Health on the Homefront: TBI & Challenging Behaviors in ......6/19/2014 4 Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors. Uniqueness of every human brain

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Traumatic Brain Injury and Challenging Behaviors in Wounded Warriors

Paul F. Aravich, Ph.D.Eastern Virginia Medical School

Health on the Homefront:

16/17/2014 Health on the Homefront

The quintessential public health imperative is behavioral health

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Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.

Affiliations relevant to this presentation• Behavioral Neuroscientist & Professor of Pathology/Anat,

Geriatrics, PM&R, Eastern Virginia Medical School

• Former head of the Virginia Brain Injury Council & of its statewide position paper on tx needs for the behavioral complications of BI

• Former gubernatorial appointee and head of Virginia Public Guardian & Conservator Advisory Board

• Advisory Board, Virginia Center on Aging

• Member, Virginia Geriatric Mental Health Coalition

• Member, American Brain Coalition research/advocacy for brain disorders

• Former MERIT Review winner & Res. Scientist, Hampton VAMC

• Former Head, Joint Hampton VAMC/EVMS Research Com.

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Disclosure: Not-for-profit Affiliations related to this Presentation no compensation provided• Board Member, Tidewater Arts Outreach

Music/arts to uplift the spirits of isolated/disabled persons, including veterans http://www.tidewaterartsoutreach.org/

• Board Member, Buckley Foundation Clubhouse/enrichment/advocacy for persons w/ brain injury

• Board Member, I Need a Lighthouse Foundation Youth depression/suicide awareness http://ineedalighthouse.org/about/

• Board Member, Chas Foundation Mental illness awareness http://thechasfoundation.org/

• Board Member, Alternatives, Inc. http://www.altinc.org/

Empower young people; promote civic engagement/leaders• Interview w/ Brainline.org and Brainlinemilitary.org6/17/2014 Health on the Homefront 3


Outline• Introduction: Brain; VHA; & behavioral health

• Traumatic brain injury (TBI) in general

• TBI: PTSD and dementia

• Neurobehavioral position paper Virginia Brain Injury Council

• Potential Hampton Roads Regional Wounded Warrior Research Coalition?

• Conclusions


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The last great frontier of science

Renaissance: Neuroscience

Renaissance: Biopsychosocial Modelfor Brain/SCI Diseases/Trauma

Fatal Subdural


Neurological possibilities• 100 billion neurons Milky Way Galaxy

• 1 trillion supportive cells glia• 1014 synapses 1 quadrillion• but, synapses always changing dynamic

• conclude: infinite possibilities

• "nothing is more constant about the nervous system than its ability to change”1

– Called: neural plasticity– Called: hope– “If you don’t use it you lose it”

1p 1475, Barinaga. Science 1994 266:1475‐1476


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Uniqueness of every human brain

• All persons w/o brain injury have unique brains

• All persons w/ brain injury have unique brains

“If you’ve seen one person with a brain injury,

…You’ve seen one person with a brain injury”



But that which is among the most miraculous of things….• Is also among the most fragile

• Easily injured

• And easily injured another time

• Once injured “All the kings horses and all the kings men” have a

tuff time putting it back together again


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Types of Brain injuries


• Congenital brain injury, e.g., Cerebral palsy, Autism, Trisomy 21 (Down’s), Fragile X, Fetal

alcohol, neural tube, prenatal malnutrition

• Degenerative brain injury: Alzheimer’s, Parkinson’s, Huntington’s, ALS

• Acquired brain injury (ABI), e.g. Stroke, traumatic brain injury (TBI)

Lack of oxygen (anoxia), metabolic (liver/kidney), tumor, infection, electrical, toxic chemicals etc.

• Chemical dependence various pathological biological changes

• Mental illness various pathological biological changes

Each is unique. Each overlaps w/ others.


Common features of all BI’s• Specific pathological biological factors related to:

Regional metabolic activity

Regional epigenetics

Regional brain atrophy

Dendritic pathology

Neurotransmitters

Membrane channels

Growth/trophic factors

Inflammatory cytokines

Gender differences

Genetic predispositions

• And each interacts w/ psychosocial factors

Other common features: e.g., psychosocial deprivation; caregiver stress; impact on families; education; jobs; housing; transportation; access to care

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OEF/OIF/OND Signature Injuries: TBI & PTSD• “unprecedented # of TBI’s” 1

• People living instead of dying 75% TBI mortality rate in Vietnam 2

Now-Better equipment/acute care 1

• Issue now: long-term care 1

• Armed Forces oath: support /defend the constitution 3

• Our “oath:” Protect constitutional rights of disabled vets Because the terrorism of disease & terrorism of trauma

steal their Life, Liberty & Pursuit of Happiness 4


http://www.stripes.com/dod-identifies-five-u-s-troops-killed-in-ied-blast-in-afghanistan-1.152181

1 Drazen. N Engl J Med. 2005 May 19;352(20):2121 2 Okie. N Engl J Med. 2005 May 19;352(20):2043-73 Armed Forces Oath of Office4 Declaration of independence

IED kills 5 soldiers


Veterans Affairs Health Care System• A veterans’ specific national health care system 1

Called the Veterans Health Administration (VHA)

• Largest US integrated direct health care system 1

• Universal coverage for veterans

• Numerous strengths, e.g.: PTSD & antipsychotic tx/research

Substance use disorders programs

Integrated VA Polytrauma/TBI System of care discussed later

Homelessness programs

Leadership in electronic medical records for quality and safety

Leadership in telemedicine

Medication safety/pharmacy awards

Rural/women/tribal/public-private initiatives/partnerships

1 Congressional Research Service https://www.fas.org/sgp/crs/misc/R41198.pdf

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http://www.visn6.va.gov/VISN 6: Mid-Atlantic Health Care Network

27 Community-based primary-care outpatient clinics (CBOC). VA-owned and/or outside contract; 8 in Virginia

8 VA Medical Centers: 3 in VA

Vet Centers: Combat behav health 5 In VA: Alexand, Rich, Norfolk, VA Bch, Roan

NC,WV, VA

http://www.visn6.va.gov/


VHA Polytrauma/TBI System of Care: 4 care levels• Five national Polytrauma/TBI Rehabilitation Centers

Richmond, Tampa, Minneapolis, San Antonio, Palo Alto

• Transition to Polytrauma/TBI Network Sites One in each VISN: VISN 6 site is in Richmond

• Then to Polytrauma Support Clinic Teams, Va.: Hampton, Salem

• Polytrauma Points of Service Contact none in Va


http://www.polytrauma.va.gov/images/Map-Polytrauma-Locations.jpg

HamptonSalem2014 Military Case-Management Winner fromDorland Health, a national care coordination training org http://www.dorlandhealth.com/case-in-point-platinum-awards

System now piloting Assisted Living programs http://www.polytrauma.va.gov/news-and-resources/

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Veterans Health Admin.: Issues• Countless former service members/families not taking

advantage of benefits 1

Major outreach efforts to inform vets about their benefitssee 1) contact info below.

• Better integration w/ DoD & w/ Community (rural)

• “Inappropriate scheduling practices” that “are “systemic throughout VHA” 2

A pending report will discuss impact of delays on outcomes

1 Countless veterans not seeking Veterans Affairs health benefits entitled. Contact 1-877-222-VETS (8387), 8am-8pm, M-F or online at http://www.va.gov/healthbenefits/apply/

2 Veterans Health Administration, Report of the Office of Inspect. General 5/28/14 http://www.va.gov/oig/pubs/VAOIG-14-02603-178.pdf


2 Virginia VISN 6 sites need further review


http://www.va.gov/health/access-audit.asp

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VHA response to wait-time issue 6/9/14 press release

http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2552Details http://www.va.gov/health/access-audit.asp

• Hire more staff

• Use high performance sites to help under performing

• Accelerate care for those waiting Improve productivity; capacity, care in the community

• Mobile vet centers for counseling in rural areas

• Change selected senior leaders



Recent Congressional Bills: Veterans Healthcare

• House & Senate Cong. bills week ending 6/13/14

Allows outside tx of veterans >40 miles away and/or

If face long wait time

• Senate bill also authorizes $500M in deficit spending to hire more health workers House passed 426-0 & Senate passed 93-3


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Another VHA issue: Costs related to the War on Terrorism• 2.3M active-duty/reservists deployed to combat end of 3/11

• 52% sought VA healthcare 2002-11• As of end 6/11: 44,600 wounded

Survival rates: Iraq-90.2% vs. Vietnam-86.5%.

• Prevalence of pathology as of end 3/11 55% Musculoskeletal 51% Mental disorders (PTSD: 5-25% of all pathologies)

-though uncertainty about real prevalence of PTSD 3% Amputations TBI: see next slide

CBO 7/27/11 http://www.cbo.gov/doc.cfm?index=12315


Veteran Health Costs: TBI• Uncertainty re real prevalence of TBI• TBI: DOD statistics

35K w/ symptoms (e.g., headache, memory, sleep) 90% had mild TBI (i.e., concussion)

• TBI: Veterans Affairs statistics 26K w/ symptoms 7% of OEF/OIF cases from 2007-2009

• Distinction between: TBI Prevalence vs. Burden of pathology

CBO 7/27/11 http://www.cbo.gov/doc.cfm?index=12315

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Veteran Health Costs & Terrorism Wars• Total VHA care cost in 2010 for OEF/OIF/OND: 1

$1.9B for 400K OEF/OIF/OND veterans 4.8K/yr/pt budgeted for these vets. vs. 8.8K/yr/pt budgeted for other vets, usually older/sicker

• Total VA added OEF/OIF/OND $$ 2011-2020: 1

Will more than double entire 2010 VHA budget Will approximate $40B-$55B

• The issue of promoting successful aging in Wounded Warriors

1 CBO 7/27/11 http://www.cbo.gov/doc.cfm?index=12315

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Recent “overseas contingency operations”

Congressional Budget Office, 2012

TBI + PTSD: especially costly, b/c, e.g.,

long-term tx

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Brain Disorders: Most costly health care problems in general• Psychiatric and Neurological

Each is a form of nervous system injury• Account for well over half of all health $$• Behavioral health problems alone: $1.2T/yr

Importantly associated w/TBI Among most prevalent problems in TBI Among most difficult TBI problems Hidden epidemic of behavioral complications

• Negatively impact successful aging


Selected Behavioral Health Costsannual direct & indirect costs• Substance use disorders: $621B 1

• Serious mental disorders: $318B 2

• Alzheimer’s and other dementias:3 $214B 3

Total : $1.153 ~$1.2TrillionComparisons:

-10 yrs. of War Afghanistan/Iraq: ~$1.2T 10/01-10/11-Congressional Super Committee:$1.2T over 10 yrs.-Sequestration 1/2013 fiscal cliff; ditto

Each associated w/ causes/consequences TBI1 NIDA fact sheet http://www.nida.nih.gov/infofacts/understand.html2 NIMH fact sheet http://www.nimh.nih.gov/statistics/4COST_TOTAN.shtml3 Alzheimer’s Assoc http://www.alz.org/alzheimers_disease_facts_and_figures.asp#quickFacts

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Single most costly US health problem:Substance Use Disorders. Often related to serous mental disorders/TBI

• #1: $235 billion for alcohol 2nd mostly deadly drug Most violent drug: 1/3 all violent crime

• #2: $193 billion for tobacco: most deadly drug Kills >400K people/yr

• #3: $193 billion for illicit drugs• $621B total direct/indirect annual costs

Data from NIDA fact sheet http://www.nida.nih.gov/infofacts/understand.html


2. Nucleus accumbensseptal cortex removed

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Substance Use Disorders 4 selected regions

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WHO “Mental Health GAP” program: a critical global issue• Mental

• Neurological e.g., dementia, epilepsy, head injury

• Substance use disorders

• in non-specialized health settings

http://www.who.int/mental_health/evidence/mhGAP_intervention_guide/en/index.html


Global Mental Health Resources: the 3 “I’s”• Inadequate

• Insufficient

• Inequitably distributed

A failed system of care

Horton. The Lancet, Volume 370, Issue 9590, Page 806, 8 September 2007

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The world’s largest minority population • Persons w/ disabilities 1

About 10% of all people• The most disadvantaged

Even in the poorest countries Barriers to care, social isolation, stigma etc.

• Importance of 1990 Amer. w/ Disabilities Act• Predominate disorder: behavioral health disorders• Common denominator: social isolation

1 UN http://www.un.org/disabilities/convention/facts.shtml


Isolation stress: “the human brain... is...a social brain" p. 114 of ref. 3 below

• Adverse immunological & health effects, especially in elderly, poor? 1,2

• Causes a brain injury see next slide

• Social psychoneuroimmunology 3

"...just as we discover the importance of social relationships for health, & see and increasing need for them, their prevalence & availability may be declining.. in today's society”

• Mental Health America: Live your life well: “connect w/ others”

1 Kropiunigg. Ann Med 1993 25:473-4792 Cacioppo Psychophysiology 1994 31:113-1283 House et al quoted on p. 114 of Cacioppo Psychophysiology 1994 31:113-128

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Hippocampus proper: short term memory; consolidation long term memory

Amygdala: PTSD

Body of corpus callosum retracted

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lobe

Psychosocial deprivation: injures adult stem cells in dentate gyrus part of hippocampal formation

Psychosocial deprivation: causes a brain injury


Clinical Implications• If “The human brain is a social brain”• Then psychosocial enrichment should be a

standard of care


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Americans living w/ a disability

• 54 million Americans• most (52 million) reside in community settings• Prevalence varies markedly as a function of

gender, ethnicity, class, age, geography with significant healthcare disparities across these variables

• Largest discrepancy for life expectancy at birth: persons w/ serious mental disorders worse than gender, ethnicity, & geography

See Aravich & Copeland. Aging and the Behavioral Problems of Brain Injury Age in Action. Winter 2010.


“Beyond the disability”• Surgeon General’s 2005 call to action

• Replace the illness model, with a

• Holistic person-centered model

• Continuity of care & wellness programs, & a

• Focus on the promotion of successful aging For both kids and adults

See Aravich & Copeland. Aging and the Behavioral Problems of Brain Injury Age in Action. Winter 2010.

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Disability & “Healthy People 2020:” Overarching GoalsUS goals for next decade direct quote

1. Eliminate preventable disease, disability, injury, and premature death

2. Achieve health equity, eliminate disparities, and improve the health of all groups

3. Create social and physical environments that promote good health for all.

4. Promote healthy development and healthy behaviors across every stage of life.

http://www.healthypeople.gov/hp2020/advisory/PhaseI/summary.htm







• Conclusions


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Army & Maries: highest rates/100K


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TBI Severity Index DoD/DVA consensus

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For non-penetrating TBI

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Most OEF/OIF TBI: Mild TBI, AKA Concussion

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Mild TBIPathology of blast mild TBI blunt-force mild TBI Mendez et al, Brain Inj. 2013;27(1):10-8

Pre-deployment baseline testing procedures are flawed. Cole et al. Arch Clin Neuropsychol. 2013 Nov;28(7):732-42

Need for helmet-mounted sensor systems Report to Congress on Traumatic Brain

Injury in the United States, 6/13


Mild TBI concussion: a transient metabolically stressed state• Transient changes in:

neuronal membrane function, ionic balance, energy metabolism, excitatory amino acids, blood flow

• First 30 min: hypermetabolic state coupled with decreased mitochondrial oxidation Rats

• Then a switch to a hypometabolic state 6 hrs later lasting several days if not months

Echlin et al. Neurosurg Focus. 2012 Dec:33(6):Introduction:1-2

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3 Core Neurocognitive Networks• Each disrupted by ~all psych/neuro disorders

• Functionally connected (as seen by fMRI)

• Structurally connected (as seen by dMRI)

• There are 3 core neurocognitive networks Central executive network

Default network (AKA default mode network)

Salience network

• Network focus in psychiatry & neurology: “A paradigm shift” from specific regions to integrated circuits

Goal: biomarkers for psychiatric & neurological disorders• See, e.g., the Connectome Project, including fMRI, DTI, MEG & EEG

Menon. Trends Cogn Sci. 2011 Oct;15(10):483‐506

http://www.humanconnectome.org/hosted/downloads/HCP%20Fact%20Sheet%202011.pdf

Selected Network Pathways: Diffusion MRI Diffusion Tensor Imaging (DTI) type tractography; measures volumes etc.

Green: Cingulum; e.g., Salience Network

Purple: Uncinate fasiculus; e.g., Default Network

Blue: Arcuate fasiculus; part of language network

Red: Sup. long. fasiculus; e.g., Exec. Network

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Potential to ID, e.g. pathology to large fiber tracts due to, e.g., mild TBI, diffuse axonal TBI or PTSD?

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Central Executive Network nodes, e.g.:• Attention, “working memory,” encoding

• A frontoparietal system 1 Dorsal lateral prefrontal cortex

2 Lateral part of posterior parietal lobe

cerebellum

• Disrupted in most psych/neuro disorders


1 1

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Default network (default mode network)

• Active while unfocused but awake & resting i.e., active when internally focused & introspective

• Activity suppressed when doing a task

• Disrupted in most psych/neuro disorders

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Default Network nodal areas, e.g.:1. Medial prefrontal cortex: “self,” emotion, value, social

2. Ventral part anterior cingulate gyrus: w/ amygdala, MD thalamus, orbitofrontal/medial prefrontal cortex, hypothalamus

3. Medial temporal lobe: declarative memory

4. Posterior part cingulate gyrus: declarative memory

5. Precuneus: declarative memory

Disrupted in most psych/neuro disorders


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Salience Network

• Activated when something salient/significant: Novel external or internal stimulus

Mental/emotional challenge

• Plays a role in altering: attention, working memory

cognition, initiation of action

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Salience network nodal areas, e.g.:1. Insular cortex: internal & external sensations, emotion

2. Dorsal part of ant. cingulate gyr: cognitive aspects emotion

3. Amygdala not shown: e.g., emotional salience

4. Ventral tegmental area: reward salience

5. Medial premotor cortex (supplementary motor ctx)


112

Disrupted in most psych/neuro disorders

5 5







• Conclusions


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Psychiatric Disorders w/ median age of onset

• Mood disorders: Major depression 32, dysthymic 31, bipolar 25

• Schizophrenia males: teens-20’s; females: 20’s-30’s

• Anxiety disorders, e.g.: Panic 24, obsessive-compulsive disorder 19, PTSD 23,

generalized anxiety disorder 31, and phobias 13

• Eating disorders: Bulimia nervosa, Anorexia nervosa, Binge eating disorder

• ADHD and Autism

• Personality disorders, e.g., borderline personality, antisocial personality disorders


http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml


Mental illness in children• Occurs earlier than many other diseases

~age of 14 but not treated sometimes for decades, if at all

• Like other diseases: earlier detected better outcome• Needs for DoD/VHA/Private pediatric mental health:

Better child and family education Better school and parent outreach More pediatric psychiatrists More behavioral therapists More resilience training More creativity & leadership training

“It is better to build a child than to fix a broken adult” National Alliance on Mental Illness (NAMI)

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Suicide vs. Homicide. Often related to TBI• 88.4% more suicides than homicides

Suicide deaths: 34,598 50.2% by fire arms Homicide death: 18,361 68.8% by firearms

• Suicide death rates are increasing Unlike death rates from heart attack, cancer, stroke

• Ms. “K:” Person w/ both a schizoaffective disorder & ABI “Oh Giving Tree, Oh Giving Tree, let me be me” Died by hanging

Xu et al. National Vital Statistics Report 58(19). National Center for Health Statistics, May 20, 2010


Causes of death by age: rank(%)Age Accidents Homicide Suicide1-4 1(34.8) 4(7.9) not top 105-9 1(38.2) 4(5.4) ditto10-14 1(35.6) 3(7.1) 4(6.3)15-19 1(48.5) 2(16.7) 3(11.3)20-24 1(45.3) 2(16.2) 3(12.5)25-34 1(34.8) 3(11.7) 2(11.6)35-44 1(21.1) 6(3.6) 4(7.9)45-54 3(10.6) not top 10 5(4.0)55-64 4(4.1) ditto 8(2.6)65-74 6(2.2) ditto not top 1075-84 9(2.1) ditto ditto85+ 9(2.1) ditto ditto

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Suicide: a top 4 killer-ages 10-44

Most suicides: spring and fall. Lowest: December http://www.cdc.gov/ViolencePrevention/suicide/holiday.html

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Suicide hot spots: Rural America


Military/Veteran Suicide Hotline: 1-800-273-8255


“You are not alone”

http://www.dcoe.mil/PsychologicalHealth/Suicide_Prevention.aspx

Click Active duty tab @ http://veteranscrisisline.net/

Click Veteran tab @ http://veteranscrisisline.net/

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Suicide Risk Factors: Complex• >90% related to serious mental

disorders/substance abuse 1• Previous attempt(s)• Suicidal thinking• Male• Social isolation• Family conflict/loss• Financial difficulty• Physical health/chronic illness• Family history• Geriatric• Access to firearms6/17/2014 Health on the Homefront 57

1 NIMH http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml

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Emotion/Cognition: Lots of neurotransmitters.;affected by multiple disorders. Here is a small sample

Glutamate: from prefrontal cortex (FC), cingulate gyrus, amygdala (Amy), hippocampus (HP). Benefits of Ketamine (NMDA blocker) vs. its link to causing schizophrenia-like symptoms

GABA: from, e.g., accumbens Nac, hypothalamus Hyp

Norepinephrine: locus ceruleus LC

Dopamine: (VTA)

Serotonin: (dorsal/median raphe DR)

Monoamines from:

Peptides e.g., BDGF* inside hippocampal formation HP, brain CRH projections from, e.g., hypothalamus Hyp and basal forebrain*brain-derived neurotrophic factor

Acetylcholine, e.g. from basal forebrain. Scopolamine (blocker) use

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A: amygdala. ACG: ant. cingulate gyrus. S/A: septal cortex w/ accumbens deep. Hp: hipp formation. Hb: habenula. Hy: hypothalamus. L: locus ceruleus norepinephrine; R: raphe serotonin. SM: stria medullaris. V: VTA dopamine. vmPFC: ventral medial prefrontal ctx. Not seen: stria terminalis.

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Mild TBI ↑ PTSD. One hypothesis:it disrupts the medial Prefrontal cortex?

Amygdala

Medial PFC normally inhibits amygdala, which attaches emotional significance to events

Mild TBI disrupts medial PFC, which causes the amygdala to fire excessively

Aravich EVMS

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• “Traumatic brain injury (TBI) represents the strongest environmental risk factor for dementia”

• But this does not mean everyone w/ a moderate/severe TBI will get dementia

P 211. Smith et al. Nature Reviews Neurology 9, 211-221 (April 2013)

TBI & Dementia


TBI risk of dementia• Alzheimer’s & previous head trauma1

hazard ratios: moderate 2.32; severe 4.51

And worsens behavioral complicaitons3

• Chronic traumatic encephalopathy (CTE) A “frontal-temporal” type “tauopathy” dementia

1Plassman et al. Neurology 2000 Oct 24;55(8):1158-662Stern et al. PM R. 2011 Oct;3(10 Suppl 2):S460-7 ht

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Chronic Traumatic Encephalopathy• Repeated mild TBI

• No agreed upon diagnostic criteria 1

• Tauopathy, amyloid-beta & TDP-43 TDP-43 is an amyotrophic lateral sclerosis risk factor

• Dx only post-mortem

1 Smith et al. Nat Rev Neurol. 2013 Apr;9(4):211-212

DeKosky, S.T. et al. (2Nat. Rev. N

eurol.

doi:10.1038/nrneurol.2013.36

HippocampusCortex

Insular cortex Perivascular

Abnormal cortical tau

CTE Research is in its early stages, as is its strength of evidence


Potential mechanisms for TBI & Dementia

• TBI promotes other factors related to dementias Amyloid-beta and abnormal tau protein

• Neuron reserve hypothesis TBI reduces the # of neurons needed to protect

against dementia

• Epigenetic view Modulation of gene expression by extrinsic factors Behavior exercise/diet/etc. affects gene expression; Pathologies like TBI, PTSD affect gene expression


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Via Methyl (-CH3) & Acetyl (-COCH3) epigenetic switches

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Chromosome

Epigenetics: Behavior/TBI alter gene expression

1. Methyl binds gene promoter region: Off switch. Folic acid is a methyl donor

4. Acetylation: DNA unwraps & exposes gene. On switch for this gene. Resveratrol(plants): deacetylation= “off”

3. Acetyl binds histone tails.

2. Other gene are hidden by “histones”


LEARn Latent Early–life Associated Regulation model for Alzheimer’s (AD)• Hit #1: Early life environmental “stressors”

Malnutrition, toxins like lead, various stressors etc. Cause latent epigenetic changes These are predisposing factors

• Hit #2: Later life “stressors,” e.g. Poor diet, sedentary lifestyle, PTSD, TBI? These are precipitating factors They trigger the latent epigenetic changes, which Cause dementia/senescence

Debomoy and Maloney. Exp Gerontol. 2012 April; 45(4): 291-296

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Hypothesis. Epigenetic & TBI itself:

• Question 1: Early-life epigenetic TBI prophylaxis ↑ Nutrition/behavioral health; ↓Environmental stress

Arts, youth empowerment, resilience training

Will they mitigate adverse effects of later TBI?

• Question 2: Acute & Post-Acute epigenetics? Exercise, nutrition, enrichment, social support, meds

Ranging, e.g., from creatine & progesterone to

BI Club Houses/Arts/Caregiver-Family support programs

Mitigation of adverse effects?

Schober et. al. J Neurotrauma. 2012 Jul 20;29(11):2075-85. Epub 2012 Apr 20







• Conclusions


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Aravich, EVMS

www.biav.net/_literature_65798/Virginia_Neurobehavioral_Paper

Proposes 3 levels of care



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• >250,000 Virginians +18 years have ABI related complications

e.g., Stroke complications (141,800); TBI complications (~116,700)

• Only 20 neurobehavioral treatment beds; privately owned/not reimbursed by Medicaid/most private insurance.

• Behavioral/psychiatric complications woefully under addressed.

• Need specialized assessment/treatment programs. (e.g. + behav controls)

• Virginians w/ BI & Medicaid sent out of state w/ vacant beds here.

• Virg. Medicaid modification to cover in-state neurobehavioral programs, including those not designated as skilled nursing programs.

• Medicaid: TBI specific waiver of LTC facility requirement is needed.

• Medicaid: Need for Home and Community-Based BI waiver

• A small percentage have intensive tx treatment needs.

• Majority of persons can be addressed in community settings.

• Integrated neurobehavioral program: more effective/less costly than acute psych hospitals, mental health institutions, SNF’s, jails.


Major Neurobehavioral Consensus Conclusions


Conclusions cont.• Evidence-based best practices must occur across continuum of care.

• Standards, oversight mechanisms, and outcome accountability needed.

• Directly relates to mental health reform & Olmstead efforts.

• A lack of community based services for persons after discharge.

• Need interagency agreements, including Behav Health & Corrections.

• Review current licensing for non-Medicaid residential facilities.

• Use objective acuity measures for behavioral risk…a priority that should begin in the Executive Branch at the Secretariat level.

• Need for a $8M demonstration grant.


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• Conclusions



Hampton Roads Wounded Warrior Research Coalition?• One of highest densities of service

members/vets in USA• EVMS vision to be “most community oriented”

academic medical center in the country• Hampton VAMC• Naval Medical Center Portsmouth• Warrior Transition Unit, Ft. Eustice• ODU Modeling/simulation• Sentara Neurology/Neurosurgery• NASA6/17/2014 Health on the Homefront 74

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• Conclusions



True inter-dependent partnerships are needed• National Family Caregivers Association• Veterans Affairs• Wounded Warriors/Veterans Service Organizations• National Alliance on Mental Illness• Other advocacy groups (Alzheimer, Parkinson, TBI)• Community service boards• Criminal Justice System• Law & Medical Schools• Communities• Schools/Churches• Case managers• Across all levels of care

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Yet, still have parallel, non-intersecting universes Competition instead of collaboration

• Cooperation Founding principal of the American Brain Coalition


http://www.americanbraincoalition.org/

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Will you remember:• Goethe: “You see what you look for”

Will you look for greatness in service members, veterans and their families

• Serious mental & substance use disorders Brain pathologies w/ psychosocial interactions

• Rosalynn Carter: we’re all caregivers• Behavioral health:

the quintessential public health problem• Mother Theresa:

you an do no great things only small things w/ great love

Documents

Health on the Homefront: TBI & Challenging Behaviors in ......6/19/2014 4 Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors. Uniqueness of every human brain