By Stephen Spotswood
WASHINGTON–The news that patients with TBI could have a higher risk of dementia later in life has reverberated far outside the veteran patient community where the research was conducted. With TBI accounting for 22% of casualties in Iraq and Afghanistan and 59% of troops exposed to blasts, veterans and service organizations are concerned that the coming decades could see a virtual epidemic of dementia in these servicemembers.
Lt. Col. (Dr.) Margaret Swanberg tests a solder for signs of concussion in 2008. She was the only Army neurologist deployed to Iraq at the time. Photo courtesy of the Army.
VA clinical leaders stress caution going forward, however, noting that the highly-publicized research is from one unpublished study. The full link between TBI and dementia remains unknown, they maintain.
Last summer, researchers at the San Francisco VA Medical Center (SFVAMC) presented findings at the 2011 Alzheimer’s Association International Conference in France showing that patients diagnosed with TBI had more than twice the risk of developing dementia within seven years of diagnosis.
Their findings came from a study of 280,000 older veterans at the SFVAMC, where 15% of veterans who received a diagnosis of TBI developed dementia compared with 7% of those without a diagnosis.
These findings have yet to be published.
“The reports that are emerging about potential links between TBI and dementia are very important to us, but it’s an area that requires more research,” explained Susan Cooley, PhD, VA’s chief of geriatrics. “It’s especially important from the perspective of those of us having to plan ahead for dementia care in VA.”
Suggestions that brain injury could lead to dementia have been in the medical literature since the 1970s, explained David Cifu, MD, VA’s national director of physical medicine and rehabilitation services. “It isn’t a stretch to the imagination that having one serious brain injury or a series of smaller ones would lead to a degenerative brain condition over time, but there’s a huge leap from what seems to make sense and the science that there is a specific association.”
According to Cifu, the available research into the link shows an association between TBI and dementia about 50% of the time.
“We’re only seeing associations but no proven correlations,” he said.
Dementia incorporates complex processes, with multiple factors that promote it and an equal number that prevent it from developing, he pointed out. The currently available research has far too many variables to prove a definitive link.To Plan for Future Care VA Must Assume TBI-Dementia Link
Planning Ahead for Dementia
VA and DoD, however, are partnering to change that situation and funding research that would allow for a clearer picture of the relationship between brain injury and development of dementia.
“It’s a very important issue that needs the right kind of research and the funding for it,” Cifu said. “The VA and military are leading the charge on this. We really want to figure this out.”
Suggestions that brain injury could lead to dementia have been in the medical literature since the 1970s.
In the meantime, the philosophy of VA as it plans ahead for dementia services is to assume a high likelihood that a link will be conclusively proven and plan accordingly.
For the first time since 2004, VA is updating its projections for how many veterans will develop dementia in the next 20 years.
“We have a lot more information to enter into our equations now,” Cooley said.
Much of that equation is based on the national prevalence rate, which has changed since 2004. According to the Alzheimer’s Association, one in eight people 65 years of age and older has Alzheimer’s disease, and 43% of those older than 85 have the disease. By 2030, an estimated 7.7 million Americans will have Alzheimer’s, with the growth curve steadily rising every decade.
“A lot of things have changed in the world of projections in dementia, and we’ll be applying those to the updated VA projections,” Cooley said. “That includes factoring in things like TBI, even though it’s not clear yet whether there is a connection between TBI and later development of dementia or exactly what the connection is.”
Those projections will include sensitivity analyses involving TBI. “If ‘X’ proportion of people with TBI are expected to develop dementia, how would that affect our basic projections into the future?” Cooley said.
Those projection models will help determine what funding VA will require, the number of clinicians it will need to hire and what kind of long-term care VA will have to offer in the coming decades.
The projections are expected to be completed sometime this year. The basic numbers will be available within the next six months, with more detailed analyses to come later, Cooley said.
Planning ahead also includes developing treatment options for patients with TBI. If there is a correlation between TBI and dementia, swift and effective treatment might lower the risk.
“We’re doing lots of research into cognitive rehabilitation,” Cifu said, noting that the emerging field of research could have a critical effect for patients with head injuries. “What can we do to ameliorate and reduce the impact of that injury?”
The history of cognitive-rehabilitation research has been on nonblast-related TBI among civilian patients. Whether blast-related TBI victims will respond the same way is unproven, though numerous VA studies are targeting that question.
VA research is under way to look at the impact of structured cognitive-rehabilitation therapy on cognitive function, daily functioning and psychiatric symptoms of blast-related TBI patients.
“That’s one of our questions. If these methods are developed, would that reduce the risk of later development of dementia,” Cooley said. “because there are a lot of [treatments] that can be done between the occurrence of TBI and the eventual development of dementia.”
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