Comparison of Racial and Ethnic Mortality Disparities among Post-9/11 Veterans with and without Traumatic Brain Injury to the Total U.S. Adult Population.

INTRODUCTION: The extent of racial/ethnic disparities and whether they are attenuated in the Veteran population compared to the total US population is not well understood. We aimed to assess racial/ethnic mortality disparities from all-cause, cardiovascular (CVD) and cancer among post-9/11 military Veterans with and without exposure to TBI, compared to the total US population. METHODS: This cohort study included 2,502,101 US military Veterans (18,932,083 person-years) who served after 09/11/2001 with 3 or more years of care in the Military Health System (MHS); or had 3 or more years of care in the MHS and 2 or more years of care in the Veterans Health Administration. Mortality follow-up occurred from 01/01/2002 to 12/31/2020. Mortality rate ratios (MRR) from negative binomial regression models were reported for racial/ethnic groups compared to White non-Hispanic Veterans for all-cause, CVD and cancer mortality. Veteran MRR were compared to the total US population. RESULTS: Mortality rates for Black Non-Hispanic Veterans were higher for all-cause (MRR = 1.21;95%CI: 1.13-1.29; p < 0.001), CVD (MRR = 1.78;95%CI: 1.62-1.96; p < 0.001) and cancer (MRR = 1.17;95%CI: 1.10-1.25; p < 0.001) than in White Non-Hispanic Veterans. Among Veterans with TBI, only Black Non-Hispanics had higher mortality than White Non-Hispanics and only for CVD (MRR = 1.32;95%CI: 1.12-1.54; p < 0.001), while CVD mortality was higher among Veterans without TBI (MRR = 1.77;95%CI: 1.63-1.93;p < 0.001). MRR for Black Non-Hispanics in the total US population, were consistently higher than those in the Veteran population for all-cause (MRR = 1.52;95%CI: 1.46-1.58; p < 0.001), CVD (MRR = 2.03;95%CI: 1.95-2.13; p < 0.001) and cancer (MRR = 1.26;95%CI: 1.22-1.30; p < 0.001). CONCLUSION: This Veteran cohort experienced less racial/ethnic disparity in mortality than the total US population, especially among Veterans with TBI.

Traumatic Brain Injury and Subsequent Risk of Brain Cancer in US Veterans of the Iraq and Afghanistan Wars.

Importance: While brain cancer is rare, it has a very poor prognosis and few established risk factors. To date, epidemiologic work examining the potential association of traumatic brain injury (TBI) with the subsequent risk of brain cancer is conflicting. Further data may be useful. Objective: To examine whether a history of TBI exposure is associated with the subsequent development of brain cancer. Design, Setting, and Participants: A retrospective cohort study was conducted from October 1, 2004, to September 20, 2019, and data analysis was performed between January 1 and June 26, 2023. The median follow-up for the cohort was 7.2 (IQR, 4.1-10.1) years. Veterans Affairs (VA) and Department of Defense (DoD) administrative data on 1 919 740 veterans from the Long-Term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium were included. Exposure: The main exposure of interest was TBI severity (categorized as mild, moderate or severe [moderate/severe], and penetrating). Main Outcomes and Measures: The outcome of interest was the development of brain cancer based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic codes in either the DoD/VA medical records or from the National Death Index. Results: After 611 107 exclusions (predominately for no encounter during the study period), a cohort including 1 919 740 veterans was included, most of whom were male (80.25%) and non-Hispanic White (63.11%). Median age at index date was 31 (IQR, 25-42) years. The cohort included 449 880 individuals with TBI (mild, 385 848; moderate/severe, 46 859; and penetrating, 17 173). Brain cancer occurred in 318 individuals without TBI (0.02%), 80 with mild TBI (0.02%), 17 with moderate/severe TBI (0.04%), and 10 or fewer with penetrating TBI (≤0.06%). After adjustment, moderate/severe TBI (adjusted hazard ratio [AHR], 1.90; 95% CI, 1.16-3.12) and penetrating TBI (AHR, 3.33; 95% CI, 1.71-6.49), but not mild TBI (AHR, 1.14; 95% CI, 0.88-1.47), were associated with the subsequent development of brain cancer. Conclusions and Relevance: In this cohort study of veterans of the Iraq and Afghanistan wars, moderate/severe TBI and penetrating TBI, but not mild TBI, were associated with the subsequent development of brain cancer.

Role of Deployment History on the Association Between Epilepsy and Traumatic Brain Injury in Post-9/11 Era US Veterans.

BACKGROUND AND OBJECTIVES: Traumatic brain injury (TBI) is a well-established epilepsy risk factor and is common among service members. Deployment-related TBI, where combat/blast may be more common, may have different outcomes than nondeployment-related TBI. This work examined associations of all TBI exposures (not just combat), and epilepsy, while adjusting for comorbidities associated with epilepsy, among veterans by deployment status. METHODS: The cohort included post-9/11 veterans with ≥2 years of care in both Veterans Health Administration and Defense Health Agency systems. We identified epilepsy using ICD-9/10-CM codes, antiseizure medication, and service-connected disability for epilepsy. We conducted a logistic regression model with interaction terms for conditions by deployment history that adjusted for demographics and military characteristics. RESULTS: The cohort (n = 938,890) included post-9/11 veterans of whom 27,436 (2.92%) had epilepsy. Most veterans had a history of deployment (70.64%), referred to as "deployed." Epilepsy was more common among veterans who were never deployed ("nondeployed") (3.85% vs 2.54%). Deployed veterans were more likely to have had TBI, compared with the nondeployed veterans (33.94% vs 14.24%), but nondeployed veterans with moderate/severe TBI had higher odds of epilepsy compared with deployed veterans (adjusted odds ratio [aOR] 2.92, 95% CI 2.68-3.17 vs aOR 2.01, 95% CI 1.91-2.11). Penetrating TBI had higher odds of epilepsy among the deployed veterans (aOR 5.33, 95% CI 4.89-5.81), whereas the odds of epilepsy for mild TBI did not significantly differ by deployment status. Although most neurologic conditions were more prevalent among the nondeployed veterans, they were often associated with higher odds of epilepsy in the deployed veterans. DISCUSSION: Deployment history had a significant differential impact on epilepsy predictors. As expected, penetrating TBI had a greater epilepsy impact among deployed veterans perhaps due to combat/blast. Some epilepsy predictors (moderate/severe TBI, multiple sclerosis, and Parkinson disease) had a stronger association in the nondeployed veterans suggesting a potential healthy warrior effect in which such conditions preclude deployment. Other neurologic conditions (e.g., brain tumor, Alzheimer disease/frontotemporal dementia) had a greater epilepsy impact in the deployed veterans. This may be attributable to deployment-related exposures (combat injury, occupational exposures). A better understanding of deployment effects is critical to provide targeted epilepsy prevention in veterans and military service members.

Comorbidity and polypharmacy impact neurobehavioral symptoms and symptom validity failure among post-9/11 veterans with mild traumatic brain injury.

Objective: The study aimed to examine the association between post-concussive comorbidity burdens [post-traumatic stress disorder (PTSD), depression, and/or headache] and central nervous system (CNS) polypharmacy (five or more concurrent medications) with reported neurobehavioral symptoms and symptom validity screening among post-9/11 veterans with a history of mild traumatic brain injury (mTBI). Setting: Administrative medical record data from the Department of Veterans Affairs (VA) were used in the study. Participants: Post-9/11 veterans with mTBI and at least 2 years of VA care between 2001 and 2019 who had completed the comprehensive traumatic brain injury evaluation (CTBIE) were included in the study. Design: Retrospective cross-sectional design was used in the study. Main measures: Neurobehavioral Symptom Inventory (NSI), International Classification of Diseases, Ninth Revision, and Clinical Modification diagnosis codes were included in the study. Results: Of the 92,495 veterans with a history of TBI, 90% had diagnoses of at least one identified comorbidity (PTSD, depression, and/or headache) and 28% had evidence of CNS polypharmacy. Neurobehavioral symptom reporting and symptom validity failure was associated with comorbidity burden and polypharmacy after adjusting for sociodemographic characteristics. Veterans with concurrent diagnoses of PTSD, depression, and headache were more than six times more likely [Adjusted odds ratio = 6.55 (99% CI: 5.41, 7.92)]. to fail the embedded symptom validity measure (Validity-10) in the NSI. Conclusion: TBI-related multimorbidity and CNS polypharmacy had the strongest association with neurobehavioral symptom distress, even after accounting for injury and sociodemographic characteristics. Given the regular use of the NSI in clinical and research settings, these findings emphasize the need for comprehensive neuropsychological evaluation for individuals who screen positively for potential symptom overreporting, the importance of multidisciplinary rehabilitation to restore functioning following mTBI, and the conscientious utilization of symptom validity measures in research efforts.

Musculoskeletal Conditions and Secondary Cardiovascular Morbidity Increase Veterans' Rehabilitation and Orthopaedic Service Utilization.

Background Musculoskeletal conditions often affect patients' mobility and ability to participate in health behaviors such as exercise, potentially affecting their systemic health. The purpose of this research is to determine how frequently cardiac-related comorbidities present in a veteran population with musculoskeletal service-connected disability and how this affects musculoskeletal health care utilization.  Methodology A retrospective cohort of Iraq and Afghanistan Veterans who received a Veterans Affairs (VA) disability determination for service-connected musculoskeletal disability were categorized according to the diagnosis of cardiac comorbidity including diabetes mellitus, hyperlipidemia, hypertension, and obesity, and atherosclerosis disease documented by ICD-9 codes in the VA administrative data. Among veterans with musculoskeletal service-connected disability, logistic regression was modeled to determine if musculoskeletal clinic utilization was associated with also having a cardiac comorbid condition.  Results Veterans with musculoskeletal disability had a comorbid cardiac disorder 43% of the time. Post-traumatic arthritis was the only musculoskeletal condition positively associated with comorbid cardiac conditions. Veterans with comorbid cardiac diagnoses had 26-37% higher odds of receiving care by physical and occupational therapy, physical medicine, and orthopaedic surgery clinics compared to veterans without comorbid cardiac disease. Conclusions Veterans in this cohort with musculoskeletal service-connected disability, plus cardiac conditions had greater clinic use for musculoskeletal and rehabilitation services compared to those without cardiac conditions. These results have implications for the rehabilitation and other health service needs of a new generation of veterans.

Persistent Pain, Physical Dysfunction, and Decreased Quality of Life After Combat Extremity Vascular Trauma.

BACKGROUND: Combat-related extremity vascular injuries (EVI) have long-lasting impact on Iraq/Afghanistan veterans. The purpose of this study is to describe long-term functional outcomes in veterans with EVI using survey measures and identify modifiable factors that may be improved to reduce chronic pain and injury-related dysfunction. METHODS: Veterans with upper and lower EVI undergoing an initial limb salvage attempt were identified using the Department of Defense Trauma Registry and validated with chart abstraction. Surveys measured pain; Short Musculoskeletal Function Assessment (SMFA) for self-reported bother and dysfunction; and Veterans RAND 12-Item Health Survey (VR-12) physical and mental component scores (PCS; MCS) for quality of life, depression, post-traumatic stress disorder, and the potentially modifiable factors of reintegration into civilian life, resilient coping, resilience, and family functioning. RESULTS: Eighty-one patients responded with an average time since injury of 129 months (SD: 31; range 67-180 months). Mechanism of injury included 64% explosions and 31% gunshot wounds; 16% of the respondents were diagnosed with moderate/severe/penetrating traumatic brain injury. Limb salvage rates were 100% and 77% for upper and lower extremities, respectively (P = 0.004). Respondents screened positive for probable depression (55%) and post-traumatic stress disorder (51%). Compared with population norms, SMFA bother and dysfunction indices were higher (worse), MCS was lower (worse), and PCS was similar. The multivariable models adjusted for age, marital status and pain. The higher SMFA is part of the results of the multivariable models. MCS decreased with difficulty reintegrating into civilian life and was positively correlated with increased resilience and resilient coping. SMFA scores were greater for patients with high pain intensity and increased 6-11 points per point increase in difficulty with civilian-life reintegration. SMFA dysfunction was associated with better family functioning. CONCLUSIONS: EVI results in significant long-term disability with lasting deficits in physical function, frequent depressive symptoms, and below average self-reported quality of life. Strengthening modifiable factors including resiliency and resilient coping, and providing ongoing assistance to improve reintegration into civilian life, may ameliorate the functional disabilities and chronic pain experienced by veterans with EVI.

Patency of arterial repairs from wartime extremity vascular injuries.

BACKGROUND: Extremity vascular injury (EVI) causes significant disability in Veterans of the Afghanistan/Iraq conflicts. Advancements in acute trauma care improved survival and decreased amputations. The study of wartime EVI has relied on successful limb salvage as a surrogate for vascular repair. We used imaging studies as a specific measure of arterial repair durability. METHODS: Service members with EVI were identified using the Department of Defense Trauma Registry and validated by chart abstraction. Inclusion criteria for the arterial patency subgroup included an initial repair attempt with subsequent imaging reports (duplex ultrasound, CT angiography, and angiogram) documenting initial patency. RESULTS: The cohort of 527 included 140 Veterans with available imaging studies for 143 arterial repairs; median follow-up from injury time to last available imaging study was 19 months (Q1-Q3: 3-58; range: 1-175). Injury mechanism was predominantly explosions (52%) and gunshot wounds (42%). Of the 143 arterial repairs, 81% were vein grafts. Eight repairs were occluded, replaced or included in extremity amputations. One upper extremity and three transtibial late amputations were performed for chronic pain and poor function averaging 27 months (SD: 4; range: 24-32). Kaplan-Meier analysis estimated patency rates of 99%, 97%, 95%, 91% and 91% at 3, 6, 12, 24, and 36 months, respectively, with similar results for upper and lower extremity repairs. Explosive and gunshot wound injury mechanisms had similar patency rates and upper extremity injuries repaired with vein grafts had increased patency. CONCLUSIONS: Arterial repair mid-term patency in combat-related extremity injuries is excellent based on imaging studies for 143 repairs. Assertive attempts at acute limb salvage and vascular repair are justified with decisions for amputation versus limb salvage based on the overall condition of the patient and degree of concomitant nerve, orthopedic and soft tissue injuries rather than the presence of arterial injuries. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Arthritis, comorbidities, and care utilization in veterans of operations enduring and Iraqi Freedom.

Veteran populations are known to have frequencies of arthritis higher than civilian populations. The aim of this study is to define the prevalence of arthritis among a cohort of veterans from ongoing U.S. military operations. A retrospective cohort study using Veterans Administration data sources for service connected disability, comorbidities, clinic utilization, and pharmacy utilization was conducted including veterans who deployed in service to operations in Afghanistan or Iraq, comparing veterans with a diagnosis of arthritis, arthritis plus back pain, and veterans with no pain diagnoses. The frequency of arthritis was 11.8%. Veterans with arthritis and arthritis plus back pain had greater frequencies of diabetes, hyperlipidemia, hypertension, and obesity compare to veterans with no pain diagnosis. Veterans with arthritis plus back pain had the highest pain clinic utilization and prescription use of opioids and anti-inflammatories. Veterans with no pain diagnosis had higher frequencies of diagnosis and clinic utilization for mental health disorders. Arthritis is prevalent among the latest generation of combat veterans and is associated with diabetes, obesity, and cardiovascular comorbidities. The need for arthritis care and associated comorbidities is expected to increase as the Veterans Administration and the civilian health care sector assumes care of these veterans. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:682-687, 2017.

Increasing Prevalence of Chronic Lung Disease in Veterans of the Wars in Iraq and Afghanistan.

Research from the wars in Afghanistan and Iraq have focused on traumatic brain injury (TBI) and mental health conditions; however, it is becoming clear that other health concerns, such as respiratory illnesses, warrant further scientific inquiry. Early reports from theater and postdeployment health assessments suggested an association with deployment-related exposures (e.g., sand, burn pits, chemical, etc.) and new-onset respiratory symptoms. We used data from Veterans Affairs medical encounters between fiscal years 2003 and 2011 to identify trends in chronic obstructive pulmonary disease, asthma, and interstitial lung disease in veterans. We used data from Veterans Affairs and Department of Defense sources to identify sociodemographic (age, sex, race), military (e.g., service branch, multiple deployments) and clinical characteristics (TBI, smoking) of individuals with and without chronic lung diseases. Generalized estimating equations found significant increases over time for chronic obstructive pulmonary disease and asthma in both unadjusted and adjusted analyses. Trends for interstitial lung disease were significant only in adjusted analyses. Age, smoking, and TBI were also significantly associated with chronic lung diseases; however, multiple deployments were not associated. Research is needed to identify which characteristics of deployment-related exposures are linked with chronic lung disease.

Traumatic brain injury in veterans of the wars in Iraq and Afghanistan: communication disorders stratified by severity of brain injury.

OBJECTIVE: To describe the prevalence of communication disorders in veterans of the wars in Iraq and Afghanistan with traumatic brain injury (TBI). DESIGN: Retrospective study of the prevalence of aphasia, fluency and voice disorders among veterans with different severity levels of TBI. Data was obtained from the VA National repository for OEF/OIF/OND veterans who received VA care in Fiscal Years 2010 and 2011. RESULTS: Among the 303,716 veterans in this study, 1848 were diagnosed with a communication disorder; 40% of these were also diagnosed with a TBI. Voice disorders were the most prevalent diagnosis (3.5 per 1000) followed by aphasia (1.9 per 1000) and fluency disorder (0.7 per 1000). Individuals with a TBI diagnosis were more likely to have a diagnosis of aphasia, followed by fluency and then voice disorder. The odds ratio (OR) of aphasia with TBI was 11.09-252.75 (95% CI = 8.78-441.52, p < 0.01). OR for fluency disorders with TBI was 3.58-10.41 (95% CI = 2.56-42.40, p < 0.01) and association of voice disorders with TBI was significant for all levels of TBI severity (OR = 1.5-6.61, 95% CI = 1.24-14.05, p < 0.01). CONCLUSIONS: Veterans who sustained a TBI were more likely to have a diagnosis of a communication disorder, regardless of TBI severity. Those with TBI, including mild TBI, should be screened and evaluated for communication disorders.

Prevalence of potentially preventable unplanned hospitalizations caused by therapeutic failures and adverse drug withdrawal events among older veterans.

Background. Studies of drug-related hospitalizations have focused on adverse drug reactions, but few data are available on therapeutic failures (TFs) and adverse drug withdrawal events (ADWEs) leading to hospitalization among community-dwelling older adults. Thus, we sought to describe the prevalence of unplanned hospitalizations caused by TFs and ADWEs. In addition, we evaluated factors associated with these events in a nationally representative sample of older Veterans. Methods. This study included 678 randomly selected unplanned hospitalizations of older (age ≥ 65 years) Veterans between December 1, 2003, and November 9, 2006. The main outcomes were hospitalizations caused by a TF and/or an ADWE as determined by a pair of health professionals from review of medication charts and application of the Therapeutic Failure Questionnaire and/or Naranjo ADWE algorithm, respectively. Preventability (ie, medication error) of the admission was also assessed. Results. Thirty-four TFs and eight ADWEs involving 54 drugs were associated with 40 (5.9%) Veterans' hospitalizations; of these admissions, 90.0% (36/40) were rated as potentially preventable mostly due to medication nonadherence and suboptimal prescribing. The most common TFs that occurred were heart failure exacerbations (n = 8), coronary heart disease symptoms (n = 6), tachyarrhythmias (n = 3), and chronic obstructive pulmonary disease exacerbations (n = 3). Half (4/8) of the ADWEs that occurred were cardiovascular in nature. Multivariable logistic regression modeling indicated that black Veterans (adjusted odds ratio 2.92, 95% CI 1.25-6.80) were significantly more likely to experience a TF-related admission compared with white Veterans. Conclusions. TF-related unplanned hospitalizations occur more frequently than ADWE-related admissions among older Veterans. Almost all TFs and/or ADWEs are potentially preventable.

Prevalence of unplanned hospitalizations caused by adverse drug reactions in older veterans.

OBJECTIVES: To describe the prevalence of unplanned hospitalizations caused by adverse drug reactions (ADRs) in older veterans and to examine the association between this outcome and polypharmacy after controlling for comorbidities and other patient characteristics. DESIGN: Retrospective cohort. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Six hundred seventy-eight randomly selected unplanned hospitalizations of older (aged ≥ 65) veterans between October 1, 2003, and September 30, 2006. MEASUREMENTS: Naranjo ADR algorithm, ADR preventability, and polypharmacy (0-4, 5-8, and ≥9 scheduled medications). RESULTS: Seventy ADRs involving 113 drugs were found in 68 (10%) hospitalizations of older veterans, of which 25 (36.8%) were preventable. Extrapolating to the population of more than 2.4 million older veterans receiving care during the study period, 8,000 hospitalizations may have been unnecessary. The most common ADRs that occurred were bradycardia (n = 6; beta-blockers, digoxin), hypoglycemia (n = 6; sulfonylureas, insulin), falls (n = 6; antidepressants, angiotensin-converting enzyme inhibitors), and mental status changes (n = 6; anticonvulsants, benzodiazepines). Overall, 44.8% of veterans took nine or more outpatient medications and 35.4% took five to eight. Using multivariable logistic regression and controlling for demographic, health-status, and access-to-care variables, polypharmacy (≥9 and 5-8) was associated with greater risk of ADR-related hospitalization (adjusted odds ratio (AOR) = 3.90, 95% confidence interval (CI) = 1.43-10.61 and AOR = 2.85, 95% CI = 1.03-7.85, respectively). CONCLUSION: ADRs, determined using a validated causality algorithm, are a common cause of unplanned hospitalization in older veterans, are frequently preventable, and are associated with polypharmacy.

Trends in use of high-risk medications for older veterans: 2004 to 2006.

OBJECTIVES: To examine the change in use of high-risk medications for the elderly (HRME), as defined by the National Committee on Quality Assurance's Healthcare Effectiveness Data and Information Set (HEDIS) quality measure (HEDIS HRME), by older outpatient veterans over a 3-year period and to identify risk factors for HEDIS HRME exposure overall and for the most commonly used drug classes. DESIGN: Longitudinal retrospective database analysis. SETTING: Outpatient clinics within the Department of Veterans Affairs (VA). PARTICIPANTS: Veterans aged 65 by October 1, 2003, and who received VA care at least once each year until September 30, 2006. MEASUREMENTS: Rates of use of HEDIS HRME overall and according to specific drug classes each year from fiscal year 2004 (FY04) to FY06. RESULTS: In a cohort of 1,567,467, high-risk medication exposure fell from 13.1% to 12.3% between FY04 and FY06 (P<.001). High-risk antihistamines (e.g., diphenhydramine), opioid analgesics (e.g., propoxyphene), skeletal muscle relaxants (e.g., cyclobenzaprine), psychotropics (e.g., long half-life benzodiazepines), endocrine (e.g., estrogen), and cardiac medications (e.g., short-acting nifedipine) had modest but statistically significant (P<.001) reductions (range -3.8% to -16.0%); nitrofurantoin demonstrated a statistically significant increase (+36.5%; P<.001). Overall HEDIS HRME exposure was more likely for men, Hispanics, those receiving more medications, those with psychiatric comorbidity, and those without prior geriatric care. Exposure was lower for individuals exempt from copayment. Similar associations were seen between ethnicity, polypharmacy, psychiatric comorbidity, access-to-care factors, and use of individual HEDIS HRME classes. CONCLUSION: HEDIS HRME drug exposure decreased slightly in an integrated healthcare system. Risk factors for exposure were not consistent across drug groups. Future studies should examine whether interventions to further reduce HEDIS HRME use improve health outcomes.

Choice of initial antiepileptic drug for older veterans: possible pharmacokinetic drug interactions with existing medications.

OBJECTIVES: To identify clinically meaningful potential drug-drug interactions (PDIs) with antiepileptic drugs (AEDs), the AEDs and co-administered drugs commonly associated with AED-PDIs, and characteristics of patients with high likelihood of AED-PDI exposure. DESIGN: Five-year retrospective cohort study of veterans with new-onset epilepsy. SETTING: National Veterans Affairs and Medicare databases. PARTICIPANTS: Veterans aged 66 and older with a new diagnosis of epilepsy between October 1, 1999, and September 30, 2004 (N=9,682). MEASUREMENTS: AED-PDI was restricted to clinically meaningful PDIs identified using prior literature review. AED-PDIs were identified using participants' date of initial AED prescription and overlapping concomitant medications. Logistic regression analysis identified factors associated with AED-PDI, including demographic characteristics, chronic disease states, and diagnostic setting. RESULTS: AED-PDI exposure was found in 45.5% (4,406/9,682); phenytoin, a drug with many PDIs, was the most commonly prescribed AED. Cardiovascular drugs, lipid-lowering medications, and psychotropic agents were the most commonly co-administered AED-PDI medications. Individuals with AED-PDI exposure were more likely to have hypertension (odds ratio (OR)=1.46, 99% confidence interval (CI)=1.24-1.82) and hypercholesterolemia (OR=1.40, 99% CI=1.24-1.57) than those without and to be diagnosed in an emergency or primary care setting than a neurology setting (emergency: OR=1.30, 99% CI=1.08-1.58; primary care: OR=1.29 99% CI=1.12-1.49). CONCLUSION: Exposure to AED-PDI was substantial but less common in patients with epilepsy diagnosed in a neurology setting. Because potential outcomes associated with AED-PDI include stroke and myocardial infarction in a population already at high risk, clinicians should closely monitor blood pressure, coagulation, and lipid measures to minimize adverse effects of AED-PDIs. Interventions to reduce AED-PDIs may improve patient outcomes.

New-onset epilepsy risk factors in older veterans.

OBJECTIVES: To identify risk factors for new-onset geriatric epilepsy that may trigger clinicians to consider a differential diagnosis of epilepsy at symptom onset. DESIGN: Retrospective cohort study. SETTING: National Veterans Affairs (VA) databases. PARTICIPANTS: Veterans aged 66 and older in fiscal year 2000 (FY00) who received VA care in FY99 and FY00. Individuals with new-onset epilepsy based on a validated algorithm constituted the epilepsy cohort (n=1,843), and individuals without epilepsy constituted the geriatric cohort (n=1,023,376). MEASUREMENTS: Age, sex, and race were derived from VA databases. Clinical conditions associated with new-onset geriatric epilepsy (e.g., cerebrovascular disease, dementia, brain tumor) and stroke risk-factors (e.g., hypertension, diabetes mellitus, cardiovascular disease) were identified using validated International Classification of Diseases, Ninth Revision, Clinical Modification, codes before epilepsy onset (epilepsy cohort) and in FY00 (geriatric cohort). RESULTS: Multivariable logistic regression analysis indicated that patients with cerebrovascular disease (odds ratio (OR)=3.50, 95% confidence interval (CI)=3.13-3.91), cerebrovascular disease and dementia (OR=4.14, 95% CI=3.46-4.96), brain tumor (OR=2.14, 95% CI=1.46-3.13), head injury (OR=2.11, 95% CI=1.41-3.14), and other central nervous system (CNS) conditions (OR=1.57, 95% CI=1.32-1.88) were more likely to experience new-onset epilepsy. Statin prescription (OR=0.64, 95% CI=0.56-0.73), older age (> or =85 vs 66-74, OR=0.66, 95% CI=0.50-0.87), obesity (OR=0.74, 95% CI=0.62-0.87), and hypercholesterolemia (OR=0.87, 95% CI=0.76-0.98) were associated with a lower likelihood of epilepsy. CONCLUSION: These data suggest greater epilepsy risk for older individuals with CNS insult and an additive effect of cerebrovascular disease and dementia. The statin finding requires further exploration but points to a possible target for prevention of geriatric epilepsy.

Sex differences in inappropriate prescribing among elderly veterans.

BACKGROUND: Previous studies have suggested that older women may be more likely than older men to receive potentially inappropriate prescriptions. A better understanding of sex differences in inappropriate prescribing can help inform the development of effective interventions. OBJECTIVE: This study was conducted to assess sex differences in rates of inappropriate prescribing before and after accounting for potentially appropriate indications and to examine sex differences in predictors of inappropriate drug use. METHODS: This was a retrospective cohort study of administrative data from the national Veterans Health Administration (VA). Participants were veterans aged >or=65 years who had >or=1 patient visit at VA outpatient facilities in fiscal year 1999 (FY99) and 2000 (FY00). The main outcome measure was the diagnosis-adjusted prevalence of 33 potentially inappropriate medications as judged by the Beers criteria in FY00: overall, by individual drug, and in 3 categories grouped by potential indication ("always avoid," "rarely appropriate," and "some indications"). RESULTS: The study population included 965,756 patients (946,641 men and 19,115 women). Women were more likely than men to receive inappropriate medications overall and in all 3 categories, even after accounting for diagnoses that may have justified the prescription. Women were more likely to receive 16 of the 33 medications (analgesics, psychotropic drugs, and anticholinergic agents), and men were more likely to receive 3 of the 33. After controlling for sociodemographic characteristics, number of medications, and care characteristics, women remained more likely to receive inappropriate drugs. Receipt of geriatric care was equally protective for men and women, although only a small proportion received this care. Psychiatric comorbidity was associated with inappropriate prescribing for men but not for women. CONCLUSIONS: Analgesic, psychotropic, and anticholinergic medications that should be avoided contributed to higher rates of inappropriate drug use among older women than among older men. Targeted efforts to avoid these medications in older women may help reduce overall rates of inappropriate prescribing. Sex-stratified reporting of quality indicators that assess inappropriate prescribing among community-dwelling elders would help monitor the effectiveness of improvement efforts.

The role of comorbid psychiatric conditions in health status in epilepsy.

Comorbid psychiatric conditions are highly prevalent in patients with epilepsy, yet the long-term implications across multiple mental health conditions are poorly understood. We examined the association between psychiatric diagnoses and self-reported health status in veterans with epilepsy. ANCOVA models were used to derive adjusted SF-36V scores for individuals with epilepsy alone (N=7379) or with additional psychiatric conditions (N=6320): depression, schizophrenia, bipolar disorder, anxiety disorder, substance abuse, and posttraumatic stress disorder (PTSD). Compared with patients with epilepsy alone, scores of veterans with comorbid psychiatric diagnoses averaged 21% lower across all domains. Role Limitation scales exhibited the greatest decrement across domains. A PTSD diagnosis consistently corresponded to lower scores, followed by depression. Schizophrenia contributed the least detriment to perceived health status. Comorbid psychiatric conditions impart significant emotional and physical burdens, requiring timely recognition and treatment of these disorders. Patients with epilepsy are uniquely at risk for high physical-psychiatric comorbidity profiles, with concomitant losses in perceived health status.