Incidence of Traumatic Brain Injury in a Longitudinal Cohort of Older Adults.

Importance: Traumatic brain injury (TBI) occurs at the highest rate in older adulthood and increases risk for cognitive impairment and dementia. Objectives: To update existing TBI surveillance data to capture nonhospital settings and to explore how social determinants of health (SDOH) are associated with TBI incidence among older adults. Design, Setting, and Participants: This nationally representative longitudinal cohort study assessed participants for 18 years, from August 2000 through December 2018, using data from the Health and Retirement Study (HRS) and linked Medicare claims dates. Analyses were completed August 9 through December 12, 2022. Participants were 65 years of age or older in the HRS with survey data linked to Medicare without a TBI prior to HRS enrollment. They were community dwelling at enrollment but were retained in HRS if they were later institutionalized. Exposures: Baseline demographic, cognitive, medical, and SDOH information from HRS. Main Outcomes and Measures: Incident TBI was defined using inpatient and outpatient International Classification of Diseases, Ninth or Tenth Revision, diagnosis codes received the same day or within 1 day as the emergency department (ED) visit code and the computed tomography (CT) or magnetic resonance imaging (MRI) code, after baseline HRS interview. A cohort with TBI codes but no ED visit or CT or MRI scan was derived to capture diagnoses in nonhospital settings. Descriptive statistics and bivariate associations of TBI with demographic and SDOH characteristics used sample weights. Fine-Gray regression models estimated associations between covariates and TBI, with death as a competing risk. Imputation considering outcome and complex survey design was performed by race and ethnicity, sex, education level, and Area Deprivation Index percentiles 1, 50, and 100. Other exposure variables were fixed at their weighted means. Results: Among 9239 eligible respondents, 5258 (57.7%) were female and 1210 (9.1%) were Black, 574 (4.7%) were Hispanic, and 7297 (84.4%) were White. Mean (SD) baseline age was 75.2 (8.0) years. During follow-up (18 years), 797 (8.9%) of respondents received an incident TBI diagnosis with an ED visit and a CT code within 1 day, 964 (10.2%) received an incident TBI diagnosis and an ED code, and 1148 (12.9%) received a TBI code with or without an ED visit and CT scan code. Compared with respondents without incident TBI, respondents with TBI were more likely to be female (absolute difference, 7.0 [95% CI, 3.3-10.8]; P < .001) and White (absolute difference, 5.1 [95% CI, 2.8-7.4]; P < .001), have normal cognition (vs cognitive impairment or dementia; absolute difference, 6.1 [95% CI, 2.8-9.3]; P = .001), higher education (absolute difference, 3.8 [95% CI, 0.9-6.7]; P < .001), and wealth (absolute difference, 6.5 [95% CI, 2.3-10.7]; P = .01), and be without baseline lung disease (absolute difference, 5.1 [95% CI, 3.0-7.2]; P < .001) or functional impairment (absolute difference, 3.3 [95% CI, 0.4-6.1]; P = .03). In adjusted multivariate models, lower education (subdistribution hazard ratio [SHR], 0.73 [95% CI, 0.57-0.94]; P = .01), Black race (SHR, 0.61 [95% CI, 0.46-0.80]; P < .001), area deprivation index national rank (SHR 1.00 [95% CI 0.99-1.00]; P = .009), and male sex (SHR, 0.73 [95% CI, 0.56-0.94]; P = .02) were associated with membership in the group without TBI. Sensitivity analyses using a broader definition of TBI yielded similar results. Conclusions and Relevance: In this longitudinal cohort study of older adults, almost 13% experienced incident TBI during the 18-year study period. For older adults who seek care for TBI, race and ethnicity, sex, and SDOH factors may be associated with incidence of TBI, seeking medical attention for TBI in older adulthood, or both.

Telehealth delivery of group-format cognitive rehabilitation to older veterans with TBI: a mixed-methods pilot study.

Traumatic brain injury (TBI) is common among Veterans and may interact with aging, increasing risk for negative cognitive, emotional, and functional outcomes. However, no accessible (i.e., in-home) group interventions for TBI targeted to older adults exist. Goal Oriented Attentional Self-Regulation (GOALS) is a manualized, group cognitive rehabilitation training that improves executive function and emotional regulation among Veterans with TBI and healthy older adults. Our objectives were to adapt GOALS for delivery to older Veterans via in-home video telehealth (IVT) and evaluate feasibility and participant-rated acceptability of the telehealth GOALS intervention (TeleGOALS). Six Veterans 69+, with multiple TBIs completed the 10-session intervention in groups of 2. One participant withdrew, and another completed the remaining sessions alone (total n enrolled = 8). Required adaptations were noted; questionnaire responses were quantified; and feedback was analyzed and coded to identify themes. Quantitative and qualitative methods were used to examine feasibility (i.e., recruitment and retention) and participant-rated acceptability. Minimal adaptations were required for IVT delivery. Key themes emerged: (a) the importance of telehealth logistics, (b) facilitators' roles in prioritizing interpersonal connection, and (c) telehealth's capability to create opportunities for community reintegration. Thematic saturation (the point at which feedback from respondents is consistent and no further adaptations are required) was achieved. Participants stated they would likely recommend TeleGOALS to other Veterans. Although further study with a larger, more diverse sample is required, the adapted TeleGOALS intervention appears highly feasible and acceptable for older Veterans with TBI able and willing to participate in a group-format IVT intervention.

TReating Incontinence for Underlying Mental and Physical Health (TRIUMPH): a study protocol for a multicenter, double-blinded, randomized, 3-arm trial to evaluate the multisystem effects of pharmacologic treatment strategies for urgency-predominant urinary incontinence in ambulatory older women.

BACKGROUND: Urgency-type urinary incontinence affects one in four older community-dwelling women and overlaps with other common aging-associated health syndromes such as cognitive impairment, physical mobility impairment, and depression. Observational studies have raised concern about potentially higher rates of delirium and dementia in older adults taking anticholinergic bladder medications, but few prospective data are available to evaluate the effects of these and other pharmacologic treatments for urgency incontinence on cognition and other multisystem functional domains important to older women. METHODS: The TRIUMPH study is a randomized, double-blinded, 3-arm, parallel-group trial comparing the multisystem effects of anticholinergic versus beta-3-adrenergic agonist bladder therapy and versus no active bladder anti-spasmodic pharmacotherapy in older women with urgency incontinence. Women aged 60 years and older (target N = 270) who have chronic urgency-predominant urinary incontinence and either normal or mildly impaired cognition at baseline are recruited from the community by investigators based in northern California, USA. Participants are randomized in equal ratios to take identically encapsulated oral anticholinergic bladder therapy (in the form of tolterodine 2 mg extended release [ER]), oral beta-3 adrenergic agonist bladder therapy (mirabegron 25 mg ER), or placebo daily for 24 weeks, with the option of participant-directed dose titration (to tolterodine 4 mg ER, mirabegron 50 mg ER, or matching placebo daily). Participants also receive patient-oriented information and instructions about practicing first-line behavioral management strategies for incontinence. The primary outcome is change in composite cognitive function over 24 weeks assessed by a comprehensive battery of cognitive tests, with a secondary exploration of the persistence of change at 36 weeks. Secondary outcomes include changes over 24 and 36 weeks in domain-specific cognitive function; frequency, severity, and impact of urgency-associated urinary symptoms; physical function and balance; sleep quality and daytime sleepiness; psychological function; and bowel function. DISCUSSION: The TRIUMPH trial addresses the need for rigorous evidence to guide counseling and decision-making for older women who are weighing the potential multisystem benefits and risks of pharmacologic treatments for urgency incontinence in order to preserve their day-to-day functioning, quality of life, and independence in older age. TRIAL REGISTRATION: ClinicalTrials.gov NCT05362292. Registered on May 5, 2022.

Improvement in executive functioning after Goal-Oriented Attentional Self-Regulation training is associated with reduction in PTSD hyperarousal symptoms among veterans with comorbid PTSD and mild TBI.

Goal-Oriented Attentional Self-Regulation (GOALS) is a cognitive rehabilitation training program that combines mindfulness-based attention regulation with individualized goal management strategies to improve functioning in daily life after traumatic brain injury (TBI). While not a specific target of GOALS training, previous research has indicated improvements in emotional functioning following GOALS training, specifically symptoms related to depression and posttraumatic stress disorder (PTSD). The current study is based on the hypothesis that improvements in cognitive control processes related to executive functioning and attention after GOALS training generalize to improvements in emotional functioning, thereby resulting in reductions in emotional distress. The current study analyzed archival data from 33 Veteran participants with a confirmed diagnosis of PTSD and a history of mild TBI who received either GOALS training or a psychoeducational intervention matched for time, therapist attention, and participation format. Regression analysis was used to assess the strength of the relationship between improvements in Overall Attention/Executive Functioning and decreases in hyperarousal symptoms associated with PTSD. Results from the regression analysis revealed that improvements in Overall Attention/Executive Functioning after GOALS was significantly associated with reductions in hyperarousal symptoms associated with PTSD (R2 = 0.26, F(1,15) = 5.01, ß = -.51, p < .05). The current findings suggest that cognitive improvements after GOALS training may lead to changes in emotional functioning, resulting in decreased emotional distress. This is important, particularly in VA settings, because the results potentially highlight additional areas of research and focus on the treatment of comorbid mild TBI and PTSD among Veterans.

Systematic Review, Meta-Analysis, and Population Attributable Risk of Dementia Associated with Traumatic Brain Injury in Civilians and Veterans.

Traumatic brain injury (TBI) is an established risk factor for dementia. However, the magnitude of risk is highly variable across studies. Identification of sub-populations at highest risk, with careful consideration of potential sources of bias, is urgently needed to guide public health policy and research into mechanisms and treatments. We conducted a systematic review and meta-analysis of risk of all-cause dementia after all-severity TBI. We assessed for effect of participant age and sex, veteran status, research methods, and region. The search window covered January 1990 to January 2019. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Thirty-two studies met inclusion criteria. Data were pooled using random effects models. Population attributable risk (PAR) of dementia due to TBI in the U.S. was calculated by sex and veteran status. Pooled risk ratio (RR) for dementia after TBI was 1.66 (95% confidence interval 1.42-1.93). Younger age, male sex, and studies from Asia were associated with significantly higher risk; veteran status was not. Risk of dementia associated with "head injury/trauma" was not significantly different from that associated with "TBI" diagnosis specifically. PAR of dementia due to TBI among U.S. veterans was twice that of the general U.S. population, largely due to the high prevalence of TBI exposure in the majority male veteran population. This meta-analysis found that TBI is associated with nearly 70% increased risk of dementia. Risk may be highest among younger adults, men, and cohorts in Asia. Efforts to prevent TBI and also to prevent post-TBI dementia are of high importance. Additionally, improved methods for diagnosing and tracking TBI on a public health level, such as national registries, may improve the quality and generalizability of future epidemiological studies investigating the association between TBI and dementia.

Association of Race and Ethnicity With Incidence of Dementia Among Older Adults.

Importance: The racial and ethnic diversity of the US, including among patients receiving their care at the Veterans Health Administration (VHA), is increasing. Dementia is a significant public health challenge and may have greater incidence among older adults from underrepresented racial and ethnic minority groups. Objective: To determine dementia incidence across 5 racial and ethnic groups and by US geographical region within a large, diverse, national cohort of older veterans who received care in the largest integrated health care system in the US. Design, Setting, and Participants: Retrospective cohort study within the VHA of a random sample (5% sample selected for each fiscal year) of 1 869 090 participants aged 55 years or older evaluated from October 1, 1999, to September 30, 2019 (the date of final follow-up). Exposures: Self-reported racial and ethnic data were obtained from the National Patient Care Database. US region was determined using Centers for Disease Control and Prevention (CDC) regions from residential zip codes. Main Outcomes and Measures: Incident diagnosis of dementia (9th and 10th editions of the International Classification of Diseases). Fine-Gray proportional hazards models were used to examine time to diagnosis, with age as the time scale and accounting for competing risk of death. Results: Among the 1 869 090 study participants (mean age, 69.4 [SD, 7.9] years; 42 870 women [2%]; 6865 American Indian or Alaska Native [0.4%], 9391 Asian [0.5%], 176 795 Black [9.5%], 20 663 Hispanic [1.0%], and 1 655 376 White [88.6%]), 13% received a diagnosis of dementia over a mean follow-up of 10.1 years. Age-adjusted incidence of dementia per 1000 person-years was 14.2 (95% CI, 13.3-15.1) for American Indian or Alaska Native participants, 12.4 (95% CI, 11.7-13.1) for Asian participants, 19.4 (95% CI, 19.2-19.6) for Black participants, 20.7 (95% CI, 20.1-21.3) for Hispanic participants, and 11.5 (95% CI, 11.4-11.6) for White participants. Compared with White participants, the fully adjusted hazard ratios were 1.05 (95% CI, 0.98-1.13) for American Indian or Alaska Native participants, 1.20 (95% CI, 1.13-1.28) for Asian participants, 1.54 (95% CI, 1.51-1.57) for Black participants, and 1.92 (95% CI, 1.82-2.02) for Hispanic participants. Across most US regions, age-adjusted dementia incidence rates were highest for Black and Hispanic participants, with rates similar among American Indian or Alaska Native, Asian, and White participants. Conclusions and Relevance: Among older adults who received care at VHA medical centers, there were significant differences in dementia incidence based on race and ethnicity. Further research is needed to understand the mechanisms responsible for these differences.

Sex Differences in the Risk of Dementia in Older Veterans.

BACKGROUND: Studies have demonstrated women to have a higher prevalence of dementia compared to men. However, sex differences in dementia incidence are controversial with conflicting reports showing women with higher, lower, or similar incidence. Source of difference may be due to clinical setting and lack of consideration of competing risk of death. We examined dementia incidence in a sample of the national Veteran population to determine differences by sex. METHODS: We examined data from the Veterans Health Administration (VHA), the largest integrated health care system in the United States. We studied 947 797 Veterans aged ≥55 years (mean age: 69.9 ± 8.4, 3% female) evaluated in the VHA from October 1, 1999 to September 30, 2019. We estimated age-adjusted incidence rates of dementia (International Classification of Diseases, 9th and 10th Edition codes) by sex, and used Fine-Gray proportional hazards models with age as time scale to examine time to diagnosis, accounting for competing risk of death. RESULTS: During the follow-up (mean 8.4 years), 11.3% (n = 106 977, 11.4% men and 8.0% women) of Veterans developed dementia. Age-adjusted incidence was 12.6/1 000 person-years for men and 12.7/1 000 person-years for women. Compared to male Veterans, risk dementia was slightly higher among females (hazard ratio = 1.15; 95% confidence interval: 1.10-1.20), and on average, female Veterans developed dementia 0.2 years earlier than male Veterans. After additional adjustment for race, education, medical, and psychiatric conditions, results were similar. CONCLUSIONS: Among older Veterans in a national cohort, women had a slightly increased risk for developing dementia compared to men after accounting for competing risk of death.

Traumatic brain injury, cardiovascular disease, and risk of dementia among older US Veterans.

OBJECTIVE: Traumatic brain injury (TBI) is associated with elevated rates of cardiovascular disease (CVD), and both CVD and TBI are risk factors for dementia. We investigated whether CVD and its risk factors underlie the association between TBI and dementia. MATERIALS AND METHODS: Cox proportional hazards models among 195,416 Veterans Health Administration patients age 55+ with TBI and a non-TBI, age/sex/race-matched comparison sample. RESULTS: Veterans +TBI were more likely to have any CVD diagnosis (24% vs 36% p = <0.001) or risk factor (83 vs. 90% p < .001) compared to -TBI. During follow-up (mean ~7 years), 12.0% of Veterans with TBI only (HR: 2.17 95% CI 2.09-2.25), and 10.3% with CVD only developed dementia (HR 1.21 95% CI 1.15-1.28), compared to 6.5% with neither. There was an additive association between TBI and CVD on dementia risk (HR 2.51, 95% CI 2.41-2.61). Among those +TBI (±CVD), risk was minimally attenuated by adjustment for CVD/CVD risk factors (unadjusted HR: 2.38, 95% CI: 2.31-2.45; adjusted HR: 2.17, 95% CI 2.10-2.23). CONCLUSIONS: Older veterans TBI have increased prevalence of CVD/CVD risk factors. TBI and CVD had an additive statistical association, with dementia risk increased by ~2.5-fold. However, CVD accounted for little of the association between TBI and dementia. More research is needed to understand mechanisms of TBI-dementia and inform clinical guidelines post-TBI.

Goal-Oriented Attention Self-Regulation Training Improves Executive Functioning in Veterans with Post-Traumatic Stress Disorder and Mild Traumatic Brain Injury.

Difficulties in executive-control functions are common sequelae of both traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). The goal of this study was to assess whether a cognitive rehabilitation training that was applied successfully in civilian and military TBI would be effective for military Veterans with comorbid PTSD and mild TBI (mTBI). In the previous study, Veterans with a history of mild to severe TBI improved significantly after goal-oriented attentional self-regulation (GOALS) training on measures of attention/executive function, functional task performance, and emotional regulation. The objective of this study was to assess effects of GOALS training in Veterans with comorbid PTSD and mTBI. Forty Veterans with a current PTSD diagnosis and history of mTBI (6+ months post) were randomized to either five weeks of GOALS or Brain-Health Education (BHE) training matched in time and intensity. Evaluator-blinded assessments at baseline and post-training included neuropsychological and complex functional task performance, and self-report measures of emotional functioning/regulation. After GOALS but not BHE training, participants significantly improved from baseline on primary outcome measures of: overall complex attention/executive function neuropsychological performance composite (F = 12.35, p = 0.001; Cohen d = 0.48), and overall mood disturbance -POMS emotional regulation self-report (F = 4.29, p = 0.05, Cohen d = 0.41). In addition, GOALS but not BHE participants indicated a significant decrease in PTSD symptoms (PCL-M Total Score) (F = 4.80, p = 0.05, Cohen d = 0.60), and demonstrated improvement on complex functional task performance-GPS Learning and Memory (F = 5.06, p = 0.05, Cohen d = 0.56]. Training in attentional self-regulation applied to participant-defined goals may improve cognitive functioning in Veterans with comorbid PTSD and mTBI. Improving cognitive control functioning may also improve functioning in other domains such as emotional regulation and functional performance, potentially making it particularly relevant for Veterans with a history of mTBI and comorbid psychiatric symptoms.

Long-Term Effect of Cognitive Rehabilitation Regardless of Prerehabilitation Cognitive Status for Veterans with TBI.

Persisting difficulties in executive functioning (EF) are common after traumatic brain injury (TBI). Cognitive rehabilitation can be effective, but the impact of pretreatment neurocognitive functioning on long term effects of rehabilitation is unknown. Because this information can impact treatment planning, we examined the relationship between prerehabilitation neurocognitive status and long-term effects of EF training. Archival data were drawn from a trial of Goal-Oriented Attentional Self-Regulation group-format EF training for Veterans with TBI [mild-severe; 11 years postinjury; 96% male, 32% nonwhite, 14.21 years education (SD 1.72), 41.13 years old (SD 11.39)]. Using prerehabilitation neurocognitive performance, participants were clustered into cognitive difficulty (CD) and cognitively normal (CN) groups. Six-plus months after EF rehabilitation training, participants completed a structured telephone interview and/or in-person cognitive/functional/emotional assessment using standardized measures of cognitive, daily, and emotional functioning frequently employed in TBI research. At 6+ months post-EF training compared to prerehabilitation, CD and CN improved in multiple cognitive (Overall Attention/EF: F(1,18) = 26.17, partial η2 = .59; Total Memory: F(1,18) = 6.82, partial η2 = .28) and functional domains (Goal Processing Scale [GPS] total score: F(1,15) = 6.71, partial η2 = .31). CD improved more than CN on Learning and Memory functional domain [F(1,15) = 6.10, partial η2 = .29]. Results of our small archival analysis raise the possibility that Veterans with chronic TBI may demonstrate long-term effects of EF training.

Sex, race, and risk of dementia diagnosis after traumatic brain injury among older veterans.

OBJECTIVE: To investigate whether sex and race differences exist in dementia diagnosis risk associated with traumatic brain injury (TBI) among older veterans. METHODS: Using Fine-Gray regression models, we investigated incident dementia diagnosis risk with TBI exposure by sex and race. RESULTS: After the exclusion of baseline prevalent dementia, the final sample (all veterans ≥55 years of age diagnosed with TBI during the 2001-2015 study period and a random sample of all veterans receiving Veterans Health Administration care) included nearly 1 million veterans (4.3% female; 81.8% White, 11.5% Black, and 1.25% Hispanic), 96,178 with TBI and 903,462 without TBI. Compared to those without TBI, Hispanic veterans with TBI were almost 2 times more likely (17.0% vs 10.3%; hazard ratio [HR] 1.74, 95% confidence interval [CI] 1.51-2.01), Black veterans with TBI were >2 times more likely (11.2% vs 6.4%; HR 2.15, 95% CI 2.02-2.30), and White veterans with TBI were nearly 3 times more likely to receive a dementia diagnosis (12.0% vs 5.9%; HR 2.71, 95% CI 2.64-2.77). A significant interaction between TBI and race for dementia diagnosis was observed (p < 0.001). Both male and female veterans with TBI were more than twice as likely (men 11.8% vs 5.9%, HR 2.60, 95% CI 2.54-2.66; women 6.3% vs 3.1%, HR 2.36, 95% CI 2.08-2.69) to receive a diagnosis of dementia compared to those without. There was a significant interaction effect between sex and TBI (p = 0.02), but the magnitude of differences was small. CONCLUSIONS: In this large, nationwide cohort of older veterans, all race groups with TBI had increased risk of dementia diagnosis, but there was an interaction effect such that White veterans were at greatest risk for dementia after TBI. Further research is needed to understand the mechanisms for this discrepancy. Differences in dementia diagnosis risk for men and women after TBI were significant but small, and male and female veterans had similarly high risks of dementia diagnosis after TBI.

Prevalence of Lifetime History of Traumatic Brain Injury among Older Male Veterans Compared with Civilians: A Nationally Representative Study.

Traumatic brain injury (TBI) is common among older adults as well as among veterans in the United States and can increase risk for dementia. We compared prevalence of TBI in older male veterans and civilians using a nationally representative sample. We examined data from 599 male respondents to the 2014 wave of the Health and Retirement Study (HRS), a nationally representative survey of older adults, randomly selected to participate in a comprehensive TBI survey. Respondents self-reported no injury, non-TBI head/neck injury (NTI), or TBI. We used weighted analyses to examine prevalence of injury and relative risk of injury subtypes. Among male veterans, we found a national prevalence of more than 70% for lifetime history of any head/neck injury (TBI plus NTI), 14.3% for multiple NTI, and 36% for lifetime history of at least one TBI. In contrast, prevalence estimates for male civilians were 58% for lifetime history of head/neck injury, 4.8% for multiple NTI, and 45% for lifetime history of at least one TBI (all comparisons, p < 0.001). Male civilians have higher self-reported TBI prevalence, whereas male veterans have higher self-reported NTI and multiple-NTI prevalence. Further research on drivers of the unexpectedly higher prevalence of lifetime history of TBI in male civilians, as well as on mechanisms and sequelae of the highly prevalent non-TBI head/neck injuries among older male veterans, is warranted.

Physical and Functional Impairment Among Older Adults With a History of Traumatic Brain Injury.

OBJECTIVES: To examine the association of lifetime history of traumatic brain injury (TBI) with later-life physical impairment (PI) and functional impairment (FI) and to evaluate the impact of neurobehavioral symptoms that frequently co-occur with TBI on these relations. PARTICIPANTS: A total of 1148 respondents to the 2014 Wave of the Health and Retirement Study, a nationally representative survey of older community-dwelling adults, randomly selected to participate in a TBI exposure survey. They reported no prior TBI (n = 737) or prior TBI (n = 411). DESIGN: Cross-sectional survey study. MAIN MEASURES: Physical impairment (self-reported difficulty with ≥1 of 8 physical activities); FI (self-reported difficulty with ≥1 of 11 activities of daily living); self-reported current neurobehavioral symptoms (pain, sleep problems, depression, subjective memory impairment); The Ohio State University TBI Identification Method (OSU-TBI-ID)-short form. ANALYSES: Stepwise logistic regression models ([1] unadjusted; [2] adjusted for demographics and medical comorbidities; [3] additionally adjusted for neurobehavioral symptoms) compared PI and FI between TBI groups. RESULTS: Traumatic brain injury-exposed (mean: 33.6 years postinjury) respondents were younger, less likely to be female, and reported more comorbidities and neurobehavioral symptoms. Although TBI was significantly associated with increased odds of PI and FI in unadjusted models and models adjusted for demographics/comorbidities (adjusted odds ratio, 95% confidence interval: PI 1.62, 1.21-2.17; FI 1.60, 1.20-2.14), this association was no longer statistically significant after further adjustment for neurobehavioral symptoms. CONCLUSION: History of TBI is associated with substantial PI and FI among community-dwelling older adults. Further research is warranted to determine whether aggressive management of neurobehavioral symptoms in this population may mitigate long-term PI and FI in this population.

Impact of baseline neurocognitive functioning on outcomes following rehabilitation of executive function training for veterans with history of traumatic brain injury.

Traumatic brain injury (TBI) is common among Veterans, and sequelae frequently include deficits in attention and executive function and problems with emotional regulation. Although rehabilitation has been shown to be effective, it is not clear how patient characteristics such as baseline cognitive status may impact response to rehabilitation in this sample. Explore the relationship between baseline neuropsychological status and postintervention functional outcomes in Veterans with chronic TBI. Thirty-three Veterans with chronic mild-severe TBI completed a neuropsychological evaluation, a functional assessment of executive function (EF), and measures of emotional and everyday functioning pre- and post-EF training or control training. Performance on baseline neuropsychological measures was used to cluster participants. Participants' performance at baseline and postintervention assessments was compared by cluster using multivariate analyses of variance (MANOVAs). Cognitive Difficulty (CD; n = 19) and Cognitively Normal (CN; n = 14) clusters were identified. CD was characterized by z ≤ -.75 on neuropsychological measures of overall attention/EF, working memory, and memory. CD participants performed worse on functional EF assessment and endorsed more PTSD symptoms and community integration problems, at baseline. CD participants improved post-EF training, but not control training, on neuropsychological and functional measures. CN participants did not show statistically significant improvement. For Veterans with chronic TBI, cognitive assessment can aid in identifying functional impairment and assist treatment planning. Cognitive rehabilitation training appears to be a beneficial treatment option for TBI patients with cognitive, emotional, and daily living difficulties.

Goal-Oriented Attention Self-Regulation (GOALS) training in older adults.

Objectives: A common cognitive complaint of older adulthood is distractibility, or decline in ability to concentrate and maintain focus, yet few evidence-based interventions exist to address these deficits. We implemented s pilot trial of an evidence-based executive function training program, to investigate whether training in applied goal-directed attention regulation and problem solving would enhance executive control abilities in a sample of cognitively normal older adults with self-reported complaints of concentration problems.Method: Consecutively recruited participants were placed into small groups and randomized to either Goal-Oriented Attentional Self-Regulation training (GOALS; N = 15) or a closely matched Brain Health Education program (BHE; N = 15).Results: GOALS participants significantly improved on: neurocognitive measures of mental flexibility (p = 0.03, partial eta squared = 0.23); real-world setting functional performance measures of: task failures (p = 0.02, Cohen's d = 0.88), task rule breaks (p = 0.02, Cohen's d = 1.06), and execution (p = 0.04, Cohen's d = 0.76); and in-lab functional assessment of goal-directed behaviour divergent thinking scale (p = 0.03, Cohen's d = 0.95). All participants improved on a neurocognitive measure of planning (p = 0.01, partial eta squared = 0.031). BHE participants' improvement over and above GOALS participants was limited to: rule adherence on the real world task (p = 0.04, Cohen's d = 0.99), and evaluator rating (p = 0.03, Cohen's d = 0.56), and average score (p = 0.02, Cohen's d = 0.71) on the in-lab functional task.Conclusion: Participation in GOALS training can enhance executive control, and lead to real-world functional improvements, for cognitively normal older adults with self-reported attention difficulties.

Long-term effects of executive function training among veterans with chronic TBI.

Objective: To investigate long-term effects of GOALS executive function training in Veterans with chronic TBI. In a recently completed study Veterans with chronic TBI showed improvement immediately post-GOALS but not control training on measures of executive function, functional task performance, and emotion regulation. We now examine the long-term maintenance of post-GOALS training changes in the same sample. Setting: San Francisco VA Health Care System (SFVAHCS), and VA Northern California Health-Care System (VANCHS) in Martinez. Participants and Design: 24 Veterans with chronic TBI were assessed at baseline, post-GOALS training, and long-term follow-up 6+ months following completion of training with a structured telephone interview, neuropsychological and complex functional performance measures, and self-report measures of daily and emotional functioning. Results: Participants reported an increased likelihood of involvement in competitive employment/volunteering at follow-up (61%) compared to baseline (26%; χ2 = 5.66, p < .01, ѱ = .35). Repeated measures MANOVAS indicated improvement on attention/executive function (F = 13.85, p < .01, partial η2 = .42), complex functional task performance (GPS Total: F = 9.12, p < .01, partial η2 = .38) and daily functioning (MPAI Total: F = 3.23, p < .05, partial η2 = .21), and reduction in overall mood disturbance (POMS Total: F = 3.42, p < .05, partial η2 = .22) at follow-up relative to baseline. Discussion: Training in attention regulation applied to participant-defined goals is associated with meaningful long-term improvement in cognitive skills, emotion regulation, and daily functioning in Veterans with chronic TBI.

Training in Goal-Oriented Attention Self-Regulation Improves Executive Functioning in Veterans with Chronic Traumatic Brain Injury.

Deficits in executive control functions are some of the most common and disabling consequences of both military and civilian brain injury. However, effective interventions are scant. The goal of this study was to assess whether cognitive rehabilitation training that was successfully applied in chronic civilian brain injury would be effective for military veterans with traumatic brain injury (TBI). In a prior study, participants with chronic acquired brain injury significantly improved after training in Goal-Oriented Attentional Self-Regulation (GOALS) on measures of attention/executive function, functional task performance, and goal-directed control over neural processing on functional magnetic resonance imaging. The objective of this study was to assess effects of GOALS training in veterans with chronic TBI. A total of 33 veterans with chronic TBI and executive difficulties in their daily life completed either 5 weeks of manualized GOALS training or Brain-Health Education (BHE) matched by time and intensity. Evaluator-blinded assessments at baseline and post-training included neuropsychological and complex functional task performance and self-report measures of emotional regulation. After GOALS, but not BHE training, participants significantly improved from baseline on primary outcome measures of Overall Complex Attention/Executive Function composite neuropsychological performance score (F = 7.10, p = 0.01; partial η2 = 0.19), and on overall complex functional task performance (Goal Processing Scale Overall Performance; F = 6.92, p = 0.01, partial η2 = 0.20). Additionally, post-GOALS participants indicated significant improvement on emotional regulation self-report measures (Profile of Mood States Confusion Score; F = 6.05, p = 0.02, partialη2 = 0.20). Training in attentional self-regulation applied to participant-defined goals may improve cognitive functioning in veterans with chronic TBI. Attention regulation training may not only impact executive control functioning in real-world complex tasks, but also may improve emotional regulation and functioning. Implications for treatment of veterans with TBI are discussed.

Police officers who responded to 9/11: Comorbidity of PTSD, depression, and anxiety 10-11 years later.

BACKGROUND: After the 9/11/2001 World Trade Center (WTC) attack, many police-responders developed PTSD and might be vulnerable to develop depression and/or anxiety. Comorbidity of PTSD, depression, and/or anxiety is examined. METHOD: Police enrollees (N = 1,884) from the WTC Health Registry were categorized into four groups based on comorbidity of PTSD, depression, and anxiety. DSM-IV diagnostic criteria for PTSD were used. Depression (PHQ-8) and anxiety (GAD-7) were assessed with standardized psychometric inventories. Multinomial logistic regression was used to identify putative risk factors associated with comorbidity of PTSD. RESULTS: Of 243 (12.9% of total) police with probable PTSD, 21.8% had probable PTSD without comorbidity, 24.7% had depression, 5.8% had anxiety, and 47.7% had comorbid depression and anxiety. Risk factors for comorbid PTSD, depression, and anxiety include being Hispanic, decrease in income, experiencing physical injury on 9/11, experiencing stressful/traumatic events since 9/11, and being unemployed/retired. CONCLUSION: Nearly half of police with probable PTSD had comorbid depression and anxiety. Am. J. Ind. Med. 59:425-436, 2016. © 2016 Wiley Periodicals, Inc.

Environmental exposure to manganese in air: Associations with tremor and motor function.

BACKGROUND: Manganese (Mn) inhalation has been associated with neuropsychological and neurological sequelae in exposed workers. Few environmental epidemiologic studies have examined the potentially neurotoxic effects of Mn exposure in ambient air on motor function and hand tremor in adult community residents. Mn exposed residents were recruited in two Ohio towns: Marietta, a town near a ferro-manganese smelter, and East Liverpool, a town adjacent to a facility processing, crushing, screening, and packaging Mn products. METHODS: Chronic (≥ 10 years) exposure to ambient air Mn in adult residents and effects on neuropsychological and neurological outcomes were investigated. Participants from Marietta (n=100) and East Liverpool (n=86) were combined for analyses. AERMOD dispersion modeling of fixed-site outdoor air monitoring data estimated Mn inhalation over a ten year period. Adult Mn-exposed residents' psychomotor ability was assessed using Finger Tapping, Hand Dynamometer, Grooved Pegboard, and the Computerized Adaptive Testing System (CATSYS) Tremor system. Bayesian structural equation modeling was used to assess associations between air-Mn and motor function and tremor. RESULTS: Air-Mn exposure was significantly correlated in bivariate analyses with the tremor test (CATSYS) for intensity, center frequency and harmonic index. The Bayesian path analysis model showed associations of air-Mn with the CATSYS non-dominant center frequency and harmonic index; while the Bayesian structural equation model revealed associations between air-Mn and lower Finger Tapping scores. Household income was significantly associated with motor dysfunction but not with tremor. CONCLUSION: Tremor and motor function were associated with higher exposure to airborne Mn.

Marital status, social support, and depressive symptoms among lesbian and heterosexual women.

The current study investigated social support and relationship status (single, dating-but-not-cohabiting, cohabiting, domestic partnership/civil union, married) as predictors of depressive symptoms among lesbian and heterosexual women. The study aimed to determine whether the documented higher rates of depressive symptoms among lesbians compared to heterosexual women could be accounted for by lesbians' reduced access to, or in many cases exclusion from, legalized relationship statuses. The effect of social support from family and social support from friends on depressive symptoms also was examined. Contrary to expectations, results indicated no difference in levels of depressive symptoms among lesbian compared to heterosexual women in this sample. However, regardless of sexual orientation, married women had lower levels of depressive symptoms than unmarried women. Thus, marriage seems to be associated with less depression in lesbian and heterosexual women alike. The interaction of social support and relationship status added to the prediction of depressive symptoms over and above the predictive power of either variable alone, although this effect was small and should be interpreted with caution.