6/19/2014 1 Traumatic Brain Injury and Challenging Behaviors in Wounded Warriors Paul F. Aravich, Ph.D. Eastern Virginia Medical School Health on the Homefront: 1 6/17/2014 Health on the Homefront The quintessential public health imperative is behavioral health http://www.pinterest.com/dcoepag e/real-warriors-campaign/ http://www.veteransaidbenefit.org/ 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. 6/17/2014 Health on the Homefront 2
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6/19/2014
1
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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Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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?
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
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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
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
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
2 Virginia VISN 6 sites need further review
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http://www.va.gov/health/access-audit.asp
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Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
VHA response to wait-time issue 6/9/14 press release
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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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Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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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Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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Hippocampus proper: short term memory; consolidation long term memory
Amygdala: PTSD
Body of corpus callosum retracted
Anterior
Superior view of temporal lobe with most of the brain removed
Part of occipital
lobe
Psychosocial deprivation: injures adult stem cells in dentate gyrus part of hippocampal formation
Psychosocial deprivation: causes a brain injury
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
Clinical Implications• If “The human brain is a social brain”• Then psychosocial enrichment should be a
standard of care
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Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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.
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
“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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Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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.
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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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
• 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
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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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Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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”
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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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• 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.
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Major Neurobehavioral Consensus Conclusions
Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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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Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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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Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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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Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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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Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
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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Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
Yet, still have parallel, non-intersecting universes Competition instead of collaboration
• Cooperation Founding principal of the American Brain Coalition
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http://www.americanbraincoalition.org/
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Health on the Homefront: TBI & Challenging Behaviors in Wounded Warriors.
Will you remember:• Goethe: “You see what you look for”
Will you look for greatness in service members, veterans and their families