower ADL-IADL in adjusted models (95% CI: 0.62, 0.85).

Conclusions: Depression and/or cognitive impairment was identified in one-third of older adults with multimorbidity, and these combinations were associated with substantially greater prospective disability than combinations comprised exclusively of somatic conditions. This argues for identifying and managing mental health conditions that co-occur with somatic conditions.
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http://dx.doi.org/10.1093/gerona/glx100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279134PMC
January 2018
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