Prevalence, predictors and correlates of insomnia in US army soldiers.

The objective of this study was to investigate the rates, predictors and correlates of insomnia in a national sample of US Army soldiers. Data were gathered from the cross-sectional survey responses of the All-Army Study, of the Army Study to Assess Risk and Resilience in Service members. Participants were a representative sample of 21 499 US Army soldiers who responded to the All-Army Study self-administered questionnaire between 2011 and 2013. Insomnia was defined by selected DSM-5 criteria using the Brief Insomnia Questionnaire. The results highlight significant functional difficulties associated with insomnia among US soldiers, as well as insights into predictors of insomnia specific to this population. Insomnia was present in 22.76% of the sample. Predictors of insomnia status in logistic regression included greater number of current mental health disorders, less perceived open lines of communication with leadership, less unit member support and less education. Insomnia had global, negative associations with health, social functioning, support, morale, work performance and Army career intentions. The results provide the strongest evidence to-date that insomnia is common in a military population, and is associated with a wide array of negative factors in the domains of health, military readiness and intentions to remain in military careers.

Mild Traumatic Brain Injury and Aggression, Impulsivity, and History of Other- and Self-Directed Aggression.

Mild traumatic brain injury (mTBI) is highly prevalent, with an estimated occurrence in the United States of more than 1.3 million per year. While one consequence of mTBI is impulsive aggressive behavior, very few studies have examined the relationship between history of mTBI and aggressive behavior in impulsively aggressive individuals. The authors examined the relationship between history of mTBI in a healthy control group (HC; N=453), a control group with psychiatric disorders (PC; N=486), and individuals with intermittent explosive disorder (IED; N=695), a disorder of primary impulsive aggression. Results demonstrated that IED study participants were significantly more likely to have a history of mTBI (with or without history of a brief loss of consciousness [LOC]) compared with both HC and PC participants. A similar observation was made with regard to self-directed aggression (i.e., suicidal or self-injurious behavior), although group differences were only among those with mTBI with LOC. For both other- and self-directed aggression variables, the authors observed a stepwise increase in dimensional aggression and impulsivity scores across participants as a function of mTBI history. Given that impulsive aggressive behavior begins very early in life, these data are consistent with the hypothesis that lifelong presence of an impulsive aggressive temperament places impulsive aggressive individuals in circumstances that put them at greater risk for mTBI compared with other individuals with and without nonimpulsive aggressive psychopathology.

Neurocognitive change over the course of a multiday external lumbar drain trial in patients with suspected normal pressure hydrocephalus.

Objective: To characterize neurocognitive response to cerebrospinal fluid (CSF) diversion during a multiday external lumbar drainage (ELD) trial in patients with suspected normal pressure hydrocephalus (NPH). Methods: Inpatients (N = 70) undergoing an ELD trial as part of NPH evaluation participated. Cognition and balance were assessed using standardized measures before and after a three-day ELD trial. Cognitive change pre- to post-ELD trial was assessed in relation to change in balance, baseline neuroimaging findings, NPH symptoms, demographics, and other disease-relevant clinical parameters. Results: Multiday ELD resulted in significant cognitive improvement (particularly on measures of memory and language). This improvement was independent of demographics, test-retest interval, number of medical and psychiatric comorbidities, NPH symptom duration, estimated premorbid intelligence, baseline level of cognitive impairment, cerebrovascular disease burden, degree of ventriculomegaly, or other NPH-related morphological brain alterations. Balance scores evidenced a greater magnitude of improvement than cognitive scores and were weakly, but positively correlated with cognitive change scores. Conclusions: Findings suggest that cognitive improvement associated with a multiday ELD trial can be sufficiently captured with bedside neurocognitive testing. These findings support the utility of neuropsychological consultation, along with balance assessment, in informing clinical decision-making regarding responsiveness to temporary CSF diversion for patients undergoing elective NPH evaluation. Implications for the understanding of neuroanatomical and cognitive underpinnings of NPH are discussed.

Association Between Insomnia and Mental Health and Neurocognitive Outcomes Following Traumatic Brain Injury.

We previously described five trajectories of insomnia (each defined by a distinct pattern of insomnia severity over 12 months following traumatic brain injury [TBI]). Our objective in the present study was to estimate the association between insomnia trajectory status and trajectories of mental health and neurocognitive outcomes during the 12 months after TBI. In this study, participants included N = 2022 adults from the Federal Inter-agency Traumatic Brain Injury Repository database and Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. The following outcome measures were assessed serially at 2 weeks, and 3, 6, and 12 months post-injury: Insomnia Severity Index, Patient Health Questionnaire, Post-Traumatic Stress Disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Patient Reported Outcomes Measurement Information System-Pain, and Quality of Life After Brain Injury-Overall Scale. Neurocognitive performance was assessed at 2 weeks, and 6 and 12 months using the Wechsler Adult Intelligence Scales Processing Speed Index and the Trails Making Test Parts A and B. Results indicated that greater insomnia severity was associated with greater abnormality in mental health, quality of life, and neuropsychological testing outcomes. The pattern of insomnia over time tracked the temporal pattern of all these outcomes for all but a very small number of participants. Notably, severe insomnia at 3 or 6 months post-TBI was a risk factor for poor recovery at 12 months post-injury. In conclusion, in this well-characterized sample of individuals with TBI, insomnia severity generally tracked severity of depression, pain, PTSD, quality of life, and neurocognitive outcomes over 12 months post-injury. More intensive sleep assessment is needed to elucidate the nature of these relationships and to help inform best strategies for intervention.

The utility of neuropsychological consultation in identifying medical inpatients with suspected cognitive impairment at risk for greater hospital utilization.

OBJECTIVE: This was a retrospective study designed to examine the relationship between inpatient neuropsychological status and future utilization costs. METHODS: We completed a retrospective chart review of 280 patients admitted to a large academic medical center who were referred for bedside neuropsychological evaluation. Patients were grouped based on neuropsychological recommendation regarding level of supportive needs post-discharge (low, moderate, high). Level of support was used as a gross surrogate indicator of cognitive status in this heterogeneous sample. We also included patients who refused assessment. Outcome variables included time to readmission, number of emergency department visits, inpatient admissions, length of hospitalization, and total costs of hospitalizations, 30 days and 1 year following discharge. RESULTS: Multivariate analysis indicated patients who refused assessment had higher inpatient service utilization (number of ED visits, number of admissions, and total cost of hospitalization) compared to those with moderate needs. Also, high needs patients had higher total cost of hospitalization at 1 year, and those with low needs used the ED more, compared to those with moderate needs. CONCLUSIONS: Our findings replicate prior studies linking refusal of neuropsychological evaluation to higher service utilization costs, and suggest a nonlinear relationship between cognitive impairment severity and future costs for medical inpatients (different groups incur different types of costs). Results preliminarily highlight the potential utility of inpatient neuropsychological assessment in identifying patients at risk for greater hospital utilization, which may allow for the development of appropriate interventions for these patients.

Insomnia prevalence among U.S. Army soldiers with history of TBI.

PURPOSE/OBJECTIVE: To determine the rate of insomnia among active-duty soldiers with and without a history of traumatic brain injury (TBI). Research Method and Design: Data were extracted from the All Army Study (AAS), a cross-sectional, self-report survey completed by a representative sample of 21,499 U.S. Army soldiers from 2011 to 2013 as part of the Army Study to Assess Risk and Resilience in Servicemembers. History and severity of TBI were determined by participants' responses to questions regarding postinjury symptomology (i.e., loss of consciousness [LOC], amnesia, etc.). Insomnia symptoms were defined using DSM-5 criteria as measured by the Brief Insomnia Questionnaire. RESULTS: Approximately 63% of respondents reported lifetime history of mild TBI (mTBI), with ∼7% endorsing a history of moderate to severe TBI. Insomnia symptom prevalence rate increased with brain injury severity and number of TBIs with LOC, with ∼51% of those with mTBI and ∼55% of those with moderate to severe TBI demonstrating clinically elevated insomnia symptoms, compared to ∼37% insomnia prevalence rate among servicemembers without TBI. CONCLUSION/IMPLICATIONS: Results suggest high (> 50%) prevalence rates of insomnia symptoms among servicemembers with a lifetime history of brain injury, underscoring the need for behavioral sleep medicine interventions among active-duty personnel. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A practical guide to evaluating sleep disturbance in concussion patients.

PURPOSE OF REVIEW: To provide an introduction and review of sleep metrics appropriate for use with an outpatient concussed population. RECENT FINDINGS: Although sleep issues are frequently identified in concussion, sleep disturbance is rarely assessed in outpatient settings. Given that sleep disturbance may be indicative of, or contribute to, delayed neurocognitive recovery, measurement tools for sleep, rest, and activity behavior may be of both practical and research utility. SUMMARY: Because sleep disturbance symptoms may vary between or within an individual throughout the course of recovery, it is recommended that sleep be measured at regular intervals over the entirety of recovery. Included is a discussion on how to select appropriate measures based on patient symptomology in addition to common practical concerns. Additional clinical considerations, a review of traditional pencil and paper methods of continuous sleep behavior monitoring, as well as technologies for measuring sleep and activity behavior are also included.

Cognitively-based methods of enhancing and maintaining functioning in those at risk of Alzheimer's disease.

Projections indicate that the prevalence of Alzheimer's disease (AD) and other dementias will increase two to three fold in the coming decades. As a result, there has been considerable interest in identifying methods that maintain or enhance cognitive functioning in these older adults. Existing pharmacological agents are limited in this respect and disease-modifying agents are years away from being available. Cognitively based interventions (i.e., cognitive training, cognitive rehabilitation) hold particular promise for maximizing patients' functioning, are relatively inexpensive, and have virtually no side effects. Everyday life is complex and multifaceted, which means that a personalized approach is essential for maximizing and prolonging functioning in each patient. Unfortunately, little is known about the factors contributing to such an approach. The current review first identifies several lifestyle factors that have been shown to be neuroprotective as well as risk factors that may ultimately contribute to the efficacy of different cognitive intervention techniques. There is a critical need to understand the conditions under which individual techniques are effective; an issue examined through characteristic examples across the AD spectrum. While limited at this time, there is some evidence of the long-term benefits of cognitive intervention. We conclude by describing several critical areas of investigation and proposing a clinically oriented framework for both furthering cognitive intervention research and providing patient-centered care.

Impact of brief cognitive behavioral treatment for insomnia on health care utilization and costs.

STUDY OBJECTIVES: To examine health care utilization (HCU) and costs following brief cognitive behavioral treatment for insomnia (bCBTi). METHODS: Reviewed medical records of 84 outpatients [mean age = 54.25 years (19.08); 58% women] treated in a behavioral sleep medicine clinic (2005-2010) based in an accredited sleep disorders center. Six indicators of HCU and costs were obtained: estimated total and outpatient costs, estimated primary care visits, CPT costs, number of office visits, and number of medications. All patients completed ≥ 1 session of bCBTi. Those who attended ≥ 3 sessions were considered completers (n = 37), and completers with significant sleep improvements were considered responders (n = 32). RESULTS: For completers and responders, all HCU and cost variables, except number of medications, significantly decreased (ps < 0.05) or trended towards decrease at post-treatment. Completers had average decreases in CPT costs of $200 and estimated total costs of $75. Responders had average decreases in CPT costs of $210. No significant decreases occurred for non-completers. CONCLUSIONS: bCBTi can reduce HCU and costs. Response to bCBTi resulted in greater reduction of HCU and costs. While limited by small sample size and non-normal data distribution, the findings highlight the need for greater dissemination of bCBTi for several reasons: a high percentage of completers responded to treatment, as few as 3 sessions can result in significant improvements in insomnia severity, bCBTi can be delivered by novice clinicians, and health care costs can reduce following treatment. Insomnia remains an undertreated disorder, and brief behavioral treatments can help to increase access to care and reduce the burden of insomnia.