External Validation of the eRADAR Risk Score for Detecting Undiagnosed Dementia in Two Real-World Healthcare Systems.

BACKGROUND: Fifty percent of people living with dementia are undiagnosed. The electronic health record (EHR) Risk of Alzheimer's and Dementia Assessment Rule (eRADAR) was developed to identify older adults at risk of having undiagnosed dementia using routinely collected clinical data. OBJECTIVE: To externally validate eRADAR in two real-world healthcare systems, including examining performance over time and by race/ethnicity. DESIGN: Retrospective cohort study PARTICIPANTS: 129,315 members of Kaiser Permanente Washington (KPWA), an integrated health system providing insurance coverage and medical care, and 13,444 primary care patients at University of California San Francisco Health (UCSF), an academic medical system, aged 65 years or older without prior EHR documentation of dementia diagnosis or medication. MAIN MEASURES: Performance of eRADAR scores, calculated annually from EHR data (including vital signs, diagnoses, medications, and utilization in the prior 2 years), for predicting EHR documentation of incident dementia diagnosis within 12 months. KEY RESULTS: A total of 7631 dementia diagnoses were observed at KPWA (11.1 per 1000 person-years) and 216 at UCSF (4.6 per 1000 person-years). The area under the curve was 0.84 (95% confidence interval: 0.84-0.85) at KPWA and 0.79 (0.76-0.82) at UCSF. Using the 90th percentile as the cut point for identifying high-risk patients, sensitivity was 54% (53-56%) at KPWA and 44% (38-51%) at UCSF. Performance was similar over time, including across the transition from International Classification of Diseases, version 9 (ICD-9) to ICD-10 codes, and across racial/ethnic groups (though small samples limited precision in some groups). CONCLUSIONS: eRADAR showed strong external validity for detecting undiagnosed dementia in two health systems with different patient populations and differential availability of external healthcare data for risk calculations. In this study, eRADAR demonstrated generalizability from a research sample to real-world clinical populations, transportability across health systems, robustness to temporal changes in healthcare, and similar performance across larger racial/ethnic groups.

Postamputation Cognitive Impairment Is Related to Worse Perceived Physical Function Among Middle-Aged and Older Prosthesis Users.

OBJECTIVE: To compare characteristics between middle-aged and older prosthesis users with and without cognitive impairment and determine whether cognitive impairment contributes to variability in perceived physical function. DESIGN: Cross-sectional, observational study SETTING: General community. PARTICIPANTS: Adults 45 years or older, at least 1-year post lower limb amputation (LLA) who were walking independently with a prosthesis (N=119). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: We identified cognitive impairment using an education-adjusted Telephone Interview for Cognitive Status-modified score. Perceived physical function was measured using the Prosthesis Mobility Questionnaire. RESULTS: Of 119 participants (mean age, 62.6±8.2 years; male: 89.1%; vascular etiology: 82.4%; years since amputation: 4.9±4.7 years), 28 (23.5%) had cognitive impairment. Compared with participants without cognitive impairment, those with cognitive impairment were more likely to use an assistive device (60.7% vs 25.3%, P=.002); were older (66.3±7.3 vs 61.5±8.1 years, P=.006) and had more chronic conditions (7.1±3.4 vs 5.4±2.5, P=.004), more depressive symptoms (6.6±5.1 vs 4.2±3.8, P=.008), and worse perceived physical function (2.0±0.6 vs 2.6±0.7, P<.001). Using backward stepwise linear regression, we found that participants with cognitive impairment had worse perceived physical function (standardized parameter estimate [ß]=-0.15, P=.02), even after adjusting for depressive symptoms (ß=-0.31, P<.001), prosthesis satisfaction (ß=0.34, P<.001), number of chronic conditions (ß=-0.19, P=.006), and assistive device use (ßcane=0.01, P=.93; ßother=-0.20, P=.003). Together, these variables explained 59% of perceived physical function variability. CONCLUSIONS: Cognitive impairment is common and associated with worse perceived physical function post LLA, even after controlling for physical and mental health differences. Tailored rehabilitation interventions may be needed to improve perceived physical function in prosthesis users with cognitive impairment.

Physical inactivity in older adults with cognitive impairment without dementia: room for improvement.

BACKGROUND: Persons with cognitive impairment without dementia are at high risk of adverse health outcomes. Tailored intervention targeting moderate-vigorous physical activity (MVPA) may reduce these risks. AIMS: To identify the prevalence and predictors of physical inactivity among older adults with cognitive impairment, no dementia (CIND); and estimate the proportion of inactive people with CIND who are capable of greater MVPA. METHODS: We studied 1875 community dwelling participants (over age 65) with CIND in the Health and Retirement Study. Physical inactivity was defined as MVPA ≤ 1x/week. Associations of physical inactivity with sociodemographic, health, and physical function were examined using chi-square and modified Poisson regression. We considered physically inactive participants capable of greater MVPA if they reported MVPA at least 1-3x/month, no difficulty walking several blocks, or no difficulty climbing several flights of stairs. RESULTS: Fifty-six percent of participants with CIND were physically inactive. Variables with the highest age, sex, and race/ethnicity adjusted risk ratio (ARR) for physical inactivity were self-rated health (poor [76.9%]vs. excellent [34.2%]; ARR [95% CI] 2.27 [1.56-3.30]), difficulty walking (across the room [86.5%] vs. none [40.5%]; ARR [95% CI] 2.09 [1.87-2.35]), total assets (lowest quartile [62.6%] vs. highest quartile [43.1%]; ARR [95% CI] 1.54 [1.29-1.83]), and lower education attainment (less than high school [59.6%] vs college graduate [42.8%]; ARR [95% CI] 1.46 [1.17-1.83]). Among physically inactive older adults with CIND, 61% were estimated to be capable of greater MVPA. CONCLUSIONS: Although physical inactivity is prevalent among older adults with CIND, many are capable of greater MVPA. Developing tailored physical activity interventions for this vulnerable population may improve cognitive, health, and quality of life outcomes.

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.

Clinical features of dementia cases ascertained by ICD coding in LIMBIC-CENC multicenter study of mild traumatic brain injury.

OBJECTIVE: Describe dementia cases identified through International Classification of Diseases (ICD) coding in the Long-term Impact of Military-relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) multicenter prospective longitudinal study (PLS) of mild traumatic brain injury (mTBI). DESIGN: Descriptive case series using cross-sectional data. METHODS: Veterans Affairs (VA) health system data including ICD codes were obtained for 1563 PLS participants through the VA Informatics and Computing Infrastructure (VINCI). Demographic, injury, and clinical characteristics of Dementia positive and negative cases are described. RESULTS: Five cases of dementia were identified, all under 65 years old. The dementia cases all had a history of blast-related mTBI and all had self-reported functional problems and four had PTSD symptomatology at the clinical disorder range. Cognitive testing revealed some deficits especially in the visual memory and verbal learning and memory domains, and that two of the cases might be false positives. CONCLUSIONS: ICD codes for early dementia in the VA system have specificity concerns, but could be indicative of cognitive performance and self-reported cognitive function. Further research is needed to better determine links to blast exposure, blast-related mTBI, and PTSD to early dementia in the military population.

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.

Partnering to cope with pain: A pilot study of a caregiver-assisted pain coping skills intervention for patients with cognitive impairment and dementia.

OBJECTIVE: To develop a new caregiver-assisted pain coping skills training protocol specifically tailored for community-dwelling persons with cognitive impairment and pain, and assess its feasibility and acceptability. METHOD: In Phase I, we conducted interviews with 10 patient-caregiver dyads to gather feedback about intervention content and delivery. Phase II was a single-arm pilot test to evaluate the intervention's feasibility and acceptability. Dyads in the pilot study (n = 11) completed baseline surveys, received five intervention sessions, and then completed post-intervention surveys. Analyses focused on feasibility and acceptability. RESULTS: Dyads responded positively to the pain coping skills presented in the interviews; their feedback was used to refine the intervention. Findings from the pilot study suggested that the intervention was feasible and acceptable. 69% of eligible dyads consented, 82% completed all five intervention sessions, and 100% completed the post-treatment assessment. Caregivers reported high satisfaction ratings. They also reported using the pain coping skills on a regular basis, and that they found most of the skills helpful and easy to use. SIGNIFICANCE OF RESULTS: These preliminary findings suggest that a caregiver-assisted pain coping skills intervention is feasible and acceptable, and that it may be a promising approach to managing pain in patients with cognitive impairment.

The PREPARE for Your Care program increases advance care planning engagement among diverse older adults with cancer.

BACKGROUND: Advance care planning (ACP) is low among older adults with cancer. In a secondary analysis of randomized trial data, the authors compared the efficacy of the PREPARE for Your Care (PREPARE) website plus an easy-to-read advance directive (AD) with an AD only among older adults with and without cancer. METHODS: Safety net, primary care patients in San Francisco were included if they were 55 years old or older, were English- or Spanish-speaking, and had 2 or more chronic conditions. The authors determined cancer diagnoses by using International Classification of Diseases, Ninth Revision/Tenth Revision codes. The primary outcome was new ACP documentation in the medical record at 15 months; the secondary outcomes were self-reported ACP engagement, ease of use, satisfaction, and depression/anxiety. The authors used mixed effects logistic and linear regression adjusted for prior ACP, health literacy, and clinician, including a cancer interaction term. RESULTS: Of 986 participants, 220 (22%) had cancer. The mean age was 63 years (SD, 6 years), 61% were women, 81% were of a minority race/ethnicity, 45% were Spanish-speaking, 39% had limited health literacy, and 27% had prior ACP. New ACP documentation was higher in the PREPARE arm versus the AD-only arm among participants with cancer (62% vs 43%; P = .01) and without cancer (38% vs 28%; P = .01), as was ACP engagement in both arms (P < .001), with no interactions by cancer. Ease of use and satisfaction were high, and depression/anxiety was low, with no differences by study arm or by cancer/no cancer. CONCLUSIONS: PREPARE plus an easy-to-read AD increased ACP documentation and engagement among diverse older adults with cancer more than an AD alone, with no increase in depression or anxiety between study arms or by cancer. PREPARE may help to decrease ACP disparities among patients with cancer. LAY SUMMARY: Advance care planning (ACP) is the process of sharing values, goals, and preferences for medical care, but engagement in ACP is low among older adults with cancer. Among 986 English- and Spanish-speaking older adults from a safety net hospital, an interactive, multimedia, web-based ACP program (PREPARE for Your Care at https://prepareforyourcare.org/) plus an easy-to-read advance directive increased ACP documentation and engagement more than an advance directive alone. There were no differences in this increase in ACP between older adults with cancer and older adults without cancer. Also, engaging in ACP did not result in increased depression or anxiety.

Engaging Diverse Older Adults With Cognitive Impairment and Caregivers in Advance Care Planning: A Pilot Study of the Interactive PREPARE Website.

INTRODUCTION: Engaging patients with cognitive impairment in advance care planning (ACP), including completing advance directives and naming health care proxies, before they lose decision-making capacity is important. METHODS: We determined the feasibility of the PREPAREforYourCare.org ACP program among 20 diverse older adults with mild-to-moderate cognitive impairment and their caregivers in a 1-week, pre-post pilot. We examined ease-of-use, satisfaction, and feasibility using validated scales, and change in ACP Engagement scores, including knowledge, contemplation, self-efficacy, and readiness subscales (5-point scales), from baseline to 1-week. RESULTS: Participants were on average 70 years old (SD=9.0), 45% Spanish-speaking, 60% had limited health literacy, and 15% felt comfortable using the internet. Patients and caregivers rated PREPARE a mean of 8.6 (SD=1.6) and 9.4 (SD=1.1) on the 10-point ease-of-use scale, 4.7 (SD=0.4) and 4.7 (SD=0.3) on the 5-point satisfaction scale, and 4.9 (SD=0.4) and 4.8 (SD=0.6) on the 5-point feasibility scale, respectively. ACP engagement scores increased for 16 of 20 (80%) patients (P=0.03) and 16 of 20 (80%) caregivers (P=0.18). Caregivers experienced increased knowledge (3.8 to 4.7, P=0.002) and self-efficacy (3.6 to 4.5, P=0.034) for ACP. DISCUSSION: The PREPARE website was feasible and may facilitate ACP engagement among diverse older adults with cognitive impairment and their caregivers.

Implementation of an integrative movement program for residents with dementia in a VA nursing home.

BACKGROUND: Preventing Loss of Independence through Exercise (PLIÉ) is an integrative group movement program developed for adults with mild-to-moderate dementia attending day programs. However, many older adults with dementia ultimately require assistance with their activities of daily living and become residents in nursing homes or other long-term care facilities with their complex comorbidities and unique needs. We conducted a post-implementation evaluation of PLIÉ at a San Francisco Veterans Affairs (VA) nursing home to assess reach and effectiveness among residents, staff, and family members who participated in ≥ 1 PLIÉ class from 9/2018 to 6/2019. METHODS: Post-implementation number of classes offered and mean attendance; anonymous satisfaction surveys (5-point Likert scales); qualitative content analysis of open-ended survey responses and clinical progress notes. RESULTS: Forty-five PLIÉ classes were offered over 9 months. Residents attended an average of 13 ± 12 classes with an average class size of 14 residents, 4 staff members, and 2 family members. Most survey respondents rated the program overall as "very good" or "excellent" (100 % residents, n = 15; 87 % staff, n = 14; 100 % family members, n = 8). Respondents reported improvements in themselves and/or others in four domains: (1) physical, (2) psychological, (3) social, and (4) cognitive. Physical improvements among veterans included mobility, strength, and energy. Psychological improvements included feelings of happiness/well-being, enjoyment, and self-empowerment. Social improvements included connection, social skills, and social support. Cognitive improvements included engagement, communication ability, and focus/attention. Responses were similar among resident, staff, and family member surveys and clinical progress notes. Participants frequently reported improvements in multiple domains (e.g., "The veterans are more alert and engaged, many are smiling and laughing."). Negative comments were primarily related to logistics, suggesting that the class occur more frequently. CONCLUSIONS: PLIÉ was successfully implemented in a VA nursing home with high attendance and satisfaction among residents, staff, and family members. Participants reported clinically meaningful physical, psychological, social, and cognitive benefits. Other long-term care facilities could potentially benefit from implementing PLIÉ to increase quality of life in residents with dementia.

Patient and caregiver perspectives on a tool to increase recognition of undiagnosed dementia: a qualitative study.

BACKGROUND: Early detection of dementia may improve patient care and quality of life, yet up to half of people with dementia are undiagnosed. Electronic health record (EHR) data could be used to help identify individuals at risk of having undiagnosed dementia for outreach and assessment, but acceptability to people with dementia and caregivers is unknown. METHODS: We conducted five focus groups at Kaiser Permanente Washington (KPWA), an integrated healthcare system in Washington State, to explore people's feelings about timing of dementia diagnosis, use of EHR-based tools to predict risk of undiagnosed dementia, and communication about risk. We recruited people enrolled in KPWA who had dementia or mild cognitive impairment, people enrolled in KPWA who had neither diagnosis, and caregivers (i.e., loved ones of people with dementia who assist with various tasks of daily life). People who were non-white or Hispanic were oversampled. Two team members analyzed transcripts using thematic coding. RESULTS: Forty people (63% women; 59% non-white or Hispanic) participated in the focus groups. Themes that arose included: perceived pros and cons of early dementia diagnosis; questions and concerns about a potential tool to assess risk of undiagnosed dementia; and preferences related to patient-provider conversations disclosing that a person was at high risk to have undiagnosed dementia. Participants supported early diagnosis, describing benefits such as time to adjust to the disease, plan, involve caregivers, and identify resources. They also acknowledged the possible psychosocial toll of receiving the diagnosis. Participants supported use of an EHR-based tool, but some people worried about accuracy and privacy. Participants emphasized that information about risk of undiagnosed dementia should be communicated thoughtfully by a trusted provider and that the conversation should include advice about prognosis, treatment options and other resources when a new dementia diagnosis was made. CONCLUSION: People with dementia or mild cognitive impairment, people with neither diagnosis, and caregivers of people with dementia supported using EHR-based tools to help identify individuals at risk of having undiagnosed dementia. Such tools must be implemented carefully to address concerns and ensure that people living with dementia and their caregivers are adequately supported.

Military Sexual Trauma in Older Women Veterans: Prevalence and Comorbidities.

BACKGROUND: Recent attention has highlighted the common occurrence and health consequences of military sexual trauma (MST) in younger women veterans. However, almost nothing is known about MST in older veterans. OBJECTIVE: To describe MST among older women veterans, including prevalence and common comorbidities. DESIGN: Cross-sectional observational study, using data from national Department of Veterans Affairs medical records. PARTICIPANTS: Population-based sample of women Veterans aged 55+ with at least one documented MST screen response and at least one clinical encounter in fiscal years 2005-2015. MAIN MEASURES: MST screen: medical diagnoses (diabetes, hypertension, hyperlipidemia, myocardial infarction, cerebrovascular disease, congestive heart failure, obesity, chronic pain conditions, back pain, dementia, insomnia, sleep apnea, menopause symptoms) and mental health diagnoses (anxiety, depression, posttraumatic stress disorder, tobacco use, alcohol use disorder, substance use disorder, opioid use disorder, suicidal ideation) from International Classification of Diseases, Ninth Revision Clinical Modification codes in the medical record. KEY RESULTS: In this cohort of older women veterans (n = 70,864, mean age 65.8 ± 10.4 years), 13% had a positive MST screen. In multivariable regression analyses adjusted for age, race/ethnicity, and marital status, MST was strongly associated with most mental health diagnoses, particularly posttraumatic stress disorder (OR 7.25, 95% CI 6.84-7.68), depression (OR 2.39, 95% CI 2.28-2.50), and suicidal ideation (OR 2.42, 95% CI 2.08-2.82). MST was also associated with multiple medical conditions, particularly sleep disorders (insomnia OR 1.61, 95% CI 1.43-1.82; sleep apnea OR 1.48, 95% CI 1.37-1.61) and pain (chronic pain OR 1.58, 95% CI 1.50-1.67; back pain OR 1.40, 95% CI 1.34-1.47). CONCLUSIONS: A history of MST is common among older women veterans and associated with a range of medical and mental health diagnoses. These findings call attention to the need for additional research in this understudied population, and the importance of trauma-informed care approaches for women across the lifespan.

A national study of TBI and risk of suicide and unintended death by overdose and firearms.

Objective: Evidence guiding suicide-prevention efforts in patients with traumatic brain injury (TBI) is imperative. We evaluated association between TBI and risk of death by drug overdose and firearms, including suicide and unintentional injury.Methods: Cohort study of all patients 18 years and older in Veterans Health Administration databases from October 1, 2001 to December 31, 2014 with TBI diagnosis (N = 230,200), and age-matched 1:1 to random sample of patients without TBI (N = 230,200).Results: After adjusting for demographics, comorbidities, and accounting for competing risk of other deaths, hazard ratios for death by drug overdose were 1.40 (95% CI = 1.21-1.62) for mild TBI and 1.51 (95% CI = 1.31-1.74) for moderate-to-severe TBI, while hazard ratios for death by firearms were 1.09 (95% CI = 0.89-1.33) for mild TBI and 1.33 (95% CI = 1.10-1.60) for moderate-to-severe TBI. Risk of overdose death due to TBI severity was mainly observed for middle and older age groups.Conclusions: Findings suggest that veterans with mild and moderate-to-severe TBI are at increased risk of death by drug overdose and firearms, with overdose risk heightened with age. Data indicate that prevention efforts in patients with TBI include targeted means reduction.

An integrative group movement program for people with dementia and care partners together (Paired PLIÉ): initial process evaluation.

Objectives: To understand feedback from participants in Paired PLIÉ (Preventing Loss of Independence through Exercise), a novel, integrative group movement program for people with dementia and their care partners, in order to refine the intervention and study procedures.Method: Data sources included daily logs from the first Paired PLIÉ RCT group, final reflections from the second Paired PLIÉ RCT group, and responses to requests for feedback and letters of support from Paired PLIÉ community class participants. All data are reports from care partners. The qualitative coding process was iterative and conducted with a multidisciplinary team. The coding team began with a previously established framework that was modified and expanded to reflect emerging themes. Regular team meetings were held to confirm validity and to reach consensus around the coding system as it was developed and applied. Reliability was checked by having a second team member apply the coding system to a subset of the data.Results: Key themes that emerged included care partner-reported improvements in physical functioning, cognitive functioning, social/emotional functioning, and relationship quality that were attributed to participation in Paired PLIÉ. Opportunities to improve the intervention and reduce study burden were identified. Care partners who transitioned to the community class after participating in the Paired PLIÉ study reported ongoing benefits.Conclusion: These qualitative results show that people with dementia and their care partners can participate in and benefit from community-based programs like Paired PLIÉ that include both partners, and focus on building skills to maintain function and quality of life.

Ten-Year Prevalence of Cognitive Impairment Diagnoses and Associated Medical and Psychiatric Conditions in a National Cohort of Older Female Veterans.

OBJECTIVE: Veterans are at risk for dementia because of elevated general risk factors and exposure to military risk factors; however, few studies have focused on female veterans despite their growing numbers. We sought to characterize the 10-year prevalence of cognitive impairment (i.e., mild cognitive impairment and dementia) and associated conditions in older female veterans. METHODS: Data were extracted from Veterans Health Administration medical records of 168,111 female veterans aged 65 and older. Cognitive impairment (CI) diagnoses were defined using International Classification of Diseases, Ninth Revision (ICD-9) codes or dementia medication prescriptions. Medical comorbidities and psychiatric conditions were determined using ICD-9 codes occurring within 2years of CI diagnosis or the last recorded medical encounter for veterans without CI. RESULTS: Ten-year prevalence was 1.8% (3,075) for mild cognitive impairment (MCI) diagnoses and 8.1% (13,653) for dementia diagnoses. Prevalence increased with age (MCI age 65: 1.4%; age 85+: 2.7%; dementia age 65: 2.5%; age 85+: 17.7%); 37.3% had dementia subtype diagnoses, with Alzheimer's disease being the most prevalent (72.7%). 47.7% of veterans with CI had at least one medical comorbidity, whereas 22.5% had at least one psychiatric condition. CONCLUSION: Few studies have characterized the prevalence of cognitive impairment in female veterans despite the expected increases in CI and impending demographic shifts in the military. The high prevalence of medical and psychiatric conditions in female veterans with CI highlights their healthcare burden and emphasizes the need for further investigations into the prevention, treatment, and care of cognitive impairment in this understudied population.

Recovery-Oriented Outcomes Associated with Long-Acting Injectable Antipsychotics in an Urban Safety-Net Population.

This study examined whether transitioning patients from oral antipsychotics (POs) to long-acting injectable antipsychotics (LAIs) helps patients achieve recovery-oriented goals. Data was extracted from San Francisco County's electronic medical record system for this retrospective pre-post observational study. Patients reflect a safety-net population treated in community-based mental health settings during 2015. The San Francisco Adult Strengths and Needs Assessment (SF ANSA), a measure of psychosocial functioning, was used to assess within-subject change when treated with POs versus LAIs. In our study sample (N = 77), LAI SF ANSA scores showed significant improvements in criminal behaviors (p = .017), medication adherence (p = .008), and spirituality (p = .028), and a non-significant trend for residential stability (p = .073). This is the first study to evaluate improvements in key psychosocial areas after treatment with LAIs. This work suggests that LAIs can be another tool for providers to help patients work towards their recovery-oriented goals.

Do postconcussive symptoms from traumatic brain injury in combat veterans predict risk for receiving opioid therapy for chronic pain?

OBJECTIVES: Opioid therapy is contraindicated in patients with traumatic brain injury (TBI) with neuropsychological impairment, yet guidelines do not consistently predict practice. We evaluated independent risk for initiation of opioid therapy among combat veterans with chronic pain diagnoses and persistent postconcussive symptoms. METHODS: We assembled a retrospective cohort of 53 124 Iraq and Afghanistan veterans in Veterans Affairs (VA) healthcare between October 2007 and March 2015 who received chronic pain diagnoses, completed a Comprehensive TBI Evaluation (CTBIE) and had not received opioid therapy in the prior year. Primary exposure variables were self-reported severe or very severe Emotional, Vestibular, Cognitive and Somatic/Sensory symptoms measured using the Neurobehavioral Symptom Inventory. Outcome measures were initiation of short-term and long-term opioid therapy within the year following CTBIE. RESULTS: Self-reported severe and very severe postconcussive symptoms predicted initiation of long-term and short-term opioid use for chronic pain in both unadjusted and adjusted analyses. In adjusted analyses, all four postconcussive symptom domains significantly predicted initiation of long-term opioid therapy, with Emotional symptoms being the strongest predictor [ARR = 1.68 (1.52, 1.86)]. CONCLUSIONS: Increased opioid prescribing in veterans with self-reported severe persistent postconcussive symptoms indicates a need to educate prescribers and make non-opioid pain management options available for veterans with TBI and neuropsychological sequelae.

A 12-week integrative exercise program improves self-reported mindfulness and interoceptive awareness in war veterans with posttraumatic stress symptoms.

OBJECTIVE: Innovative approaches to the treatment of war-related posttraumatic stress disorder (PTSD) are needed. We report on secondary psychological outcomes of a randomized controlled trial of integrative exercise (IE) using aerobic and resistance exercise with mindfulness-based principles and yoga. We expected-in parallel to observed improvements in PTSD intensity and quality of life-improvements in mindfulness, interoceptive bodily awareness, and positive states of mind. METHOD: A total of 47 war veterans with PTSD were randomized to 12-week IE versus waitlist. Changes in mindfulness, interoceptive awareness, and states of mind were assessed by self-report standard measures. RESULTS: Large effect sizes for the intervention were observed on Five-Facet Mindfulness Questionnaire Non-Reactivity (d = .85), Multidimensional Assessment of Interoceptive Awareness Body Listening (d = .80), and Self-Regulation (d = 1.05). CONCLUSION: In a randomized controlled trial of a 12-week IE program for war veterans with PTSD, we saw significant improvements in mindfulness, interoceptive bodily awareness, and positive states of mind compared to a waitlist.

Incidence and impact of subclinical epileptiform activity in Alzheimer's disease.

OBJECTIVE: Seizures are more frequent in patients with Alzheimer's disease (AD) and can hasten cognitive decline. However, the incidence of subclinical epileptiform activity in AD and its consequences are unknown. Motivated by results from animal studies, we hypothesized higher than expected rates of subclinical epileptiform activity in AD with deleterious effects on cognition. METHODS: We prospectively enrolled 33 patients (mean age, 62 years) who met criteria for AD, but had no history of seizures, and 19 age-matched, cognitively normal controls. Subclinical epileptiform activity was assessed, blinded to diagnosis, by overnight long-term video-electroencephalography (EEG) and a 1-hour resting magnetoencephalography exam with simultaneous EEG. Patients also had comprehensive clinical and cognitive evaluations, assessed longitudinally over an average period of 3.3 years. RESULTS: Subclinical epileptiform activity was detected in 42.4% of AD patients and 10.5% of controls (p = 0.02). At the time of monitoring, AD patients with epileptiform activity did not differ clinically from those without such activity. However, patients with subclinical epileptiform activity showed faster declines in global cognition, determined by the Mini-Mental State Examination (3.9 points/year in patients with epileptiform activity vs 1.6 points/year in patients without; p = 0.006), and in executive function (p = 0.01). INTERPRETATION: Extended monitoring detects subclinical epileptiform activity in a substantial proportion of patients with AD. Patients with this indicator of network hyperexcitability are at risk for accelerated cognitive decline and might benefit from antiepileptic therapies. These data call for more sensitive and comprehensive neurophysiological assessments in AD patient evaluations and impending clinical trials. Ann Neurol 2016;80:858-870.

Association of Traumatic Brain Injury With Chronic Pain in Iraq and Afghanistan Veterans: Effect of Comorbid Mental Health Conditions.

OBJECTIVE: To characterize the association between traumatic brain injury (TBI) and chronic pain and pain disability in the context of comorbid conditions, posttraumatic stress disorder (PTSD), and depression to better inform care of combat veterans. DESIGN: Retrospective cohort study. SETTING: Medical centers and community clinics. PARTICIPANTS: Combat veterans (N=116,913) who received Veterans Affairs care between October 1, 2007 and March 31, 2015, completed a Comprehensive Traumatic Brain Injury Evaluation, and received a criterion standard diagnosis of TBI (none, mild, or moderate to severe). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Chronic pain defined as ≥2 of the same pain diagnoses ≥90 days apart and pain disability defined as self-reported pain causing moderate to very severe interference with daily functioning. RESULTS: Fifty-seven percent received ≥1 chronic pain diagnosis. Compared to those with no TBI, PTSD, or depression, there was an independent risk for chronic pain in veterans with mild TBI, which was higher in veterans with moderate to severe TBI. The risk of chronic pain was additive and highest when all 3 conditions-TBI, depression, and PTSD-were copresent (adjusted relative risk, 1.53 and 1.62 [95% confidence interval, 1.50-1.66] for mild and moderate or severe TBI, respectively, plus other diagnoses). The relation of pain disability to TBI, PTSD, and depression followed a similar additive pattern. CONCLUSIONS: In combat veterans, chronic pain and pain disability are most commonly associated with TBI in conjunction with PTSD, depression, or both. Integrated models of care that simultaneously address pain in conjunction with TBI, PTSD, and depression will likely be the most clinically effective.