Neurocognitive performance and prior injury among U.S. Department of Defense military personnel.

This study examined the neurocognitive performance of U.S. military personnel completing the Automated Neuropsychological Assessment Metrics (version 4) TBI Military (ANAM4 TBI-MIL) battery as part of the Department of Defense Neurocognitive Functional Assessment Program. Descriptive analyses utilizing the ANAM4TBI Military Performance Database were performed. We examined ANAM Composite Score (ACS) differences between five injury subgroups (no injury, brain injury with current symptoms, brain injury without current symptoms, nonbrain injury with current symptoms, and nonbrain injury without current symptoms) using general linear mixed modeling. Almost 11% (70,472/641,285) reported brain injury in the 4 years before assessment. The ACS differed significantly by injury group (p < 0.0001). In comparison to the no injury group, those reporting brain injury with current symptoms (d = -0.44) and nonbrain injury with current symptoms (d = -0.24) demonstrated significantly reduced ACS scores (p < 0.0001) indicative of reduced neurocognitive proficiency. In this population-based study of U.S. military personnel, neurocognitive performance was significantly associated with reported injury within the past 4 years among those experiencing current symptoms. Occupational programs focusing on prospective brain health of injured population groups are warranted.

No Significant Acute and Subacute Differences between Blast and Blunt Concussions across Multiple Neurocognitive Measures and Symptoms in Deployed Soldiers.

Seventy-one deployed U.S. Army soldiers who presented for concussion care due to either blast or blunt mechanisms within 72 h of injury were assessed using the Military Acute Concussion Evaluation, the Automated Neuropsychological Assessment Metrics (ANAM), traditional neuropsychological tests, and health status questionnaires. Follow-up ANAM testing was performed 10 d after initial testing (±5 d). Twenty-one soldiers were excluded: two for poor effort and 19 who had combined blast/blunt injuries. Of the remaining 50 male participants, 34 had blast injuries and 16 had blunt injuries. There were no statistically significant differences between blast injury and blunt injury participants in demographic, physical, or psychological health factors, concussive symptoms, or automated and traditional neurocognitive testing scores within 72 h post-injury. In addition, follow-up ANAM scores up to 15 d post-injury were not significantly different (available on 21 blast-injured and 13 blunt-injured subjects). Pre-injury baseline ANAM scores were compared where available, and revealed no statistically significant differences between 22 blast injury and eight blunt injury participants. These findings suggest there are no significant differences between mechanisms of injury during both the acute and subacute periods in neurobehavioral concussion sequelae while deployed in a combat environment. The current study supports the use of sports/mechanical concussion models for early concussion management in the deployed setting and exploration of variability in potential long-term outcomes.

No Effect of Deployment Environment in Establishing Baseline Neurocognitive Scores in U.S. Army Soldiers.

With heavy reliance on neurocognitive testing for concussion status assessments in the U.S. warfighter, there is a need to investigate the impact of testing environment on neurocognitive functioning. The current study compared scores on computerized neurocognitive tests of 166 soldiers who were deployed to Iraq. Predeployment baseline scores (n = 53) were compared to baseline scores collected while deployed (n = 113) on the battery of tests. There was no significant difference between baseline scores acquired from the predeployment group versus the deployed group. Furthermore, only one subtest revealed a significant difference in change scores from the follow-up test session when comparing the location of initial baseline testing. The results suggest that testing environment does not significantly influence baseline neurocognitive testing. The findings also provide support for the use of neurocognitive testing in a deployment environment.

No effect of mild nonconcussive injury on neurocognitive functioning in U.S. Army soldiers deployed to Iraq.

UNLABELLED: With neurocognitive testing being heavily relied on for concussion assessments in the U.S. Warfighter, there is a need to investigate the impact of nonconcussive injury on neurocognitive functioning. OBJECTIVES: To determine if a nonconcussive injury may have a negative effect on neurocognitive functioning in a deployment setting. METHODS: The current study compared scores on computerized and traditional neurocognitive tests of 166 Soldiers deployed to Iraq. Performance on a battery of tests was compared between a group of healthy deployed Soldiers (n = 102) versus a group of deployed Soldiers seeking outpatient care for mild injuries not involving the head or blast exposure (n = 62). RESULTS: The injured group's performance was not significantly lower on any of the measures administered compared to healthy Soldiers. CONCLUSIONS: The results suggest that there was no significant effect of nonconcussive injury on neurocognitive functioning. Findings lend support to feasibility of using neurocognitive tests to evaluate the effects of concussion in theater.

Assessment of acute concussion in the combat environment.

Despite the prevalence of concussion in soldiers deployed to Iraq and Afghanistan, neuropsychological tests used to assist in concussion management have not been validated on the battlefield. This study evaluated the validity of the Automated Neuropsychological Assessment Metrics (ANAM) in the combat environment. Cases meeting criteria for concussion, healthy controls, and injured controls were assessed. Soldiers were administered the ANAM, traditional neuropsychological tests, and a background questionnaire. Cases were enrolled within 72 h of concussion. Cases exhibited poorer performance than controls on all ANAM subtests, with significant differences on simple reaction time (SRT), procedural reaction time (PRT), code substitution, and matching to sample (p<.001). Discriminant ability of scores on SRT and PRT subtests was 71%, which improved to 76% when pre-deployment baseline scores were available. An exploratory clinical decision tool incorporating ANAM scores and symptoms improved discriminant ability to 81%. Results provide initial validation of the ANAM for detecting acute effects of battlefield concussion.

The ANAM lacks utility as a diagnostic or screening tool for concussion more than 10 days following injury.

Congress has mandated that the Department of Defense perform screening for concussion, or mild traumatic brain injury, on all service members redeploying from Iraq and Afghanistan. However, the retrospective diagnosis of concussion is complicated by the subjective nature of the complaints, overlap of symptoms with other conditions, and the normally rapid recovery of neurocognitive function following a concussive event. One diagnostic and screening test in current use by the Department of Defense is the Automated Neuropsychological Assessment Metrics (ANAM). A team of researchers deployed to Iraq between January and April 2009 to test the validity of the ANAM for the diagnosis of concussion in the combat environment. Performance by concussed participants on all six ANAM subtests was compared with that of controls. The ANAM appears to have no utility as an individual diagnostic or population screening tool for the detection of neurocognitive dysfunction from a single, uncomplicated concussion when administered 10 or more days following injury. Further studies are required to determine the modalities providing optimal sensitivity and specificity for use as diagnostic or screening tests beyond the first 72-hour acute postinjury period.

Personality Assessment Inventory profiles of deployed combat troops: an empirical investigation of normative performance.

The present study examined the normative scores and psychometric properties of the Personality Assessment Inventory (PAI; Morey, 1991) within a non-treatment-seeking sample of soldiers deployed to combat zones in Iraq, compared with a sample of community adults matched with respect to age and gender. Results indicate the scores and properties of the PAI scales were generally quite similar in the Iraq and community samples, with modest differences emerging on only 3 subscales addressing antisocial behavior, issues with close relationships, and interpersonal vigilance. These results suggest that standard normative interpretation of PAI scales is appropriate even when the instrument is administered in a combat zone. In comparison with prior research, the results may suggest that documented mental health issues among combat veterans, when present, may be particularly likely to emerge postdeployment.

Evaluation of the Military Acute Concussion Evaluation for use in combat operations more than 12 hours after injury.

The diagnosis and management of concussion can be difficult in a combat environment, especially in the absence of loss of consciousness or post-traumatic amnesia. As no validated test exists to diagnose or grade neurocognitive impairment from a concussion, the military currently employs the Military Acute Concussion Evaluation (MACE) in Iraq. This is a two-part test, which incorporates the standardized assessment of concussion (SAC) as its objective score, although it has not been shown to be valid unless administered shortly after injury. A research team deployed to Iraq between January and April 2009 to examine the validity of several tests of neurocognitive function following a concussion, including the MACE. When administered more than 12 hours after the concussive injury, the MACE lacked sufficient sensitivity and specificity to be clinically useful.

Stress and alcohol use among soldiers assessed at mobilization and demobilization.

Excessive alcohol use may have negative consequences, including less force readiness among military personnel. The identification of variables associated with alcohol use may inform early intervention efforts to decrease negative consequences. This longitudinal prospective study examined the associations of demographic and stress variables with alcohol use among 876 soldiers that were mobilized and demobilized through an Army installation during a 9-month period in 2003. Participants reported a moderate level of general stress at mobilization and demobilization, and a minority reported significant combat stress. Alcohol use in the 2 weeks before the demobilization evaluation was associated with younger age, nonactive duty status before mobilization, and more general stress. Male gender was associated with more drinks per drinking day. The results suggest that younger, nonactive duty male personnel experiencing stress may be a group at risk for increased drinking after deployment and for whom intervention may be helpful.

Development, deployment and usability of a point-of-care decision support system for chronic disease management using the recently-approved HL7 decision support service standard.

Clinical decision support is recognized as one potential remedy for the growing crisis in healthcare quality in the United States and other industrialized nations. While decision support systems have been shown to improve care quality and reduce errors, these systems are not widely available. This lack of availability arises in part because most decision support systems are not portable or scalable. The Health Level 7 international standard development organization recently adopted a draft standard known as the Decision Support Service standard to facilitate the implementation of clinical decision support systems using software services. In this paper, we report the first implementation of a clinical decision support system using this new standard. This system provides point-of-care chronic disease management for diabetes and other conditions and is deployed throughout a large regional health system. We also report process measures and usability data concerning the system. Use of the Decision Support Service standard provides a portable and scalable approach to clinical decision support that could facilitate the more extensive use of decision support systems.

Predictors of aversive alcohol consequences in a military sample.

The purpose of this study was to identify predictors of risky alcohol use and alcohol-related consequences among postdeployment soldiers. Demobilizing soldiers completed an assessment packet that included questions about demographic factors, relationships, stress, and alcohol-related consequences. Significant predictors of greater alcohol-related consequences, as assessed with the CAGE questionnaire, included fewer years of formal education, male gender, not being in an intimate relationship, racial/ethnic minority status, enlisted rank, having been deployed to the continental United States, and greater stress, whereas significant predictors of drinking and driving included male gender, not being in an intimate relationship, and greater stress. Identifying the predictors of alcohol consequences that occur upon demobilization may aid in determining which soldiers are at risk for such consequences before deployment and may help to maintain military readiness.

Variables associated with intimate partner violence in a deploying military sample.

Variables associated with intimate partner violence (IPV) were examined within a sample of military personnel preparing to deploy. Soldiers with intimate relationships processed for mobilization through Fort Bliss, Texas, completed a questionnaire that queried demographic information, relationship satisfaction, stress, risky alcohol use behaviors, and tactics used during intimate relationship conflict. Four hundred forty-nine deploying soldiers (15.8% of 2,841 with usable data) reported IPV in the past year. Younger age, less education, less relationship satisfaction, more stress, and risky alcohol use behaviors were significant individual predictors of engaging in IPV. The results of this study are discussed in terms of their implications for targeting efforts to reduce IPV among military personnel.