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SDR 06-162 – HSR&D Study

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SDR 06-162
Cognitive Assessment of Veterans After Traumatic Brain Injury
Kerry T Donnelly PhD
VA Western New York Healthcare System, Buffalo, NY
Buffalo, NY
Funding Period: May 2008 - April 2012

BACKGROUND/RATIONALE:
Consequences of brain injuries from blast exposure and other war related injuries are poorly understood. The interplay of TBI and cognitive and affective symptoms in OIF/OEF veterans over time has not been adequately explored. Mild TBI and neuropsychological symptoms may not become evident until after military personnel return home. Evidence-based guidelines for diagnosis and treatment are limited. The current project, conducted in cooperation with the PT/BRI-QUERI and the Polytrauma Research Consortium, began as a clinical initiative in VISN 2. Our goal was to provide evidence-based understanding of cognitive and affective correlates of TBI in OEF/OIF veterans, symptom relationship to health care utilization and quality of life factors, and the evolution of the phenomena over time.

OBJECTIVE(S):
(1) Provide a psychometric study of the VA TBI Screening Tool.
(2) Describe war related cognitive and affective symptoms and patterns of substance abuse in OEF/OIF veterans.
(3) Construct cognitive and affective profiles of OEF/OIF veterans over time.
(4) Describe the temporal relationship between the composite stress index and the cognitive profiles of OEF/OIF veterans.
(5) Describe the temporal relationships among TBI, cognitive symptoms (attention, memory and executive functioning), patient outcomes (quality of life and community participation), and health services outcomes (VA health care utilization), controlling for patient and deployment characteristics.

METHODS:
This four-year prospective cohort study examined 500 OEF/OIF Veterans from six VISN2 sites. Participants completed comprehensive neuropsychological assessments on four occasions: baseline and at 6, 12, and 18 month intervals. Analyses included descriptive and multivariate methods, as well as sensitivity/specificity analyses of the VA TBI clinical reminder. The temporal relationships of TBI status, cognitive symptoms and patient outcomes, controlling for patient and deployment characteristics, were examined in a series of multiple regression analyses.

FINDINGS/RESULTS:
Objective 1- We found that the VA TBI clinical reminder had high internal consistency, high test-reliability, high sensitivity and moderate specificity. When Veterans with probable PTSD were excluded from analysis, the lower bound estimate of the diagnostic odds ratio for the TBI screening tool was extremely high (24). In the "real world" context, including all Veterans in our sample, the DOR remained impressive, with a lower bound DOR estimate of 12.6, suggesting that Veterans who screened positive for TBI based on this tool were over 12 times more likely to have actually sustained such an injury than were Veterans who screened negative. The presence of significant PTSD symptoms reduced the specificity of the measure and highlighted the need for careful clinical follow-up of positive screens. Nonetheless, we concluded that the VA TBI clinical reminder is a valid and reliable screening tool for Veterans and can inform primary care providers of when to refer for further workup for cases of suspected TBI.

Objective 2- While Veterans with TBI performed worse than those without TBI on several measures of attention, executive functions, and memory, all scores remained grossly within normal limits. Given the substantial mean time since TBI for our participants (approximately 3 1/2 years), it was not surprising that most, if not all, cognitive deficits directly associated with mTBI would be resolved.
In contrast to relatively few cognitive problems, the cohort as a whole reported significant symptoms of PTSD, depression, generalized anxiety and neurobehavioral symptoms. On each of these measures, Veterans with TBI reported symptom rates significantly higher than Veterans without TBI. Mean scores on the AUDIT-C did not distinguish Veterans with and without TBI. Both groups reported alcohol use above the cutoff for misuse. The groups also did not differ with regard to illicit drug use, with all Veterans reporting low levels regardless of TBI status.

Results for Objectives 3-5 are preliminary. Analyses are on-going. Healthcare utilization data are in preparation.

Objective 3- Preliminary analysis of cognitive scores at enrollment revealed that Trail Making Test- A (TMT-A: attention), TMT-B (executive functions), and California Verbal Learning Test-2 (CVLT) long-delayed free recall (memory) had the greatest effect sizes per domain in distinguishing TBI positive and negative subgroups (.26, .26, and .46, respectively). Examination of mean scores for the two groups over time showed progressive improvement for each test. Not surprisingly, the TBI negative group consistently scored better than those with TBI, but all scores for both groups remained within normal limits.
Review of affective symptom reports over time showed that Veterans without TBI endorsed mild depression and generalized anxiety and moderate PTSD across all time points. TBI positive Veterans reported moderate depression and anxiety at times one through three but declined to mild levels at time four. PTSD symptoms, however, remained severe at each assessment for this group.

Objective 4- Generalized estimating equation (GEE) models, using lagged predictor variables (TBI status, PCL, BDI, and BAI scores, and pain ratings), revealed that higher generalized anxiety and pain ratings were related to lower digit span scores, but not to other measures of attention. The other predictors, including TBI status, were non-contributory for the other attention tests. In the memory domain, positive TBI status and higher PCL scores were related to lower scores on three primary CVLT measures: list learning, short-delayed free recall, and long-delayed free recall. Poorer lagged performance on three executive functions measures, TMT-B, DKEFS Color-Word and Verbal Fluency Tests, was associated with higher PCL scores. TBI positive status was related to lower (but normal) memory performance over time and was unrelated to attention and executive function scores.

Objective 5- Life satisfaction (SWLS) was significantly associated with executive functioning (TMT-B) at each time point, after removing variance associated with the Combat Experiences Scale and positive TBI status. The Physical Functioning scale of the SF-36 also showed significant associations with executive functioning, once again controlling for combat experiences and TBI. An even greater association of executive functioning was observed in relation to the SF Mental Health score at each time point, controlling for variance associated with combat experience and TBI. An interesting pattern of effect size and statistical significance was observed in the relationship of TBI to outcomes scores. For example, at time 1, TBI accounted for 13% of mental health variance after removing 12% associated with combat experience. However, the TBI association with mental health was not significant at times 2, 3 and 4. Similarly, TBI accounted for significant proportions of life satisfaction variance at times 1 and 2 (8% and 7%, respectively), but not at times 3 and 4. Plausible explanations of this pattern include an actual decrease in TBI impact on mental health and life satisfaction as well as participant dropout (to be examined in subsequent analyses).

Project Modification: Diffusion Tensor Imaging Substudy- We studied a nested cohort of 52 participants with MRI and DTI to understand the relationship of mild TBI and blast exposure to brain white matter structure, and how these interact to impact the development of PTSD. Multivariate analyses were used to relate these clinical and neuroimaging variables to PTSD and to blast exposure. PTSD severity was related both to the severity of combat stress and underlying structural brain changes on MRI and DTI. A clinical diagnosis of mild TBI did not appear to play a role. The observed relationship between blast exposure and abnormal DTI suggested that subclinical TBI may play a role in the genesis of PTSD in a combat environment.

IMPACT:
While TBI was confirmed in almost half our sample, the injuries tended to be mild, temporally remote, and generally unrelated to significant cognitive impairment across four assessment points. By contrast, neurobehavioral complaints (including subjective sense of cognitive impairment) and emotional symptoms were common at all time points, even for Veterans without TBI. Our findings underscore the need to educate Veterans on the nature, course, and prognosis of mTBI and to explain how common comorbid conditions, such as PTSD, depression, generalized anxiety, substance misuse and pain can account for many symptoms typically considered to be related to mTBI. Just as VA has implemented a successful screening protocol for TBI, which we found to be reliable and valid, routine assessment of the comorbid conditions listed above might help to create a more comprehensive clinical profile of our Veterans, which can in turn lead to more tailored and effective treatment planning and better outcomes.

PUBLICATIONS:

Journal Articles

  1. King PR, Donnelly KT, Wade M, Donnelly JP, Dunnam M, Warner G, Kittleson CJ, Bradshaw CB, Alt M. The relationships among premilitary vocational aptitude assessment, traumatic brain injury, and postdeployment cognitive functioning in combat veterans. Archives of clinical neuropsychology : the official journal of the National Academy of Neuropsychologists. 2014 Jun 1; 29(4):391-402.
  2. Guyker WM, Donnelly K, Donnelly JP, Dunnam M, Warner GC, Kittleson J, Bradshaw CB, Alt M, Meier ST. Dimensionality, reliability, and validity of the combat experiences scale. Military medicine. 2013 Apr 1; 178(4):377-84.
  3. Bazarian JJ, Donnelly K, Peterson DR, Warner GC, Zhu T, Zhong J. The relation between posttraumatic stress disorder and mild traumatic brain injury acquired during Operations Enduring Freedom and Iraqi Freedom. The Journal of head trauma rehabilitation. 2013 Jan 1; 28(1):1-12.
  4. King PR, Donnelly KT, Donnelly JP, Dunnam M, Warner GC, Kittleson CJ, Bradshaw CB, Alt M, Meier S. A Psychometric Study of the Neurobehavioral Symptom Inventory. Journal of rehabilitation R&D / Veterans Administration, Department of Medicine and Surgery, Rehabilitation R&D Service. 2011 Dec 1; 49:879-888.
  5. Donnelly KT, Donnelly JP, Dunnam M, Warner GC, Kittleson CJ, Constance JE, Bradshaw CB, Alt M. Reliability, sensitivity, and specificity of the VA traumatic brain injury screening tool. The Journal of head trauma rehabilitation. 2011 Nov 1; 26(6):439-53.
Journal Other

  1. King PR, Donnelly KT, Donnelly JP, Dunnam M, Warner G, Kittleson CJ, Constance JE, Bradshaw CB, Alt M. Cluster analysis of Neurobehavioral Symptom Inventory Items: Fifteen Years Later. [Abstract]. The Clinical Neuropsychologist. 2011 Jul 15; 25(5):885.
Conference Presentations

  1. Donnelly KT, Donnelly JP, Dunnam M, Warner GC, Kittleson J, Bradshaw C, Alt M. Cognitive, Affective, and Behavioral Differences between OEF/OIF Veterans with and without Traumatic Brain Injury. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; National Harbor, MD.
  2. Warner GC, Miele A, Dunnam M, Donnelly KT, Donnelly JP, Kittleson J, Bradshaw C. Prevalence of Developmental Disorders in Returning Veterans. Poster session presented at: American College of Professional Neuropsychology Annual Conference; 2012 Mar 7; Las Vegas, NV.
  3. Dunnam M, Mattila L, Donnelly KT, Warner GC, Kittleson J, Bradshaw C. Clarifying the Relationship Between Mild Traumatic Brain Injury and Posttraumatic Stress Disorder. Poster session presented at: International Neuropsychological Society Annual Meeting; 2012 Feb 1; Montreal, Canada.
  4. King PR, Donnelly KT, Donnelly JP, Dunnam M, Warner G, Kittleson CJ, Constance JE, Bradshaw CB, Alt M. Cluster Analysis of Neurobehavioral Symptom Inventory Items: Fifteen Years Later. Poster session presented at: American Psychological Association Annual Convention; 2011 Aug 4; Washington, DC.
  5. Babcock-Parziale J, Donnelly KT, High W, Smith B. Advances in the Screening and Diagnosis of Mild Traumatic Brain Injury/Concussion in OEF/OIF Veterans. Paper presented at: Federal Interagency Conference on Traumatic Brain Injury; 2011 Jun 13; Washington, DC.
  6. Donnelly KT, Donnelly JP, Dunnam M, Warner GC, Kittleson J, Constance J, Bradshaw C, Alt M. Symptom Validity Test Performance in American War Veterans with Traumatic Brain Injury and Post-traumatic Stress Disorder. Poster session presented at: European Symposium on Symptom Validity Assessment; 2011 May 20; London, England.
  7. Choi M, Grohman K, Alt M, Piwowarczyk S, Donnelly KT. TBI and Alcohol Effects on Cognitive and Psychosocial Profiles of OEF/OIF Veterans. Poster session presented at: International Neuropsychological Society Annual Meeting; 2011 Feb 1; Boston, MA.
  8. Donnelly KT, Donnelly JP, Dunnam M, Warner G, Kittleson J, Constance J, Bradshaw C, Alt M. Reliability and Validity of the VA TBI Screening Tool. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 1; Washington, DC.
  9. Dunnam M, Donnelly KT, King P, Guyker W, Vanderploeg R. We Use Them, But Should We? Psychometric Properties of the VA TBI Screening Tool, NSI, and Combat Experiences Scale. Paper presented at: International Neuropsychological Society Annual Meeting; 2011 Feb 1; Boston, MA.
  10. Kozlowski KF, Homish GG, Alt M, Piwowarczyk S, Donnelly KT. Physical activity reductions in male veterans with traumatic brain injury. Poster session presented at: American Public Health Association Annual Meeting and Exposition; 2010 Nov 6; Denver, CO.
  11. Grohman K, Alt M, Piwowarczyk S, Donnelly KT. The Neurobehavioral Symptom Inventory: Responses in OEF/OIF Veterans by TBI and PTSD Status. Poster session presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 27; Little Rock, AR.
  12. Holcomb M, Donnelly KT. How Is Sleep Disturbance Related to TBI Status, Cognitive Performance, and Affective Symptoms in OEF/OIF Veterans? Poster session presented at: North American International Neuropsychological Society Annual Meeting; 2010 Feb 1; Acapulco, Mexico.
  13. King P, Donnelly KT. Relationship Between the Number of Combat Experiences & PTSD Symptom Reporting. Poster session presented at: American Psychological Association Annual Convention; 2009 Aug 1; Toronto, Canada.
  14. Donnelly KT, King P, Alt M. PTSD Status Differentiates Neurobehavioral Symptom Inventory (NSI) Responses and Attention Scores in OEF/OIF Veterans Who Screen Positive for TBI. Paper presented at: VA HSR&D National Meeting; 2009 Feb 1; Baltimore, MD.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Acute and Combat-Related Injury, Brain and Spinal Cord Injuries and Disorders
DRE: Diagnosis, Prognosis
Keywords: Assessment, Clinical Diagnosis and Screening, Quality of Care, TBI, Traumatic Brain Injury
MeSH Terms: none

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