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Health Services Research & Development

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Each week the monthly spotlight features a topic-related HSR&D study.

Spotlight on Brain Health - Unintended Consequences: The Impact of VA Antipsychotic Reduction Efforts in Dementia

June 2019

The brain is arguably the most vital organ in the human body, yet we often take our brains for granted – until something goes wrong. When neurological conditions such as Post Traumatic Stress Disorder (PTSD), Stroke, Alzheimer’s Disease, Depression, and Traumatic Brain Injury (TBI) occur, symptoms can be physically as well as emotionally debilitating1 significantly affecting an individual’s daily life. Often family members serve as primary caretakers of those with brain disorders. VA recognizes that a range of treatment for brain health is needed, for Veterans as well as those providing care2.

VA’s annual Brain Trust Summit brings together Veterans, caregivers, clinicians and innovators to take on issues of brain health3, focusing on collaboration to advance treatment for trauma-related injuries such as PTSD and TBI4. Brain conditions that are associated more with aging such as Stroke and Dementia, including Alzheimer’s disease, are usually treated by Geriatrics and Extended Care professionals5. Research on brain health and brain related conditions is a priority within VA and spans a range of innovative areas from telemedicine6 to yoga6.

Following are highlights of just some of the ongoing and completed studied within the Health Services Research and Development (HSR&D) service.

Unintended Consequences: The Impact of VA Antipsychotic Reduction Efforts in Dementia

Unintended Consequences: The Impact of VA Antipsychotic Reduction Efforts in Dementia

(Photo © iStock/Fahroni)

Due to concerns regarding risks vs. benefits, VA has embarked on initiatives to reduce off-label use of antipsychotic medications (APs) for the behavioral and psychological symptoms of dementia (BPSD). Policy makers use the percent of Veterans on APs in Community Living Centers (CLCs) as the main quality indicator for BPSD. In addition to CLCs, policymakers are also concerned with high rates of AP use in community settings. Policies focused entirely on reducing AP use may have caused unintended consequences, such as providers shifting patients to alternative psychotropic classes with even less evidence of benefit and similar risks, including benzodiazepines, mood stabilizers, and antidepressants. Rather than substituting other psychotropics, multiple expert bodies recommend the use of behavioral and environmental interventions as the preferred alternative to APs for BPSD.

This ongoing study (2017-2020) seeks to examine the system- and facility-level consequences of initiatives intended to reduce AP prescribing related to dementia. Investigators are analyzing national VA health system administrative data from 2005-2014 on 26,625 Veterans with dementia. CLC's data is also being analyzed to compare variables that may reflect both unintended and desired consequences in quality of care for CLC residents with BPSD. Informed by these findings, an expert and stakeholder panel will validate additional potential quality indicators.


  • Antipsychotic use significantly declined from 2009 to 2014 (22% to 18%) while mood stabilizer use significantly increased from 17% to 21%. The main driver of mood stabilizer increases was gabapentin.
  • Benzodiazepine and antidepressant use declined (16% to 13% and 44% to 42% respectively).
  • There was little change in the use of non-benzodiazepine sedative hypnotics (4.0% to 4.4%).

Impact: Behavioral symptoms of dementia are universal, found in all types and stages of dementia. Based on these preliminary findings, investigators note that policies focused entirely on reducing antipsychotic use may have caused unintended consequences, such as providers shifting patients to alternative psychotropic classes with even less evidence of benefit and similar risks, such as mood stabilizers. These results may benefit Veterans, families, providers, and policymakers by helping them to understand the impact of current initiatives.

Principal Investigator: Helen C. Kales, MD, is with the Ann Arbor Geriatric Research Education and Clinical Center (GRECC), Ann Arbor, MI.

Smart Phone Application for Postconcussion Symptom Reduction

Smart Phone Application for Postconcussion Symptom Reduction

(Photo © iStock/Nicolas Hansen)

A high percentage of Veterans returning from OIF/OEF/OND have been medically diagnosed with a mild traumatic brain injury (mTBI) and experience distressing symptoms. "Smart phone" mobile applications have become a primary source of information and communication among Americans, especially those of the OIF/OEF/OND generation. This 4-year randomized controlled trial completed in 2018 investigated the utility of an interactive, self-management smartphone application - Concussion Coach – one of a suite of mobile applications developed by VA. The primary goal of this study was to evaluate the efficacy of Concussion Coach for improving clinical outcomes in those with a history of mTBI and to determine what aspects of Concussion Coach are most useful to Veterans. An overarching goal of this line of research was to improve access among Veterans with mild TBI who still have symptoms months to years after injury.

Approximately 500 Veterans with a history of mTBI and current symptom complaints were recruited from Polytrauma Network Sites (PSNs) in the Tampa, FL area and 419 were eventually enrolled in the study. PSNs are designated sites that assess TBI outpatients and see the majority of mTBI patients. The Intervention Group (n=419) received an iPod touch with the Concussion Coach "Explorer" app installed, and was sent, through the app, reminders to engage with it on a weekly basis. The control group received treatment as usual and no iPod or app. At the end of the three-month trial, researchers conducted in-person interviews with 10% of the Concussion Coach group. Twenty-four interviews have been completed, and all study data are currently being analyzed.

Impact: This study’s findings will lead to the improvement of Veterans' understanding and perceptions of the use of mobile technology in VA, and in healthcare settings more broadly. Assessment of Concussion Coach’s impact on learning and outcomes and Veterans’ perceptions about the application will inform efforts to increase efficacy and usage, leading to improved clinical outcomes in those with a history of mTBI.

Principal Investigator: Tracy S. Kretzmer, PhD,is a neuropsychologist with the Polytrauma/Traumatic Brain Injury (TBI) Rehabilitation Program at the James A. Haley Veterans' Hospital, Tampa, FL.

Action Ethnography of Community Reintegration for Veterans with TBI

Action Ethnography of Community Reintegration for Veterans with TBI

(Photo © iStock/eclipse_images)

Community reintegration (CR) for Veterans with Traumatic Brain Injury (TBI) has not been studied widely. Despite numerous studies of CR among civilian TBI patients, little is known of how findings from these studies translate to Veterans' experiences and needs. VA recognizes the needs of OEF/OIF Veterans with TBI to bridge health and rehabilitation-related services from acute care and inpatient settings to Veterans' homes and communities to facilitate reintegration. This ongoing (2014-2019) study seeks to identify barriers and facilitators to CR for Veterans with TBI through examination of the experiences of Veterans with moderate to severe TBI and their families, and CR workers (Case Mangers, Care Coordinators, VA/DOD/community contacts, etc.) in Veterans’ transitions to sustained community living.

The primary study sample includes 30 Veterans and military service members (VMSM) with complicated mild, moderate, or severe TBI. The secondary sample includes primary family caregivers and CR specialists. The tertiary sample includes key stakeholders. The quaternary sample consists of 82 community events for VMSM.

Investigators are interested not only in stakeholder experiences, but also the context in which they occur, including local, state, regional and VA environments that both facilitate and impede the ability of Veterans and families to negotiate services to achieve CR. Specific objectives are to: 1) Describe the community reintegration experience as perceived by Veterans; 2) Compare and contrast barriers and facilitators to community reintegration from the perspectives of Veterans, families, and CR workers; 3) Describe how personal social networks change over time and influence CR; and 4) In partnership with Veterans, families and CR specialists, identify strategies to improve CR experiences.


  • VMSM defined CR as engaging in productive activities such as school and work, living independently, and in appropriate and responsible social relationships.
  • Veterans marked success in CR by how well they "fit in" with their social networks, communities and the world.
  • Analysis of interview data identified CR barriers in five domains:
    • Cognition - impaired memory, concentration, comprehension, speech, self-awareness
    • Physical functioning - pain, impaired mobility, seizures
    • Behavior - anger, impulsivity, irritability, mood swings
    • Psychosocial - dependency on others for assistance, economic stress, grief from multiple losses, isolation, loneliness, relationship difficulties, stigma
    • Context - difficulty in accessing services, lack of clinical or rehabilitation services after inpatient rehabilitation, limited opportunities for engaging in productive activities, requirements for complex care coordination.
  • Family support services, peer support and social network strengthening programs, psychosocial and clinical interventions, and long-term care coordination that is holistic and integrates VA and non-VA services were identified as opportunities to overcome barriers for successful CR.
  • Barriers to Veteran participation in events included stigma associated with TBI, lack of accommodation for invisible disabilities (e.g., cognitive), limited TBI-focused events, and difficulty in identifying events.
  • Opportunities for overcoming barriers included tailoring events to target audiences, providing one-to-one social support during events, better accommodation of invisible disabilities during events, and improved marketing of events.

Impact: Findings have informed development of a tip sheet that provides community organizations with helpful information for creating environments that help Veterans with TBI and multiple comorbidities to feel accepted and respected. The tip sheet has been disseminated to 54 community organizations in the study, and additional dissemination is in progress.

Principal Investigator: Gail M. Powell-Cope, PhD, is with the James A. Haley Veterans' Hospital, Tampa, FL.

Story-Call: E-Mobile Support for Community Dementia Caregivers

Story-Call: E-Mobile Support for Community Dementia Caregivers

(Photo © iStock/damircudic)

Alzheimer's disease and the isolation it produces impose a heavy burden on informal caregivers (CG) of Veterans who are persons with dementia (PWD). In fact, research indicates that dementia CG carry greater burden than those for other chronic diseases. Being engaged in a community, early use of community-based services, and support programs promoting caregiver involvement can increase CG quality of life and decrease costs of the disease by significantly delaying Veteran institutionalization. However, not all CG reach out to community and nationally-available resources, due to work, time, culture, or rurality.

Mobile technology allows providers to reach people such as dementia CG who may be isolated and need social support. The Story-Call resource delivers personalized story-telling support in the form of short success stories generated by caregivers, and access to resources via a mobile phone application (app) delivered to caregivers of community-dwelling persons with dementia (PWD).This mixed methods study sought to test the feasibility of the Story-Call mobile app, to deliver caregiver-generated success stories to minority and rural CG, and to measure Story-Call’s efficacy in improving perceived CG burden, social support, community involvement, and quality of life for the PWD.


  • Eighteen caregivers volunteered to submit success stories from their Veteran living with dementia.
  • Of the participating Veterans, 138 video recorded stories were submitted, roughly an average of eight per caregiver. Topics covered how caregivers dealt with repetition, bathing, conversations, disruptive behavior, eating, dressing, humor, medications, sleep, exercise, sundowning, and other situations.
  • Story-Call was beta tested in two forms, with the 60-second long version ultimately chosen for stories.

Impact: Quality of life for CG and Veteran PWD may be improved by access to app-recorded stories designed to decrease perceived CG burden and increase social support. The confirmed feasibility of recruitment, acceptability, and practicality of delivering recorded success stories to CG of PWD via mobile app will inform implementation to a wider population. This study’s findings will be submitted to the VA Office of Connectivity, VA Mobile Health, and VA Caregiver Support Services for consideration of the need for further effectiveness testing and potential national dissemination. The Story-Call collection is meant to serve as an archive that will be submitted to the VA Office of Connected Care for consideration as an on-going resource.

Principal Investigator: Charlene Pope, PhD, MPH, is an Implementation and Partner Research Core Leader at the HSR&D’s Health Equity and Rural Outreach Innovation Center (HEROIC) at the  Ralph H. Johnson VA Medical Center, Charleston, SC.

This study resulted in the following publications:

Davis B, Nies M, Shehab M & Shenk D. (2014). Developing a pilot e-mobile app for dementia caregiver support: Lessons learned. Available in the Online Journal of Nursing Informatics (OJNI), vol. 18(1).


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