Dementia and Cognitive Impairment Among U.S. Veterans With a History of MDD or PTSD: A Retrospective Cohort Study Based on Sex and Race

Assessing neurocognitive outcomes in PTSD: a multilevel meta-analytical approach

Background: Evidence supporting the association between posttraumatic stress disorder (PTSD) and cognitive impairment is accumulating. However, less is known about which factors influence this association.Objective: The aims of this meta-analysis were to (1) elucidate the association between PTSD and a broad spectrum of cognitive impairment, including the risk of developing neurocognitive disorder (NCD) later in life, using a multilevel meta-analytic approach, and (2) identify potential moderating factors of this association by examining the effects of age (20-39, 40-59, 60+), study design (cross-sectional or longitudinal), study population (war-exposed populations/veterans or the general population), neurocognitive outcome assessed (i.e. a diagnosis of NCD or type of cognitive domain as classified according to A Compendium of Neuropsychological tests), gender (≥50% women or <50% women), study quality (high vs low), type of PTSD measure (self-report or clinical diagnosis), as well as the presence of comorbidities such as traumatic brain injury (TBI), depression, and substance use (all coded as either present or absent).Method: Peer-reviewed studies on this topic were extracted from PubMed and Web of Science with predetermined keywords and criteria. In total, 53 articles met the criteria. Hedge's g effect sizes were calculated for each study and a three-level random effect meta-analysis conducted.Results: After accounting for publication bias, the results suggested a significant association between PTSD and cognitive impairment, g = 0.13 (95% CI: 0.10-0.17), indicating a small effect. This association was consistent across all examined moderators, including various neurocognitive outcomes, age, gender, study design, study population, study quality, type of PTSD measure, and comorbidities such as depression, substance use, and TBI.Conclusions: These findings collectively suggest that PTSD is associated with both cognitive impairment and NCD. This emphasizes the need for early intervention (including prevention strategies) of PTSD, alongside monitoring cognitive function in affected individuals.International Prospective Register of Systematic Reviews (PROSPERO) registration number: CRD42021219189, date of registration: 02.01.2021.

Altered attentional control process of individuals with high test anxiety: An exploratory fMRI study

Test anxiety (TA) has been linked to abnormalities in attentional control not only for test-related information but also in situations where irrelevant information has to be ignored. However, the neural basis of individuals with high TA (HTA) when exposed to interference from different types of information remains limited. Twenty-two individuals with HTA and twenty-three individuals with low TA (LTA) completed a Stroop task integrating emotional-word and color-word Stroop tasks. Participants were instructed to assess the font color of neutral words, generally threatening words, test-related threatening words, color-congruent words, and color-incongruent words. Functional magnetic resonance imaging data were recorded simultaneously as the task was completed. The results indicated that compared with LTA group, HTA group exhibited higher activation in the right postcentral gyrus, left cerebellum, right calcarine gyrus, and left inferior parietal lobule when individuals were exposed to interference by test-related threatening words as opposed to neutral words. However, no clusters with significant group-related differences were found when individuals were exposed to interference by generally threatening words and color-incongruent words. These results suggested that differences in attentional control processes between high- and low-test anxiety groups were mainly limited to test-related threatening stimuli and did not extend to generally threatening and cognitively task-irrelevant stimuli.

Associations of posttraumatic stress disorder symptoms with amyloid burden in cognitively normal older adults

Background

Posttraumatic stress disorder (PTSD) is associated with the development of dementia. However, the link between PTSD and preclinical Alzheimer's disease pathology (amyloid β [Aβ]) remains controversial. Moreover, the correlation between the severity of PTSD with Aβ levels remains unknown.

Methods

This cross-sectional study sought to investigate the associations of PTSD symptoms with global and regional brain Aβ burden. To this end, data were obtained from participants in the Anti-Amyloid Treatment in Asymptomatic Alzheimer's Disease (A4) Study. In addition, we explored the association between the severity of PTSD symptoms and Aβ levels.

Results

A total of 4,228 participants aged 65 to 85 years were included in the final analysis. The results showed that PTSD symptoms were significantly associated with higher global Aβ levels (1.15 ± 0.20 vs. 1.09 ± 0.19; β = 0.056; p < 0.001), after adjusting for covariates. The association between PTSD symptoms and Aβ levels was not affected by sex, age, ApoE genotype, or psychiatric diseases. Similarly, PTSD symptoms were significantly associated with Aβ levels in all subregions, including the anterior cingulate, posterior cingulate, parietal cortex, precuneus, temporal cortex, and frontal cortex. In addition, the group with severe PTSD symptoms (1.22 ± 0.24) exhibited higher global Aβ levels than the groups with moderate (1.14 ± 0.19) or mild (1.12 ± 0.20) symptoms or the control (1.08 ± 0.18), with p < 0.001.

Conclusion

The findings imply a close relationship between PTSD and brain Aβ levels, irrespective of sex, age, ApoE genotype, or psychiatric diseases. More well-designed studies are needed to further explore the relationship and mechanism underlying the association between PTSD and Aβ burden.

The Impact of Executive Function on Retention and Compliance in Physical Therapy in Veterans

Objective

To examine retention and compliance to a novel physical therapy (PT) treatment among Veterans with and without executive function deficits (EFD+/EFD-).

Design

This study was a preplanned secondary analysis of an ongoing randomized controlled trial.

Setting

Outpatient PT at VA Boston Healthcare System.

Participants

Seventy-two community-dwelling middle-aged and older Veterans (mean age, 72 years [range 51-91]; 87% male) with gait speed between 0.5 and 1.0 m/second were recruited from primary care practices.

Interventions

Eight-week moderate-to-vigorous intensity PT program.

Main outcome measure

Veterans' baseline mobility, retention (dropouts), and treatment compliance and posttreatment exercise compliance to 8-week PT treatment were evaluated based on their baseline EFD status.

Results

Of the 72 participants, 22% (n=16) were EFD+. Veterans with EFD+ at baseline had worse mobility performance (Short Physical Performance Battery [SPPB], 7.7 vs 9.5, P<.001) and patient-reported mobility (Activity Measure for Post-Acute Care [AM-PAC], 57.6 vs 62.2, P<.01) after adjusting for age, gender, number of comorbidities, depressive symptoms, and pain interference. Dropout rates for EFD+ and EFD- were 44% and 25%, respectively (P>.05). In multivariable logistic regression modeling, pain interference, depressive symptoms, mobility, and living alone but not EFD status were associated with dropping out. Among study completers, there was no evidence of significant differences in treatment compliance or posttreatment exercise compliance, measured by the number of attended sessions and the number of posttreatment exercise days by EFD status.

Conclusion

EFD+ was associated with poor baseline mobility. Although the dropout rate was higher among Veterans with EFD+, we were unable to conclude whether EFD status impacts retention or compliance due to the small sample size. Further investigation is needed to determine whether EFD status may identify individuals who need additional support during and/or after rehabilitation treatment.

Associations of Post-Traumatic Stress Disorder and Objective Subtle Cognitive Difficulties in Cognitively Unimpaired Older Veterans

INTRODUCTION

Psychiatric conditions such as post-traumatic stress disorder (PTSD) and depression have a two-fold increased dementia risk in Veterans. Prior work has shown that psychiatric factors can both impact cognitive functioning and be early symptoms associated with Alzheimer's disease (AD). Objectively defined subtle cognitive difficulties (Obj-SCD) has been associated with cognitive decline and AD biomarkers. However, Obj-SCD has not yet been investigated in the context of psychiatric disorders.

METHODS

A total of 179 cognitively unimpaired Veterans (50-92 years old) underwent a comprehensive neuropsychological evaluation at VA San Diego and a retrospective medical record review. Chi-squared tests compared rates of psychiatric diagnoses in Veterans with and without Obj-SCD.

RESULTS

About 21% of the sample was classified as Obj-SCD. Relative to cognitively unimpaired Veterans, Veterans classified as Obj-SCD had higher rates of PTSD, but not higher rates of other psychiatric conditions (e.g., depression). The PTSD findings appear to be driven by measures of cognitive efficiency.

CONCLUSION

Elevated rates of PTSD, but not other psychiatric conditions, were observed among Veterans with Obj-SCD. The prevalence and type of subtle cognitive difficulties associated with PTSD in older Veterans demonstrates a need, and informs potential targets, for intervention. Further work is needed to determine mechanisms of subtle cognitive difficulties in older Veterans with PTSD.

Enhancing trauma-informed care preparation through life story work

Trauma experience is common and may impact health and health care experiences for older adults. As such, training in trauma-informed care (TIC) is essential for health professions trainees. In this paper, we describe the use of life-story work, in the form of the My Life, My Story (MLMS) program as one platform to enhance TIC competencies. Trainees (N = 74) who were physician (57.0%) and other health professions trainees who did MLMS interviews completed a post-experience survey about trauma disclosures and confidence in responding to these. During these interviews, 36.5% of the patients described a traumatic event and 56.8% described a stressful event, framed by the patient as "ultimately positive" - leading to resilience (42.6%) or "ultimately negative" - leading to negative life outcomes (29.5%), with other responses as not sure or ambivalent. Confidence in responding to trauma disclosures increased following participation in MLMS (t(df = 60) = 5.52, p < .001). Qualitative comments indicated that MLMS helped them recognize the various expressions of trauma and provided insights into possible responses to trauma disclosure, among other TIC competencies. About half (50.8%) of trainees expressed interest in additional resources or training in responding to trauma disclosures. In conclusion, life-story work and MLMS may be one tool to enhance TIC.

An observational cohort study of alcohol use and cognitive difficulties among post-9/11 veterans with and without TBI and PTSD

BACKGROUND

Traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and alcohol use are highly prevalent among military Veterans and independently associated with cognitive difficulties; less is known about the combined effects. This study aimed to investigate the association between alcohol use patterns and cognitive diagnoses in Veterans with TBI and/or PTSD.

METHODS

Using electronic health record data,193,663 Veterans were classified into three alcohol use trajectory groups (consistently low, initially high transitioning to low, initially moderate transitioning to high) based on self-reported Alcohol Use Disorders Identification Test-C (AUDIT-C) scores. Cox proportional hazards models were used to examine the association between alcohol use patterns, TBI, PTSD, and the risk of cognitive diagnosis, while adjusting for demographic factors and comorbidities.

RESULTS

Veterans with initially high transitioning to low (HR = 1.21, 95 % CI: 1.11-1.31) and initially moderate transitioning to high (HR = 1.42, 95 % CI: 1.33-1.51) alcohol use patterns had a significantly greater risk of cognitive diagnosis compared to those with consistently low alcohol use when accounting for TBI, PTSD, and comorbidities. TBI (HR = 5.40, 95 % CI: 5.06-5.76) and PTSD (HR = 2.42, 95 % CI: 2.25-2.61) were also independently associated with an elevated risk of cognitive diagnosis.

CONCLUSIONS

Findings suggest that Higher levels of alcohol consumption, even if decreasing over time, may confer an increased risk of cognitive diagnosis for Veterans with TBI and/or PTSD. Long-term alcohol use patterns should be considered in clinical assessments and interventions to identify individuals at greater risk for experiencing cognitive difficulties.

Macular, Choroidal, and Peripapillary Perfusion Changes in Mild and Moderate Traumatic Brain Injury Using Optical Coherence Tomography and Angiography

Introduction: To compare the retinal and choroidal architecture and microvasculature between patients with mild or moderate traumatic brain injury (TBI) and controls with normal cognition using optical coherence tomography (OCT) and OCT angiography (OCTA). Methods: Patients with a documented history of TBI, and age-matched and sex-matched controls were recruited. The primary outcome measures were differences between OCT parameters, including the choroidal vascularity index, and between OCTA superficial capillary plexus metrics, including foveal avascular zone (FAZ) circularity, 3.0 mm × 3.0 mm and 6.0 mm × 6.0 mm macular vessel density and perfusion density, and 4.5 mm × 4.5 mm peripapillary capillary perfusion density and capillary flux index. Results: Sixty-seven eyes of 36 patients with TBI and 72 eyes of 36 control patients met the inclusion criteria. Twelve patients (33.3%) had a diagnosis of mild TBI without loss of consciousness (LOC), 21 (58.3%) had mild TBI with LOC, and 3 (8.3%) had moderate TBI. There was a significant reduction in FAZ circularity and in 3.0 mm × 3.0 mm macular OCTA vessel density and perfusion density in patients with TBI. In cases with TBI associated with posttraumatic stress disorder, all macular OCTA parameters were significantly reduced. There was an increase in the choroidal vascularity index across the severity of TBI; however, it was reduced in those with more than 1 TBI (P = .03). Conclusions: There was a reduction in macular perfusion in eyes of patients with mild or moderate TBI. The choroidal vascularity index helps differentiate subtle effects of more severe or mild repeated TBI. Further prospective investigation will evaluate OCT imaging and OCTA imaging as a noninvasive screening modalities to assess changes in retinal and choroidal microvasculature.

Preimplementation Evaluation of a Self-Directed Care Program in a Veterans Health Administration Regional Network: Protocol for a Mixed Methods Study

BACKGROUND

The Veteran-Directed Care (VDC) program serves to assist veterans at risk of long-term institutional care to remain at home by providing funding to hire veteran-selected caregivers. VDC is operated through partnerships between Department of Veterans Affairs (VA) Medical Centers (VAMCs) and third-party Aging and Disability Network Agency providers.

OBJECTIVE

We aim to identify facilitators, barriers, and adaptations in VDC implementation across 7 VAMCs in 1 region: Veterans Integrated Service Network (VISN) 8, which covers Florida, South Georgia, Puerto Rico, and the US Virgin Islands. We also attempted to understand leadership and stakeholder perspectives on VDC programs' reach and implementation and identify veterans served by VISN 8's VDC programs and describe their home- and community-based service use. Finally, we want to compare veterans served by VDC programs in VISN 8 to the veterans served in VDC programs across the VA. This information is intended to be used to identify strategies and propose recommendations to guide VDC program expansion in VISN 8.

METHODS

The mixed methods study design encompasses electronically delivered surveys, semistructured interviews, and administrative data. It is guided by the Consolidated Framework for Implementation Research (CFIR version 2.0). Participants included the staff of VAMCs and partnering aging and disability network agencies across VISN 8, leadership at these VAMCs and VISN 8, veterans enrolled in VDC, and veterans who declined VDC enrollment and their caregivers. We interviewed selected VAMC site leaders in social work, Geriatrics and Extended Care, and the Caregiver Support Program. Each interviewee will be asked to complete a preinterview survey that includes information about their personal characteristics, experiences with the VDC program, and perceptions of program aspects according to the CFIR (version 2.0) framework. Participants will complete a semistructured interview that covers constructs relevant to the respondent and facilitators, barriers, and adaptations in VDC implementation at their site.

RESULTS

We will calculate descriptive statistics including means, SDs, and percentages for survey responses. Facilitators, barriers, number of patients enrolled, and staffing will also be presented. Interviews will be analyzed using rapid qualitative techniques guided by CFIR domains and constructs. Findings from VISN 8 will be collated to identify strategies for VDC expansion. We will use administrative data to describe veterans served by the programs in VISN 8.

CONCLUSIONS

The VA has prioritized VDC rollout nationwide and this study will inform these expansion efforts. The findings from this study will provide information about the experiences of the staff, leadership, veterans, and caregivers in the VDC program and identify program facilitators and barriers. These results may be used to improve program delivery, facilitate growth within VISN 8, and inform new program establishment at other sites nationwide as the VDC program expands.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57341.

Comparing neuropsychological, typical, and ADNI criteria for the diagnosis of mild cognitive impairment in Vietnam-era veterans

OBJECTIVE

Neuropsychological criteria for mild cognitive impairment (MCI) more accurately predict progression to Alzheimer's disease (AD) and are more strongly associated with AD biomarkers and neuroimaging profiles than ADNI criteria. However, research to date has been conducted in relatively healthy samples with few comorbidities. Given that history of traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) are risk factors for AD and common in Veterans, we compared neuropsychological, typical (Petersen/Winblad), and ADNI criteria for MCI in Vietnam-era Veterans with histories of TBI or PTSD.

METHOD

267 Veterans (mean age = 69.8) from the DOD-ADNI study were evaluated for MCI using neuropsychological, typical, and ADNI criteria. Linear regressions adjusting for age and education assessed associations between MCI status and AD biomarker levels (cerebrospinal fluid [CSF] p-tau181, t-tau, and Aβ42) by diagnostic criteria. Logistic regressions adjusting for age and education assessed the effects of TBI severity and PTSD symptom severity simultaneously on MCI classification by each criteria.

RESULTS

Agreement between criteria was poor. Neuropsychological criteria identified more Veterans with MCI than typical or ADNI criteria, and were associated with higher CSF p-tau181 and t-tau. Typical and ADNI criteria were not associated with CSF biomarkers. PTSD symptom severity predicted MCI diagnosis by neuropsychological and ADNI criteria. History of moderate/severe TBI predicted MCI by typical and ADNI criteria.

CONCLUSIONS

MCI diagnosis using sensitive neuropsychological criteria is more strongly associated with AD biomarkers than conventional diagnostic methods. MCI diagnostics in Veterans would benefit from incorporation of comprehensive neuropsychological methods and consideration of the impact of PTSD.

No Replication of Alzheimer's Disease Genetics as a Moderator of Combat Exposure's Association with PTSD risk in 138,592 Combat Veterans

Large-scale cohort and epidemiological studies suggest that posttraumatic stress disorder (PTSD) confers risk for late-onset Alzheimer's disease (AD) and related dementias (ADRD); however, the basis for this association remains unclear. Several prior studies of military Veterans have reported that carriers of the apolipoprotein E (APOE) ε4 gene variant are at heightened risk for the development of PTSD following combat exposure, suggesting that PTSD and ADRD may share some genetic risk. This cohort study was designed to further examine the hypothesis that ADRD genetic risk also confers risk for PTSD. To do so, we examined APOE ε4 and ε2 genotypes, an AD polygenic risk score (PRS), and other Veteran-relevant risk factors for PTSD in age-stratified groups of individuals of European (n = 123,372) and African (n = 15,220) ancestry in the US Department of Veterans Affairs' Million Veteran Program. Analyses revealed no significant main effect associations between the APOE ε4 (or ε2) genotype or the AD PRS on PTSD severity or diagnosis. There were also no significant interactions between measures of AD genetic risk and either combat exposure severity or history of head injury in association with PTSD in any age group. We conclude that the association between PTSD and the primary ADRD genetic risk factor, APOE ε4, that was reported previously was not replicable in the largest relevant dataset in the world. Thus, the epidemiological association between PTSD and ADRD is not likely to be driven by the major genetic factors underlying ADRD risk.

Epigenetic age acceleration as a biomarker for impaired cognitive abilities in adulthood following early life adversity and psychiatric disorders

Background

Early life adversity and psychiatric disorders are associated with earlier declines in neurocognitive abilities during adulthood. These declines may be preceded by changes in biological aging, specifically epigenetic age acceleration, providing an opportunity to uncover genome-wide biomarkers that identify individuals most likely to benefit from early screening and prevention.

Methods

Five unique epigenetic age acceleration clocks derived from peripheral blood were examined in relation to latent variables of general and speeded cognitive abilities across two independent cohorts: 1) the Female Growth and Development Study (FGDS; n = 86), a 30-year prospective cohort study of substantiated child sexual abuse and non-abused controls, and 2) the Biological Classification of Mental Disorders study (BeCOME; n = 313), an adult community cohort established based on psychiatric disorders.

Results

A faster pace of biological aging (DunedinPoAm) was associated with lower general cognitive abilities in both cohorts and slower speeded abilities in the BeCOME cohort. Acceleration in the Horvath clock was significantly associated with slower speeded abilities in the BeCOME cohort but not the FGDS. Acceleration in the Hannum clock and the GrimAge clock were not significantly associated with either cognitive ability. Accelerated PhenoAge was associated with slower speeded abilities in the FGDS but not the BeCOME cohort.

Conclusions

The present results suggest that epigenetic age acceleration has the potential to serve as a biomarker for neurocognitive decline in adults with a history of early life adversity or psychiatric disorders. Estimates of epigenetic aging may identify adults at risk of cognitive decline that could benefit from early neurocognitive screening.

Association between stress-related disorders and the risk of dementia using the Korean National Sample Cohort: a matched cohort study

Post-traumatic stress disorder (PTSD) is associated with the development of dementia; however, the association of dementia risk with overall stress-related disorders is less known. This study investigated the association between stress-related disorders and the risk of dementia in a Korean nationwide sample cohort. The data analyzed in this study were acquired from the Korean National Health Insurance Service National Sample Cohort between 2002 and 2013. Using a 1:3 propensity score matching, 8906 patients with stress-related disorders and 26,718 control participants were included in the analysis. Patients with stress-related disorders had a higher risk of developing dementia after adjusting for covariates (hazard ratio [HR] = 1.15; 95% confidence interval [CI] 1.01-1.30) than control participants. Patients with PTSD showed the highest risk of increase (HR = 1.78) than those with other types of stress-related disorders. Patients with stress-related disorders showed the highest and significantly increased risk for Alzheimer's dementia (HR = 1.22, 95% CI 1.04-1.56). These results indicated an association between a history of stress-related disorders and the risk of dementia in the South Korean population. Further research investigating the causal mechanisms is needed.

Weaving Evidence into Action for Veterans with dementia (WEAVE): Codesigning the implementation of nonpharmacological interventions for programme fidelity and sustainability

RATIONALE

Challenges associated with translating evidence into practice are well recognised and calls for effective strategies to reduce the time lag and successfully embed evidence-based practices into usual care are loud and clear. While a plethora of nonpharmacological interventions for people with dementia exist; few are based on strong evidence and there is little consideration for programme operationalisation in the complex environment of long-term care.

AIMS AND OBJECTIVES

This paper describes the preparation for the implementation of the Weaving Evidence into Action for Veterans with dementia project, incorporating the codesign of delivery of four evidence-based, nonpharmacological interventions.

METHOD

Implementation preparation for this type 2 hybrid effectiveness-implementation project was underpinned by the Implementation Framework for Aged Care (IFAC). A sociocultural-political contextual scan was undertaken, and reflection on the IFAC question 'why change?' with key stakeholders. Delivery of the four interventions of music therapy, exercise, reminiscence therapy and sensory modulation was explored using codesign methodology. Preparation of both intervention delivery personnel and recipients was via training, establishment of a change team and promotional/awareness-raising strategies.

RESULTS

The contextual scan revealed Australian government reforms and organisational imperatives facing long-term care services, while reflections on 'why change' flagged best practice dementia care at the local care home level. Several codesign sessions involved veterans with dementia, family members, care home staff members and volunteers to ensure programme alignment with needs and preferences, accounting for existing activities. Training was designed and delivered before programme commencement. A change team was established and strategies to support behaviour change instigated. Implementation evaluation is reported elsewhere.

CONCLUSION

The extended preparatory period for implementation, afforded by the COVID-19 pandemic on programme commencement, enabled time for widespread understanding of the programme and necessary upskill of staff. Comprehensive codesign with all stakeholders of programme components identified core and flexible elements necessary for fidelity of implementation.

Which Severe Mental Illnesses Most Increase the Risk of Developing Dementia? Comparing the Risk of Dementia in Patients with Schizophrenia, Major Depressive Disorder and Bipolar Disorder

Objective

Previous studies have shown that certain severe mental illnesses (SMIs) increase the risk of dementia, but those that increase the risk to a greater degree in comparison with other SMIs are unknown. Furthermore, physical illnesses may alter the risk of developing dementia, but these cannot be well-controlled.

Methods

Using the Taiwan National Health Insurance Research Database, patients with schizophrenia, bipolar disorder and major depressive disorder (MDD) were recruited. We also recruited normal healthy subjects as the control group. All subjects were aged over 60 years, and the duration of follow-up was from 2008 to 2015. Multiple confounders were adjusted, including physical illnesses and other variables. Use of medications, especially benzodiazepines, was analyzed in a sensitivity analysis.

Results

36,029 subjects (MDD: 23,371, bipolar disorder: 4,883, schizophrenia: 7,775) and 108,084 control subjects were recruited after matching according to age and sex. The results showed that bipolar disorder had the highest hazard ratio (HR) (HR: 2.14, 95% confidence interval [CI]: 1.99-2.30), followed by schizophrenia (HR: 2.06, 95% CI: 1.93-2.19) and MDD (HR: 1.60, 95% CI: 1.51-1.69). The results remained robust after adjusting for covariates, and sensitivity analysis showed similar results. Anxiolytics use did not increase the risk of dementia in any of the three groups of SMI patients.

Conclusion

SMIs increase the risk of dementia, and among them, bipolar disorder confers the greatest risk of developing dementia. Anxiolytics may not increase the risk of developing dementia in patients with an SMI, but still need to be used with caution in clinical practices.

Traumatic disclosures in the life stories of older Vietnam era veterans

BACKGROUND

Eliciting life stories is an important component of person-centered care that may aid in understanding how an individual's unique background and narrative impacts their health. Such life stories, especially when gathered from older military Veterans, may include traumatic events, raising the urgency that clinicians be prepared to provide care that is trauma-informed and ensure Veteran's experiences are acknowledged and treated effectively.

METHODS

We examined the prevalence and type of potentially traumatic and/or adverse life events spontaneously shared by 231 older Veterans participating in a life story intervention while receiving care within the U.S. Veterans Health Administration system. Veteran life stories were extracted from the electronic medical record and deductive qualitative content analysis was used to code potentially traumatic or adverse life experiences based on a codebook adapted from the Brief Trauma Questionnaire and Adverse Childhood Experience questionnaire.

RESULTS

A majority (71.0%) of Veterans described at least one traumatic disclosure in their life story. Among narratives with a disclosure of any type, more than half (53.0%) included descriptions of combat trauma, 21.5% noted a history of life-threatening illness, and 9.5% reported having been in a serious accident. Fewer noted adverse childhood experiences (19.5%).

CONCLUSIONS

Elicitation of life stories among older Veterans may advance person-centered care and life stories frequently include disclosure of potentially traumatic and/or adverse life events. These findings underscore the normative experience of traumatic events among older Veterans and highlight the importance of developing age-sensitive trauma-informed care competencies.

Posttraumatic Stress Disorder Mediates the Association between Traumatic World Trade Center Dust Cloud Exposure and Ongoing Systemic Inflammation in Community Members

Exposure to World Trade Center (WTC) dust/fumes and traumas on 11 September 2001 has been reported as a risk factor for post-traumatic stress disorder (PTSD) and other mental/physical health symptoms in WTC-affected populations. Increased systemic inflammation and oxidative stress from the exposure and subsequent illnesses have been proposed as contributors to the underlying biological processes. Many blood-based biomarkers of systemic inflammation, including C-reactive protein (CRP), are useful for non-invasive diagnostic and monitoring of disease process, and also potential targets for therapeutic interventions. Twenty years after 9/11, however, the relationships between WTC exposure, chronic PTSD, and systemic inflammation are only beginning to be systematically investigated in the WTC-affected civilian population despite the fact that symptoms of PTSD and systemic inflammation are still common and persistent. This paper aims to address this knowledge gap, using enrollees of the WTC Environmental Health Center (EHC), a federally designated treatment and surveillance program for community members (WTC Survivors) exposed to the 9/11 terrorist attack. We conducted a mediation analysis to investigate the association between acute WTC dust cloud traumatic exposure (WDCTE) on 9/11, chronic PTSD symptoms, and levels of systemic inflammation. The data indicate that the chronic PTSD symptoms and some specific symptom clusters of PTSD significantly mediate the WDCTE on systemic inflammation, as reflected by the CRP levels. As both chronic PTSD and systemic inflammation are long-term risk factors for neurodegeneration and cognitive decline, further research on the implications of this finding is warranted.

Post-traumatic Stress Disorder in Older U.S. Military Veterans: Prevalence, Characteristics, and Psychiatric and Functional Burden

OBJECTIVE

To characterize the prevalence, characteristics, and comorbidities of subthreshold and full post-traumatic stress disorder (PTSD) in older U.S. military veterans.

DESIGN AND SETTING

A nationally representative web-based survey of older U.S. military veterans who participated in the National Health and Resilience in Veterans Study (NHRVS) between November 18, 2019 and March 8, 2020.

PARTICIPANTS

U.S. veterans aged 60 and older (n = 3,001; mean age = 73.2, SD: 7.9, range: 60-99).

MEASUREMENTS

PTSD was assessed using the PTSD Checklist for DSM-5. Self-report measures assessed sociodemographic characteristics, trauma exposures, suicidal behaviors, psychiatric and substance use disorders, as well as mental, cognitive, and physical functioning. Multivariable analyses examined correlates of subthreshold and full PTSD.

RESULTS

The vast majority of the sample (n = 2,821; 92.7%) reported exposure to one or more potentially traumatic events. Of those exposed to such events, 262 (9.6%, 95% confidence interval [CI]: 8.4%-10.9%) and 68 (1.9%, 95% CI: 1.3%-2.6%) screened positive for subthreshold and full PTSD, respectively. The prevalence of subthreshold and full PTSD was significantly higher in female veterans and veterans who use VA as their primary healthcare. Subthreshold and full PTSD groups endorsed more adverse childhood experiences and total traumas than the no/minimal PTSD symptom group, the most common traumatic experiences endorsed were combat exposure, physical or sexual assault, and life-threatening illness or injury. Veterans with subthreshold and full PTSD were also more likely to screen positive for depression, substance use disorders, suicide attempts, nonsuicidal self-injury, and suicidal ideation, and reported lower mental, cognitive, and physical functioning.

CONCLUSION

Subthreshold PTSD and full PTSD are prevalent and associated with substantial clinical burden in older U.S. veterans. Results underscore the importance of assessing both subthreshold and full PTSD in this population.

Cognitive Outcome 1 Year After Mild Traumatic Brain Injury: Results From the TRACK-TBI Study

BACKGROUND AND OBJECTIVES

The objectives of this study were to develop and establish concurrent validity of a clinically relevant definition of poor cognitive outcome 1 year after mild traumatic brain injury (mTBI), to compare baseline characteristics across cognitive outcome groups, and to determine whether poor 1-year cognitive outcome can be predicted by routinely available baseline clinical variables.

METHODS

Prospective cohort study included 656 participants ≥17 years of age presenting to level 1 trauma centers within 24 hours of mTBI (Glasgow Coma Scale score 13-15) and 156 demographically similar healthy controls enrolled in the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. Poor 1-year cognitive outcome was defined as cognitive impairment (below the ninth percentile of normative data on ≥2 cognitive tests), cognitive decline (change score [1-year score minus best 2-week or 6-month score] exceeding the 90% reliable change index on ≥2 cognitive tests), or both. Associations of poor 1-year cognitive outcome with 1-year neurobehavioral outcomes were performed to establish concurrent validity. Baseline characteristics were compared across cognitive outcome groups, and backward elimination logistic regression was used to build a prediction model.

RESULTS

Mean age of participants with mTBI was 40.2 years; 36.6% were female; 76.6% were White. Poor 1-year cognitive outcome was associated with worse 1-year functional outcome, more neurobehavioral symptoms, greater psychological distress, and lower satisfaction with life (all p < 0.05), establishing concurrent validity. At 1 year, 13.5% of participants with mTBI had a poor cognitive outcome vs 4.5% of controls (p = 0.003). In univariable analyses, poor 1-year cognitive outcome was associated with non-White race, lower education, lower income, lack of health insurance, hyperglycemia, preinjury depression, and greater injury severity (all p < 0.05). The final multivariable prediction model included education, health insurance, preinjury depression, hyperglycemia, and Rotterdam CT score ≥3 and achieved an area under the curve of 0.69 (95% CI 0.62-0.75) for the prediction of a poor 1-year cognitive outcome, with each variable associated with >2-fold increased odds of poor 1-year cognitive outcome.

DISCUSSION

Poor 1-year cognitive outcome is common, affecting 13.5% of patients with mTBI vs 4.5% of controls. These results highlight the need for better understanding of mechanisms underlying poor cognitive outcome after mTBI to inform interventions to optimize cognitive recovery.

Cognitive Function among World Trade Center-Exposed Community Members with Mental Health Symptoms

The World Trade Center Environmental Health Center (WTC EHC), is a federally designated clinical center of excellence for surveillance and treatment of WTC disaster exposed community members (WTC Survivors). Cognitive impairment (CI) has been extensively described in WTC responders and a concern for progressive impairment in all WTC disaster exposed groups has been raised. Cognitive status, however, has not been systematically characterized in the WTC Survivor population. We describe cognitive status in a subgroup of the Survivor population referred for mental health evaluation (N = 480) in the WTC EHC as measured by scores on the Montreal Cognitive Assessment (MoCA) instrument, and examine their association with WTC exposures and individual-level covariates including PTSD and depression screening inventory scores. In regression analyses, probable cognitive impairment (MoCA score < 26) was found in 59% of the study subjects and was significantly associated with age, race/ethnicity, education, income, depression and PTSD scores. Being caught in the dust cloud on 11 September 2011 was significantly associated with cognitive impairment even after controlling for the above. These data suggest an association with cognitive dysfunction in WTC Survivors with exposure to the toxic dust/fumes and psychological stress from the 9/11 terrorist attack and warrant further systematic study.

Dementia in military and veteran populations: a review of risk factors-traumatic brain injury, post-traumatic stress disorder, deployment, and sleep

The military population face a unique set of risk factors that may increase the risk of being diagnosed with dementia. Traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) have a higher prevalence in this group in comparison to the civilian population. By delving into the individual relationships between TBI and dementia, and PTSD and dementia, we are able to better explore dementia in the military and veteran populations. While there are some inconsistencies in results, the TBI-dementia association has become more widely accepted. Moderate-to-severe TBI has been found to increase the risk of being diagnosed with Alzheimer's disease. A correlation between PTSD and dementia has been established, however, whether or not it is a causal relationship remains unclear. Factors such as blast, combat and chemical exposure may occur during a deployment, along with TBI and/or PTSD diagnosis, and can impact the risk of dementia. However, there is a lack of literature exploring the direct effects of deployment on dementia risk. Sleep problems have been observed to occur in those following TBI, PTSD and deployment. Poor sleep has been associated with possible dementia risk. Although limited studies have focused on the link between sleep and dementia in military and veteran populations, sleep is a valuable factor to study due to its association and interconnection with other military/veteran factors. This review aims to inform of various risk factors to the cognitive health of military members and veterans: TBI, PTSD, deployment, and sleep.

PTSD symptoms, depressive symptoms, and subjective cognitive concerns in WTC-exposed and non-WTC-exposed firefighters

BACKGROUND

Firefighting has been associated with posttraumatic stress disorder (PTSD) and other mental health conditions. We previously found that among Fire Department of the City of New York (FDNY) responders to the World Trade Center (WTC) disaster, higher-intensity WTC-exposure predicted PTSD symptoms, depressive symptoms, and subjective cognitive concerns. The present study aims to compare these symptoms in the FDNY WTC-exposed cohort versus a comparison cohort of non-FDNY, non-WTC-exposed firefighters.

METHODS

The study population included WTC-exposed male firefighters from FDNY (N = 8466) and non-WTC-exposed male firefighters from Chicago (N = 1195), Philadelphia (N = 770), and San Francisco (N = 650) fire departments who were employed on 9/11/2001 and completed a health questionnaire between 3/1/2018 and 12/31/2020. Current PTSD symptoms, depressive symptoms, and subjective cognitive concerns were assessed via validated screening instruments. Multivariable linear regression analyses stratified by fire department estimated the impact of covariates on each outcome.

RESULTS

Adjusted mean PTSD symptom scores ranged from 23.5 ± 0.6 in Chicago firefighters to 25.8 ± 0.2 in FDNY, and adjusted mean depressive symptom scores ranged from 7.3 ± 0.5 in Chicago to 9.4 ± 0.6 in Philadelphia. WTC-exposure was associated with fewer subjective cognitive concerns (β = -0.69 ± 0.05, p < .001) after controlling for covariates. Across cohorts, older age was associated with more cognitive concerns, but fewer PTSD and depressive symptoms.

CONCLUSIONS

WTC-exposed firefighters had fewer cognitive concerns compared with non-WTC-exposed firefighters. We were unable to estimate associations between WTC exposure and PTSD symptoms or depressive symptoms due to variability between non-WTC-exposed cohorts. Longitudinal follow-up is needed to assess PTSD, depressive, and cognitive symptom trajectories in firefighter populations as they age.

Alzheimer's Disease and Alzheimer's Disease-Related Dementias in Older African American and White Veterans

BACKGROUND

Racial disparity in the epidemiology of Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) has been reported. However, less is known about this disparity among Veterans.

OBJECTIVE

To estimate the racial disparity in AD/ADRD among the Veterans.

METHODS

Of the 5,413,418 Veterans≥65 years receiving care at the Veterans Health Administration (1999-2016), 4,045,269 were free of prevalent AD/ADRD, schizophrenia, or bipolar disorder at baseline. Of these, 432,469 were African American. Race was self-identified and incident AD/ADRD during 20 (median 6.7) years of follow-up was ascertained using International Classification of Diseases codes.

RESULTS

Patients had a mean age of 70.4 (±6.6) years and 97.8% were men. Age-sex-adjusted incidence of AD/ADRD per 1,000 person-year was 19.3 and 10.8 for African American and white Veterans, respectively (age-sex-adjusted hazard ratio associated with African American race, 1.77; 95% confidence interval, 1.75-1.79; p < 0.0001). This association remained essentially unchanged after multivariable adjustment (hazard ratio, 1.67; 95% confidence interval, 1.65-1.69; p < 0.0001). Among the key baseline characteristics that were significant predictors of AD/ADRD in both races, stroke was a significantly stronger predictor among African Americans, and Hispanic ethnicity and depression among whites (p-value for all interaction,<0.0001).

CONCLUSION

The findings of a higher incidence of AD/ADRD among African American Veterans is consistent with the findings in the general population reported in the literature, although the overall incidence appears to be lower than that in the general population. Future studies need to examine this disparity in incidence as well as the between-race heterogeneity in AD/ADRD risk.

Post-traumatic stress disorder as a risk factor for dementia: systematic review and meta-analysis

BACKGROUND

Post-traumatic stress disorder (PTSD) has been identified as a potential risk factor for developing dementia. There are currently, however, no meta-analyses quantifying this risk.

AIMS

To systematically review and quantify the risk of future dementia associated with PTSD across populations. PROSPERO registration number CRD42019130392.

METHOD

We searched nine electronic databases up to 25 October 2019 for longitudinal studies assessing PTSD and risk of dementia. We used random- and fixed-effects meta-analyses to pool estimates across studies.

RESULTS

PTSD was associated with a significant risk for all-cause dementia: pooled hazard ratio HR = 1.61 (95% CI 1.43-1.81, I2= 85.8%, P < 0.001; n = 1 693 678; 8 studies). Pooled HR was 1.61 (95% CI 1.46-1.78; I2= 80.9%, P < 0.001; n = 905 896; 5 studies) in veterans, and 2.11 (95% CI 1.03-4.33, I2= 91.2%, P < 0.001; n = 787 782; 3 studies) in the general population. The association between PTSD and dementia remained significant after excluding studies with high risk of bias (HR = 1.55, 95% CI 1.39-1.73, I2= 83.9%, P < 0.001; n = 1 684 928; 7 studies). Most studies included were retrospective and there was evidence of high heterogeneity.

CONCLUSIONS

This is the first meta-analysis quantifying the association of PTSD and risk of dementia showing that PTSD is a strong and potentially modifiable risk factor for all-cause dementia. Future studies investigating potential causal mechanisms, and the protective value of treating PTSD are needed.

PTSD and Depressive Symptoms as Potential Mediators of the Association between World Trade Center Exposure and Subjective Cognitive Concerns in Rescue/Recovery Workers

We observed that World Trade Center (WTC) exposure, post-traumatic stress disorder (PTSD) symptoms and depressive symptoms were associated with subjective cognitive concerns in Fire Department of the City of New York (FDNY) rescue/recovery workers. This follow-up study examined whether PTSD symptoms and/or depressive symptoms mediate the observed association between WTC exposure and subjective cognitive concerns. We included WTC-exposed FDNY workers who completed the Cognitive Function Instrument (CFI), measuring self-perceived cognitive decline (N = 9516). PTSD symptoms and depressive symptoms were assessed using the PCL-S and CES-D, respectively. Multivariable linear regression estimated the association between WTC exposure and CFI score, adjusting for confounders. Mediation analyses followed the methods of Vanderweele (2014). Participants’ average age at CFI assessment was 56.6 ± 7.6 years. Higher-intensity WTC exposure was associated with worse CFI score, an effect that was entirely mediated by PTSD symptoms (%mediated: 110.9%; 95%CI: 83.1–138.9). When substituting depressive symptoms for PTSD symptoms, the WTC exposure–CFI association was largely mediated (%mediated: 82.1%; 95%CI: 60.6–103.7). Our findings that PTSD symptoms and depressive symptoms mediate the association between WTC exposure and subjective cognitive concerns indicate that in the absence of these symptoms, WTC exposure in rescue/recovery workers would not be associated with subjective cognition. Interventions targeting PTSD and depression may have additional value in mitigating cognitive decline in WTC-exposed populations.

Stressors in Midlife and Risk of Dementia: The Role of Race and Education

BACKGROUND

Posttraumatic stress disorder is associated with increased dementia risk but less is known about stress because of everyday problems in diverse populations.

METHODS

A total of 9605 health care plan members who provided information regarding midlife stressors in 1972 to 1973 (ages, 40 to 55 y) were followed for dementia diagnosis between 1996 and 2017. Cox proportional hazard models evaluated associations between midlife stressors and dementia adjusting for demographics and lifecourse health indicators.

RESULTS

Reporting at least 1 midlife stressor was associated with 17% greater dementia risk [hazard ratio (HR), 1.17; 95% confidence interval (CI),1.07-1.27] versus 0 midlife stressors and 26% increased risk among those with less than equal to high school education (HR, 1.26; 95% CI,1.09-1.44) adjusting for demographics. Compared with whites without stressors, whites with ≥1 stressor had 13% greater dementia risk (HR, 1.13; 95% CI, 1.02-1.24), blacks without stressors 19% greater risk (HR, 1.19; 95% CI,1.08-1.32), and blacks with ≥1 stressors 47% greater risk (HR, 1.47; 95% CI,1.27-1.69) in fully adjusted models. Resource problems were associated with 20% greater risk (HR, 1.20; 95% CI, 1.01-1.42) than interpersonal problems.

CONCLUSION

Reporting ≥1 serious midlife stressor was associated with elevated dementia risk, especially stressors related to resources problems and for those with less than equal to high school education. Everyday stressors can impact brain health over the long term and may contribute to racial inequities in dementia rates, though education can be a mitigating factor.

Mental Health Diagnoses in Veterans Referred for Outpatient Geriatric Psychiatric Care at a Veterans Affairs Medical Center

INTRODUCTION

Nearly half of the U.S. veterans are over 65 years of age. Older veterans are at higher risk for mental health (MH) conditions, which are associated with increased mortality and health care costs. Given the deficit of specialty-trained geriatric providers, we are conducting a Quality Improvement initiative to improve MH services for older veterans at Minneapolis Veterans Affairs Health Care System. Our first step is to understand the demographic and diagnostic characteristics of veterans referred for geriatric MH specialty treatment.

MATERIALS AND METHOD

We conducted a retrospective chart review of demographics and psychiatric diagnoses in veterans seen for outpatient geriatric MH intake between May 1, 2011 and April 30, 2016. We used chi-square and Spearman's rho tests to examine age, diagnoses, and service-time era variables.

RESULTS

1,059 veterans were evaluated, average age of 73.5 years. Depressive (47%), neurocognitive (42%), and anxiety disorders (22%) were the most common MH conditions. Vietnam veterans showed higher prevalence of depressive (56%), post-traumatic stress (11%), and alcohol use (10%) disorders. World War II veterans showed higher prevalence of neurocognitive disorders (71%). Neurocognitive disorder prevalence was significantly correlated with age.

CONCLUSIONS

Prevalence and comorbidity of major MH conditions is high in veterans referred for geriatric MH services. Future work will examine challenges faced by non-specialty providers in caring for older veterans, with the goal of developing targeted educational and clinical interventions to better address aging veterans' MH needs.

World Trade Center exposure, post-traumatic stress disorder, and subjective cognitive concerns in a cohort of rescue/recovery workers

OBJECTIVE

To determine whether World Trade Center (WTC)-exposure intensity and post-traumatic stress disorder (PTSD) are associated with subjective cognitive change in rescue/recovery workers.

METHOD

The population included 7875 rescue/recovery workers who completed a subjective cognition measure, the Cognitive Function Instrument (CFI), between 3/1/2018 and 2/28/2019 during routine monitoring, indicating whether they had experienced cognitive and functional difficulties in the past year. Higher scores indicated greater self-perceived cognitive change. Probable PTSD, depression, and alcohol abuse were evaluated by validated mental health screeners. Logistic regression assessed the associations of WTC exposure and current PTSD with top-quartile (≥2) CFI score, and of early post-9/11 PTSD with top-quartile CFI in a subpopulation (N = 6440). Models included demographics, smoking, depression, and alcohol abuse as covariates.

RESULTS

Mean age at CFI completion was 56.7 ± 7.7 (range: 36-81). Participants with high-intensity WTC exposure had an increased likelihood of top-quartile CFI score (odds ratio[OR] vs. low exposure: 1.32, 95%CI: 1.07-1.64), controlling for covariates. Current and early PTSD were both associated with top-quartile CFI (OR: 3.25, 95%CI: 2.53-4.19 and OR: 1.56, 95%CI: 1.26-1.93) respectively.

CONCLUSIONS

High-intensity WTC exposure was associated with self-reported cognitive change 17 years later in rescue/recovery workers, as was PTSD. Highly WTC-exposed subgroups may benefit from additional cognitive evaluation and monitoring of cognition over time.

Purpose in life is a robust protective factor of reported cognitive decline among late middle-aged adults: The Emory Healthy Aging Study

BACKGROUND

Cognitive abilities tend to decline in advanced age. A novel protective factor of cognitive decline in advanced age is purpose-in-life (PiL), a trait-like tendency to derive life meanings and purpose. However, whether PiL protects against cognitive decline in late-middle-age is unclear. Hence, we examined the association between PiL and perceived cognitive decline, one of the earliest detectable cognitive symptoms before the onset of cognitive impairment. Furthermore, we used a machine learning approach to investigate whether PiL is a robust predictor of cognitive decline when considered with the known protective and risk factors for cognition.

METHODS

PiL was assessed with a 10-item questionnaire and perceived cognitive decline with the Cognitive Function Instrument among 5,441 Emory Healthy Aging Study participants, whose mean age was 63 and 51% were employed. Association between PiL and perceived cognitive decline was examined with linear regression adjusting for relevant confounding factors. Elastic Net was performed to identify the most robust predictors of cognitive decline.

RESULTS

Greater PiL was associated with less perceived cognitive decline after adjusting for the relevant factors. Furthermore, Elastic Net modeling suggested that PiL is a robust predictor of cognitive decline when considered simultaneously with known protective (education, exercise, enrichment activities) and risk factors for cognition (depression, anxiety, diagnosed medical, mental health problems, smoking, alcohol use, family history of dementia, and others).

LIMITATION

This is a cross-sectional study.

CONCLUSIONS

PiL is a robust protective factor of perceived cognitive decline observed as early as middle age. Thus, interventions to enhance PiL merit further investigation.

Health-Promoting Strategies for the Aging Brain

As the world's population ages and people live longer, the changes in the aging brain present substantial challenges to our health and society. With greater longevity come age-related diseases, many of which have direct and indirect influences on the health of the brain. Although there is some degree of predictable decline in brain functioning with aging, meaningful cognitive decline is not inevitable and is perhaps preventable. In this review, we present the case that the course of aging-related brain disease and dysfunction can be modified. We present the evidence for conditions and risk factors that may contribute to cognitive decline and dementia and for interventions that may mitigate their impact on cognitive functioning later in life, or even prevent them and their cognitive sequelae from developing. Although much work remains to be done to meet the challenges of the aging brain, strategies to promote its health have been demonstrated and offer much promise, which can only be realized if we mount a vigorous public health effort to implement these strategies.