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SDR 08-408 – HSR&D Study

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SDR 08-408
Neuropsychological Screening of OEF/OIF Veterans in VA Primary Care
Karen H Seal MD MPH
San Francisco VA Medical Center, San Francisco, CA
San Francisco, CA
Funding Period: October 2010 - March 2015

BACKGROUND/RATIONALE:
Mild TBI (mTBI) and mental health (MH) disorders have both been associated with cognitive symptoms that may lead to poor functioning and reintegration in OEF/OIF/OND veterans. Whereas the military is implementing neurocognitive screening of soldiers using the brief computer-administered Automated Neuropsychological Assessment Metrics (ANAMTM), the VA has no systematic mechanism to detect post-deployment cognitive impairment in returned veterans. The 4-item VA first-level TBI screen has never been validated and most veterans are not asked about cognitive problems because the screen terminates and is "negative" if antecedent items are not endorsed. Thus, many OEF/OIF/OND veterans with cognitive problems go undetected, mitigating opportunities for risk communication, triage, and early intervention.

OBJECTIVE(S):
Our long-term goal was to promote early, accurate detection and triage for physical, MH, and cognitive symptoms in OEF/OIF/OND veterans. Our short-term goal was to investigate the extent to which the VA TBI screening process may fail to detect or accurately identify the source of cognitive symptoms and impairment. This study also examined whether perceived cognitive dysfunction in veterans with PTSD and TBI was associated with objective neuropsychological performance.

METHODS:
We conducted a cross-sectional study of 179 OEF/OIF/OND veterans in VA healthcare with and without positive TBI screens and with and without PTSD. Of the 179, 5 were excluded, 16 dropped out, and 2 had unusable data. We completed our final analysis of 156 subjects. Subjects completed the computerized ANAM test, the VA level 1 TBI screen, the Clinician-Administered PTSD Scale (CAPS), the Neurobehavioral Symptom Inventory for self-reported cognitive functioning, standardized post-deployment mental health assessments, and objective clinician-administered tests of verbal, visual, and working memory, processing speed, and executive functioning.
We hypothesized that both a positive TBI screen and PTSD diagnosis would be associated with poorer objective neuropsychological test performance, as measured by both the computer-administered ANAM battery and traditional clinician-administered neuropsychological tests. We also hypothesized that ANAM results have sufficient correlation with traditional neuropsychological test results to consider using ANAM as a triage tool for objective cognitive impairment in primary care patients with concerning cognitive symptoms. Finally, we hypothesized that perceived cognitive dysfunction in veterans with PTSD and TBI would be associated with poorer neuropsychological functioning as well as difficulties with reintegration and quality of life. This study also included qualitative hypotheses around the feasibility of administering the ANAM and NSI in primary care; those analyses are ongoing and results will not be presented here. Also, through secondary data analyses of a sample of 66,089 veterans, we examined relationships between the TBI screen, PTSD status, and self-reported memory problems.

FINDINGS/RESULTS:
Both PTSD and TBI were associated with perceived cognitive dysfunction on the NSI, with stronger effects for PTSD than TBI. In contrast, neither perceived cognitive deficits nor PTSD or TBI screen status were associated with neuropsychological test performance on both clinician-administered tests and ANAM. Veterans who perceived themselves as having cognitive difficulties reported significantly poorer performance at work, school, and with reintegration and daily functioning (p's < 0.001).
Through secondary data analyses of VA first and second-level TBI screen data, we found that (1) Cognitive symptoms are among the most frequently reported postconcussive symptoms in veterans with positive TBI screens; (2) Veterans who endorse current "memory problems" on a TBI screen are more likely to have diagnoses of PTSD or depression with or without mTBI than mTBI alone; and (3) A minority of veterans that screens positive for mTBI, attends second-level neurological evaluation and lack of follow-up is independently associated with individual and system-level factors.

IMPACT:
This study examined neuropsychological functioning in veterans with and without positive VA TBI screens and PTSD, as well as examined the feasibility of utilizing the ANAM, a shorter, computerized neuropsychological test and compared results of ANAM with more time-intensive clinician-administered neuropsychological tests. Results indicate that a positive VA TBI screen and/or PTSD diagnosis are not associated with objective neurocognitive deficits in Iraq and Afghanistan veterans. However, veterans with PTSD and TBI endorsed high rates of concerns of perceived cognitive dysfunction, which was in turn related to poorer psychosocial functioning and reintegration. These results suggest that in Iraq and Afghanistan veterans with PTSD- or mild TBI-related perceived cognitive dysfunction, cognitive behavioral therapy focused on changing negative self-perceptions may be more beneficial than cognitive rehabilitation in improving daily functioning and reintegration in civilian life. This study will advance the field by highlighting the importance of accurate evaluation, assessment and triage of veterans in an integrated, primary care-based clinic to the appropriate intervention for cognitive complaints related to TBI, mental health, and reintegration.

PUBLICATIONS:
None at this time.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Diagnosis
Keywords: Clinical Diagnosis and Screening
MeSH Terms: none

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