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Health Services Research & Development

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Brain Health Research

June 2017

The brain is a complex and important organ: It's responsible for the human body's "daily operations", and keeping it healthy and safe is vital. Some decline in brain function is considered a normal part of aging—according to the National Institutes of Health's Institutes on Neurological Disorders and Stroke, between the age of 60 and 70, cognitive processing speed (how fast we think) may take longer, as some parts of the brain may be shrinking.[1] Outside of the normal aging process, disease or physical injury can have a major impact on brain health and function, often seriously affecting an individual's daily life. Conditions such as Alzheimer's or Parkinson's disease can interfere with basic memory and motor control. A blow to the head or exposure to concussive force (such as an explosion) can result in traumatic brain injury (TBI), which can have a wide range of physical or emotional symptoms.

For Veterans receiving care in VA who are affected by compromised brain function, research focusing on a range of interventions—from prevention to caretaker support—is critical. Researchers within VA's Health Services Research and Development Service conduct a variety of studies that look at brain health, and the following are just a few of those ongoing and recently completed investigations.

Implementing a Home Safety Toolkit for Veterans with Dementia

A person with Alzheimer's disease-related dementia (ADRD) will live an average of four to eight years (and as long as 20 years) after the onset of symptoms. During that time, family and friends provide the overwhelming majority of an individual's care. However, caretakers of Veterans with ADRD often experience increased strain and stress in their own lives as a result.

Research has shown that a Home Safety Toolkit (HST) can improve safety for Veterans with dementia while decreasing caregiver strain. A previous HSR&D-funded study demonstrated that the HST for ADRD showed benefits in reducing both family caregiver strain and Veteran risky behaviors and accidents, as well as increasing family caregiver home safety modifications and self-efficacy.

In this currently ongoing, three-year multi-site study, researchers from the New England and Durham VA Geriatric Research and Education Clinical Centers and the Asheville, NC, VA Medical Center are looking at the processes necessary to make the HST for Veterans with ADRD and related disorders accessible to patients and their caregivers; and are gathering additional information about the effectiveness of the HST when implemented in VA primary care clinics. In the first phase of the study, investigators conducted qualitative interviews with key stakeholders across six VA medical centers, with the results informing a strategy for subsequent adoption of the toolkit with accompanying workbook and caregiver education.

Preliminary study data pointed toward key factors necessary for full implementation of the HST across VA; however, organizational elements unique to VA do not currently supportive of full adoption. Investigators have responded by adapting the self-paced workbook as a stand-alone educational product. The workbook is intended to be a resource for family caregivers to refer to, as dementia progression requires home modifications to create an optimally safe environment for Veterans with ADRD.

The dementia home safety workbook is available for download for both VA providers and the general public. In addition, for VA providers caring for Veterans with dementia, a companion PowerPoint presentation explaining the target population and goals of the workbook are also available from the VA intranet at (copy and paste into your browser).

Implications: Producing a widely available, home safety workbook and offering it at no cost to Veteran caregivers may help improve the home environment of Veterans with ADRD. Further, as study results are refined, and organizational factors with VA change, a full implementation of the HST may also contribute toward improved care for those Veterans by supporting their home-based caregivers and clinical providers.

Principal Investigator: Lauren R. Moo, MD, is a Core Investigator with the HSR&D Center for Healthcare Organization and Implementation Research, in Bedford, MA.

Telephone Assessment and Skill-Building Intervention for Informal Caregivers

Stroke and traumatic brain injury (TBI) are leading causes of long-term disability among Veterans, and both conditions may result in the need for assistance from informal caregivers in a home-based setting. There are very few evidence-based, easy-to-deliver, follow-up programs to train Veterans and their informal caregivers across multiple domains post-injury. The "Acquiring New Skills While Enhancing Remaining Strengths for Veterans (ANSWERS-VA)" intervention aims to provide Veterans and their primary caregivers with a practical skill-set each can use in coping with and managing symptoms of a brain injury.

In this ongoing, randomized controlled trial, investigators are evaluating the efficacy of the ANSWERS-VA intervention with Veterans who have sustained a stroke and/or TBI and their informal caregivers.

The ANSWERS-VA intervention group is being compared with an educational intervention that will serve as an attention control group. The study has been ongoing at two VA Medical Centers and includes Veterans with stroke (N = 222) or TBI (N = 108) and their informal caregivers. Both the intervention and control involve 8 telephone sessions delivered over 8 weeks, with a booster session at 12 weeks. Data collection occurs at baseline, 8 weeks (short-term intervention effect), 12 weeks (after booster), 24 weeks, and 1 year after baseline (long-term sustainability of intervention effect). To date, investigators have enrolled 88 teams (dyads) of Veterans and caregivers at the two study sites.

Implications: With the combination of an aging Veteran population at risk for stroke, and a considerable number of OEF/OIF/OND Veterans impacted by TBI, implementing efficacious and cost-effective interventions for informal caregivers of Veterans with these conditions is critical. Building informal caregiver skills through dyadic interventions such as ANSWERS-VA should improve both Veterans caregivers' support and Veterans' health outcomes. Investigators also expect that study results will positively impact readmission costs, skilled nursing care, and premature long-term institutionalization.

Principal Investigator: Ginger S. Daggett, PhD, MSN, RN is part of HSR&D's Center for Health Information and Communication in Indianapolis, IN.

Dual Use of VA and Medicare Drug Benefits and Unsafe Prescribing in Veterans with Dementia

VA estimates that more than 570,000 Veterans have dementia, and of those, approximately 40 percent seek care in VA medical facilities. Care coordination for persons with dementia is challenging for healthcare systems under the best of circumstances. The average dementia patient has four comorbid illnesses, receives care from five different providers, and uses an average of six different prescription medications. These coordination challenges are exacerbated in Medicare-eligible Veterans who receive care through both Medicare and VA. While dual eligibility for healthcare coverage may offer Veterans greater flexibility for accessing medical care, seeking prescriptions across uncoordinated systems may increase the risk of unsafe medication prescribing —particularly in Veterans who may have difficulty relaying complex information across VA and non-VA providers.

In this ongoing study, investigators are using both quantitative and qualitative data to look at several aspects of dual use among Veterans diagnosed with dementia, including: describing patterns of outpatient medication use for those with VA-coverage only, those with Medicare Part D-only, and those who use both; identifying risk factors for dual use and evaluating the effect of dual use on potentially harmful medications in the elderly; and exploring Veteran, caregiver, and VA provider perspectives on reasons for and risks associated with dual use.

Investigators looked at a national cohort of VA outpatient users with dementia (N=80,017)2. Using a retrospective cohort design with linked VA and Medicare utilization and prescription data for a three-year period (2007-2010), results showed:

  • 78% of VA outpatient users obtained all their medications from VA only,
  • 20% obtained medications from both VA and Medicare Part D (dual-users), and
  • 2% obtained all medications from Medicare Part D only.

Investigators also found that being a non-Hispanic Black, having more generous VA drug benefits (lower VA priority score), receipt of home-based primary care, and original Medicare entitlement due to disability were all associated with lower odds of being a dual-user. Preliminary results also suggest dual-users may be at greater risk of exposure to a range of potentially unsafe medications.

Implications: Results to date provide valuable insight into which Veterans are most likely to engage in dual use of VA and Medicare prescription drug benefits. Investigators expect final study results to improve the knowledge base around outcomes associated with receiving prescriptions through VA and Medicare in Veterans with dementia. This additional data should support both VA prescribing policy and pharmacy care coordination practices for this Veteran population.

Principal Investigator: Joshua Thorpe, PhD, MPH, is an investigator with HSR&D's Center for Health Equity Research and Promotion (CHERP) Pittsburgh, and Associate Director of Analytics and Research in VA's Center for Comprehensive End-of-Life Care.

Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) Initiative: Long-Term Care. Approximately 800,000 Veterans enrolled in VA healthcare depend on assistance with at least one activity of daily living (ADL). Further, estimates indicate that by 2020, some 700,000 Veterans enrolled in VA healthcare will be over the age of 85—and most will require some kind of assistance with at least one ADL. These Veterans (and many others, particularly those wounded in combat) will need comprehensive long-term care (LTC). The studies included in the LTC CREATE Initiative aim to provide tools, evidence, and evaluation information necessary for VA's Geriatric and Extended Care (GEC) policymakers and staff to transform the spectrum of LTC services. The studies include:

[1] The Changing Brain. HHS Administration for Community Living Brain Health website. Updated 2015.

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