Military

Sleep Disturbances Among Soldiers with Combat Related Traumatic Brain Injury

Authors: Collen J, Orr N, Lettieri CJ, Carter K, Holley AB.

BACKGROUND: Sleep complaints are common among patients with traumatic brain injuries. Evaluation of this population is confounded by polypharmacy and comorbid disease, with few studies addressing combat-related injuries. Our aim is to assess the prevalence of sleep disorders among Soldiers sustaining combat-related traumatic brain injury.
METHODS:
Retrospective review of Soldiers returning from combat with mild-moderate traumatic brain injury. All underwent comprehensive sleep evaluations. We determined the prevalence of sleep complaints and disorders in this population. We assessed demographics, mechanism of injury, medication use, comorbid psychiatric disease, and polysomnographic findings to identify variables that correlated with the development of specific sleep disorders.
RESULTS:
116 consecutive patients; 96.6% were men, mean age 31.1±9.8 years, and mean BMI was 27.8±4.1 Kg/m(2). 29.5% sustained blunt and 70.5% sustained blast injuries. Nearly all (97.4%) reported sleep complaints. Hypersomnia and sleep fragmentation were reported in 85.2% and 54.3%, respectively. Obstructive sleep apnea syndrome (OSAS) was diagnosed in 34.5% and 55.2% had insomnia. Patients with blast injuries developed more anxiety (50.6% vs. 20.0% p=0.002), and insomnia (63% vs. 40%, p=0.02), while patients with blunt trauma had significantly more OSAS (54.3% vs. 25.9%, p=0.003). In multivariate analysis blunt trauma was a significant predictor of OSAS (OR 3.09, 95% CI 1.02-9.38, p=0.047).
CONCLUSIONS:
Sleep disruption is common following traumatic brain injuries and the majority developed a chronic sleep disorder. It appears that sleep disturbances may be influenced by mechanism of injury in those with combat-related traumatic brain injury, with blunt injury potentially predicting the development of OSAS.

A case-control study examining whether neurological deficits and PTSD in combat veterans are related to episodes of mild TBI

Authors: Ruff RL, Riechers RG 2nd, Wang XF, Piero T, Ruff SS.

BACKGROUND: Mild traumatic brain injury (mTBI) is a common injury among military personnel serving in Iraq or Afghanistan. The impact of repeated episodes of combat mTBI is unknown.
OBJECTIVE: To evaluate relationships among mTBI, post-traumatic stress disorder (PTSD) and neurological deficits (NDs) in US veterans who served in Iraq or Afghanistan.
METHODS: This was a case-control study. From 2091 veterans screened for traumatic brain injury, the authors studied 126 who sustained mTBI with one or more episodes of loss of consciousness (LOC) in combat. Comparison groups: 21 combat veterans who had definite or possible episodes of mTBI without LOC and 21 veterans who sustained mTBI with LOC as civilians.
RESULTS: Among combat veterans with mTBI, 52% had NDs, 66% had PTSD and 50% had PTSD and an ND. Impaired olfaction was the most common ND, found in 65 veterans. The prevalence of an ND or PTSD correlated with the number of mTBI exposures with LOC. The prevalence of an ND or PTSD was >90% for more than five episodes of LOC. Severity of PTSD and impairment of olfaction increased with number of LOC episodes. The prevalence of an ND for the 34 combat veterans with one episode of LOC (4/34=11.8%) was similar to that of the 21 veterans of similar age and educational background who sustained civilian mTBI with one episode of LOC (2/21=9.5%, p-NS).
CONCLUSIONS: Impaired olfaction was the most frequently recognised ND. Repeated episodes of combat mTBI were associated with increased likelihood of PTSD and an ND. Combat setting may not increase the likelihood of an ND. Two possible connections between mTBI and PTSD are (1) that circumstances leading to combat mTBI likely involve severe psychological trauma and (2) that altered cerebral functioning following mTBI may increase the likelihood that a traumatic event results in PTSD.

The impact of head injury mechanism on mental health symptoms in veterans: Do number and type of exposures matter?

Authors: Maguen S, Madden E, Lau KM, Seal K.

This study examined the association between screening results for mental health problems and the number and type of head injuries in 1,082 Iraq and Afghanistan War veterans who received population-based screening for traumatic brain injury at a Veterans Administration health care facility. Nearly one third of all veterans reported multiple types of head injuries (median = 1 among those with any head injury, range = 1-6 types of head injury). Veterans reporting multiple head injury mechanisms had 6 times the odds of screening positive for posttraumatic stress disorder (PTSD), adjusted odds ratio (OR) = 6.15, 95% confidence interval (CI) , p < .001, over 4 times the odds of screening positive for depression, adjusted OR = 4.09, 95% CI , p < .001, and about twice the odds of screening positive for alcohol misuse, adjusted OR = 1.64, 95% CI , p = .003, compared to those without head injuries. Veterans reporting a blast plus another head injury mechanism had higher odds of screening positive for all mental health outcomes than any other group (e.g., compared to no head injury group): PTSD, adjusted OR = 6.52, 95% CI , p < .001; depression, adjusted OR = 4.42, 95% CI , p < .001; alcohol misuse, adjusted OR =1.59, 95% CI , p = .006. Given their association with a variety of mental health outcomes, number and type of head injury mechanism should be considered as part of any postdeployment evaluation.

Trends in the Incidence of Physician-Diagnosed Mild Traumatic Brain Injury Among Active Duty US Military Personnel between 1997 and 2007

Authors: Cameron KL, Marshall SW, Sturdivant RX, Lincoln AE.

Mild traumatic brain injury (mTBI) has been described as the most common form of traumatic brain injury within military populations; however, few epidemiologic studies have examined incidence rates for mTBI in this population. The objective of this study was to examine trends in the incidence of mTBI among active duty US service members between 1997 and 2007. Specifically, we were interested in evaluating trends in the incidence rates in relation to the initiation of combat operations in Iraq and Afghanistan. A retrospective cohort study was conducted utilizing data extracted from the Defense Medical Surveillance System to identify all incident cases of mTBI within the study population. The primary outcome of interest was the incidence rate of mTBI per 1000 person-years. Multivariable Poisson regression was used to analyze the data. There were 98,012 mTBI cases and 14,956,955 person-years of follow-up, for an overall incidence rate of 6.55 (95%CI: 6.51, 6.59) per 1,000 person-years. There was a steady increase in the mTBI rate over time. The average change in the mTBI rate was 8.5% (95%CI: 8.2%, 8.8%) per year; however, the rate rose dramatically in the last two years of the study period. Overall, for 2006-2007 vs. 1997-2005, the rate ratio was 1.61 (95%CI: 1.58, 1.65). The greatest increase in the rate of mTBI was observed among those serving in Iraq, who experienced a 38.4% (95%CI: 35.4%, 41.1%) annual increase in new cases. The observed increase in the incidence of mTBI in this population has significant policy implications in terms of allocating appropriate healthcare resources.

Influence of poor effort on neuropsychological test performance in U.S. military personnel following mild traumatic brain injury

Authors: Lange RT, Pancholi S, Bhagwat A, Anderson-Barnes V, French LM.

The purpose of this study was to examine the influence of poor effort on neuropsychological test performance in military personnel following mild traumatic brain injury (MTBI). Participants were 143 U.S. service members who sustained a TBI, divided into three groups based on injury severity and performance on the Word Memory Test and four embedded markers of poor effort: MTBI-pass (n = 87), MTBI-fail (n = 21), and STBI-pass (n = 35; where STBI denotes severe TBI). Patients were evaluated at the Walter Reed Army Medical Center on average 3.9 months (SD = 3.4) post injury. The majority of the sample was Caucasian (84.6%), was male (93.0%), and had 12+ years of education (96.5%). Measures included the Personality Assessment Inventory (PAI) and 13 common neurocognitive measures. Patients in the MTBI-fail group performed worse on the majority of neurocognitive measures, followed by the Severe TBI-Pass group and the MTBI-pass group. Using a criterion of three or more low scores <10th percentile, the MTBI-fail group had the greatest rate of impairment (76.2%), followed by the Severe TBI-Pass group (34.3%) and MTBI-pass group (16.1%). On the PAI, the MTBI-fail group had higher scores on the majority of clinical scales (p < .05). There were a greater number of elevated scales (e.g., 5 or more elevated mild or higher) in the MTBI-fail group (71.4%) than in the MTBI-pass group (32.2%) and Severe TBI-Pass group (17.1%). Effort testing is an important component of postacute neuropsychological evaluations following combat-related MTBI. Those who fail effort testing are likely to be misdiagnosed as having severe cognitive impairment, and their symptom reporting is likely to be inaccurate.

Caregiver Reports of Subsequent Injuries Among Veterans With Traumatic Brain Injury After Discharge From Inpatient Polytrauma Rehabilitation Programs

Authors: Carlson KF, Meis LA, Jensen AC, Simon AB, Gravely AA, Taylor BC, Bangerter A, Schaaf KW, Griffin JM.

OBJECTIVE: We examined prevalence of, and potential risk factors for, nonfatal injuries among Veterans with traumatic brain injury (TBI) postdischarge from Veterans Affairs inpatient polytrauma rehabilitation programs.
METHODS: We surveyed caregivers of patients who had military service anytime from 2001 to 2009, sustained polytrauma including TBI, received Veterans Affairs inpatient care from 2001 to 2009, were discharged at least 3 months before the study, and were alive when the study was fielded about caregiver and patient health, including patients' medically treated "accidents/new injuries" since discharge. We examined prevalence and source(s) of subsequent injuries and estimated patients' injury risk in reference to hypothesized risk factors. Odds ratios and 95% confidence intervals were calculated using multivariate logistic regression.
RESULTS: Caregivers reported that nearly one-third (32%) of patients incurred medically treated injuries after discharge; most were associated with falls (49%) and motor vehicles (37%). Odds of subsequent injury were associated with select demographics, initial injury characteristics, and postdischarge health and functioning. Characteristics of caregivers, including physical and mental health, were also associated with patients' odds of subsequent injury.
CONCLUSIONS: A significant number of caregivers reported subsequent nonfatal injuries among patients treated for TBI/polytrauma in inpatient rehabilitation settings. Enhanced injury prevention efforts may be beneficial for this population.

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