Adult Veterans Research Articles

Trends in Initial Antihypertensive Medication Prescribing Among >2.8 Million Veterans Newly Diagnosed With Hypertension, 2000 to 2019.

Among patients diagnosed with high blood pressure (BP), initial dual therapy has been recommended for patients with high pretreatment systolic BP (≥160 mm Hg) since 2003, and first-line β-blocker use without a compelling condition has fallen out of favor in US guidelines. This serial cross-sectional study of national Veterans Health Administration data included adult Veterans with incident hypertension initiating antihypertensive medication between January 1, 2000, and December 31, 2019. We assessed annual trends in initial regimens dispensed (index date: first antihypertensive dispense date) by number of classes and unique class combinations used overall and by pretreatment systolic BP (<140, 140 to <160, and ≥160 mm Hg), as well as trends in subgroups (age, sex, race and ethnicity, and comorbidities warranting β-blocker use). Among 2 832 684 eligible Veterans (average age 61 years, 95% men, 65% non-Hispanic White, and 8% with cardiovascular disease), from 2000-2004 to 2015-2019, initial monotherapy increased across all pretreatment systolic BP levels (<140 mm Hg: 62.1% to 66.4%; 140 to <160 mm Hg: 70.7% to 76.8%; ≥160 mm Hg: 64.2% to 69.7%). Initiation of dual therapy decreased across all pretreatment systolic BP levels (<140 mm Hg: 25.0% to 24.2%; 140 to <160 mm Hg: 20.4% to 17.6%; ≥160 mm Hg: 22.7% to 22.0%). Among 2 521 696 Veterans (89% of overall) without a β-blocker-indicated condition in 2015 to 2019, 20% initiated a β-blocker, most commonly as monotherapy. More than half of US Veterans diagnosed with hypertension with a pretreatment systolic BP ≥160 mm Hg were started on antihypertensive monotherapy. There are disparities between guideline-recommended first-line treatments and the actual regimens initiated for newly diagnosed Veterans with hypertension.

Validation of the Chumlea Equation in Home Bound Older Adult Veterans

Validation of the Chumlea Equation in Home Bound Older Adult Veterans

Frequency and Determinants of Levothyroxine Therapy Initiation for Veterans with Subclinical Hypothyroidism.

Background/Objectives: There is evidence of overtreatment in patients with subclinical hypothyroidism (SCH). We aimed to identify the proportion of patients treated for SCH and the determinants of thyroid hormone therapy initiation. Methods: We included a random sample of adult Veterans diagnosed with SCH from 1 January 2016 to 31 December 2018 and conducted univariate and multivariable logistic regression to identify factors associated with levothyroxine initiation. Results: Out of 229 Veterans with SCH [90.0% male, 87.2% White, 99.1% non-Hispanic, median age (interquartile range; IQR) 68 (17) years], 27.5% were treated with levothyroxine. The treated group had a higher proportion of White patients (95.2% vs. 84.2%, p = 0.039), a higher thyrotropin level [median (IQR), 6.98 (2.06) mIU/L vs. 6.14 (1.10) mIU/L, p = 0.0002], a higher proportion of patients with thyrotropin level ≥ 10 mIU/L (11.1% vs. 3.0%, p = 0.021), a lower frequency of confirmatory thyroid testing before initiating levothyroxine (49.2% vs. 97.0%, p < 0.0001), and a similar frequency of thyroid autoimmunity testing (3.2% vs. 0.6%, p = 0.18) compared to the untreated group. In a multivariable logistic regression analysis, White race (OR = 4.50, 95% CI 1.19 to 17.08, p = 0.026) and index thyrotropin level [OR = 1.71, 95% CI 1.24 to 2.35, p = 0.001; for every SD increase (1.6 mIU/L)] were associated with higher odds of treatment. Conclusions: Three in 10 Veterans with SCH received levothyroxine, often based on a single abnormal thyroid test without autoimmunity assessment. White race and higher thyrotropin level were linked to increased odds of starting treatment, indicating potential disparities and the influence of SCH severity on decision-making.

Reducing Alcohol Misuse and Promoting Treatment Initiation Among Veterans Through a Brief Internet-Based Intervention: Protocol for a Randomized Controlled Trial.

Young adult veterans who served after the September 11 attacks on the United States in 2001 (ie, post-9/11) are at heightened risk for experiencing behavioral health distress and disorders including hazardous drinking, posttraumatic stress disorder, and depression. These veterans often face significant barriers to behavioral health treatment, and reaching them through brief mobile phone-based interventions may help reduce drinking and promote treatment engagement. Following a successful pilot study, this randomized controlled trial (RCT) aims to further test the efficacy of a brief (ie, single session) mobile phone-delivered personalized normative feedback intervention enhanced with content to promote treatment engagement. We will conduct an RCT with 800 post-9/11 young adult veterans (aged 18 to 40 years) with potentially hazardous drinking and who have not recently received treatment for any behavioral health problems. Participants will be randomly assigned to the personalized intervention or a control condition with resources for seeking care. The personalized normative feedback module in the intervention focuses on the correction of misperceived norms of peer alcohol use and uses empirically informed approaches to increase motivation to address alcohol use and co-occurring behavioral health problems. Past 30-day drinking, alcohol-related consequences, and treatment-seeking behaviors will be assessed at baseline and 3, 6, 9, and 12 months post intervention. Sex, barriers to care, posttraumatic stress disorder, depression, and severity of alcohol use disorder symptoms will be explored as potential moderators of outcomes. We expect recruitment to be completed within 6 months, with data collection taking 12 months for each enrolled participant. Analyses will begin within 3 months of the final data collection point (ie, 12 months follow-up). This RCT will evaluate the efficacy of a novel intervention for non-treatment-seeking veterans who struggle with hazardous drinking and possible co-occurring behavioral health problems. This intervention has the potential to improve veteran health outcomes and overcome significant barriers to treatment. ClinicalTrials.gov NCT04244461; https://clinicaltrials.gov/study/NCT04244461. DERR1-10.2196/59993.

Association between metabolic syndrome and white matter integrity in young and mid-age post-9/11 adult Veterans.

Metabolic syndrome has been associated with reduced brain white matter integrity in older individuals. However, less is known about how metabolic syndrome might impact white matter integrity in younger populations. This study examined metabolic syndrome-related global and regional white matter integrity differences in a sample of 537 post-9/11 Veterans. Metabolic syndrome was defined as ≥3 factors of: increased waist circumference, hypertriglyceridemia, low high-density lipoprotein cholesterol, hypertension, and high fasting glucose. T1 and diffusion weighted 3T MRI scans were processed using the FreeSurfer image analysis suite and FSL Diffusion Toolbox. Atlas-based regions of interest were determined from a combination of the Johns Hopkins University atlas and a Tract-Based Spatial Statistics-based FreeSurfer WMPARC white matter skeleton atlas. Analyses revealed individuals with metabolic syndrome (n = 132) had significantly lower global fractional anisotropy than those without metabolic syndrome (n = 405), and lower high-density lipoprotein cholesterol levels was the only metabolic syndrome factor significantly related to lower global fractional anisotropy levels. Lobe-specific analyses revealed individuals with metabolic syndrome had decreased fractional anisotropy in frontal white matter regions compared with those without metabolic syndrome. These findings indicate metabolic syndrome is prevalent in this sample of younger Veterans and is related to reduced frontal white matter integrity. Early intervention for metabolic syndrome may help alleviate adverse metabolic syndrome-related brain and cognitive effects with age.

Axonal injury, sleep disturbances, and memory following traumatic brain injury.

Traumatic brain injury (TBI) is associated with sleep deficits, but it is not clear why some report sleep disturbances and others do not. The objective of this study was to assess the associations between axonal injury, sleep, and memory in chronic and acute TBI. Data were acquired from two independent datasets which included 156 older adult veterans (69.8 years) from the Alzheimer's Disease Neuroimaging Initiative (ADNI) with prior moderate-to-severe TBIs and 90 (69.2 years) controls and 374 (39.6 years) from Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) with a recent mild TBI (mTBI) and 87 controls (39.6 years), all who completed an MRI, memory assessment, and sleep questionnaire. Older adults with a prior TBI had a significant association between axonal injury and sleep disturbances [β = 9.52, 95% CI (4.1, 14.9), p = 0.01]. Axonal injury predicted changes in memory over 1-year in TBI [β = -8.72, 95% CI (-18, -2.7), p = 0.03]. We externally validated those findings in TRACK-TBI where axonal injury within 2 weeks after mTBI was significantly associated with higher sleep disturbances in the TBI group at 2 weeks[β = -7.2, 95% CI (-14, -0.50), p = 0.04], 6 months [β = -16, 95% CI (-24, -7.6), p ≤ 0.01], and 12 months post-injury [β = -11, 95% CI (-19, -0.85), p = 0.03]. These associations were not significant in controls. Axonal injury, specifically to the left anterior internal capsule is robustly associated with sleep disturbances in multiple TBI populations. Early assessment of axonal injury following mTBI could identify those at risk for persistent sleep disturbances following injury.

Does neuropsychological intraindividual variability index cognitive dysfunction, an invalid presentation, or both? Preliminary findings from a mixed clinical older adult veteran sample

ABSTRACT Introduction Intraindividual variability across a battery of neuropsychological tests (IIV-dispersion) can reflect normal variation in scores or arise from cognitive impairment. An alternate interpretation is IIV-dispersion reflects reduced engagement/invalid test data, although extant research addressing this interpretation is significantly limited. Method We used a sample of 97 older adult (mean age: 69.92), predominantly White (57%) or Black/African American (34%), and predominantly cis-gender male (87%) veterans. Examinees completed a comprehensive neuropsychological battery, including measures of reduced engagement/invalid test data (a symptom validity test [SVT], multiple performance validity tests [PVTs]), as part of a clinical evaluation. IIV-dispersion was indexed using the coefficient of variance (CoV). We tested 1) the relationships of raw scores and “failures” on SVT/PVTs with IIV-dispersion, 2) the relationship between IIV-dispersion and validity/neurocognitive disorder status, and 3) whether IIV-dispersion discriminated the validity/neurocognitive disorder groups using receiver operating characteristic (ROC) curves. Results IIV-dispersion was significantly and independently associated with a selection of PVTs, with small to very large effect sizes. Participants with invalid profiles and cognitively impaired participants with valid profiles exhibited medium to large (d = .55–1.09) elevations in IIV-dispersion compared to cognitively unimpaired participants with valid profiles. A non-significant but small to medium (d = .35–.60) elevation in IIV-dispersion was observed for participants with invalid profiles compared to those with a neurocognitive disorder. IIV-dispersion was largely accurate at differentiating participants without a neurocognitive disorder from invalid participants and those with a neurocognitive disorder (areas under the Curve [AUCs]=.69–.83), while accuracy was low for differentiating invalid participants from those with a neurocognitive disorder (AUCs=.58–.65). Conclusions These preliminary data suggest IIV-dispersion may be sensitive to both neurocognitive disorders and compromised engagement. Clinicians and researchers should exercise due diligence and consider test validity (e.g. PVTs, behavioral signs of engagement) as an alternate explanation prior to interpretation of intraindividual variability as an indicator of cognitive impairment.

Palliative care in the older adult Veteran.

The United States military Veteran population is aging, thus leading to a group of Veterans who have functional disabilities, sensory impairments, and geriatric syndromes such as frailty and dementia. As they age, Veterans are also at risk of being diagnosed with a variety of serious illnesses, such as neurologic conditions and cancers, some of which are a consequence of prior military service or toxic exposures. In addition to frailty and multicomplexity, Veterans have higher rates of mental health disorders than civilians. All of these factors lead to a population of older Veterans who can benefit from palliative care involvement. Major tenets of palliative care focus on enhancing quality of life and provision of goal-concordant care, which are also aims of the services provided by the Veterans Health Administration (VHA) to all enrolled Veterans. Palliative care involvement in the holistic care of Veterans can deliver expert pain and symptom management, promote Veteran-centric plans of care, and provide crucial support of complex medical decision making often required for those Veterans with serious illness. In this review article, we discuss the unique palliative care needs of Veterans as they age, while also sharing information about relevant resources and services provided by the VHA.

The effectiveness of cognitive behavioral therapy for insomnia on sleep outcomes in the context of pain among older adult veterans.

Cognitive behavioral therapy for insomnia (CBT-I) is the gold-standard treatment for insomnia disorder in adults. Compared to young adults, older adults have increased risk for the development of conditions associated with chronic pain, which may impact the efficacy of CBT-I in improving insomnia symptoms in older adults. This study evaluated the effect of participant-rated pain on sleep-related outcomes of a supervised, non-clinician administered CBT-I program in older adult patients with chronic insomnia disorder. Secondary analysis was conducted using data from a randomized controlled trial among 106 community-dwelling older adult veterans (N = 106; mean age 72.1 years, 96% male, 78.3% White, 6.6% Hispanic, 5.7% African American) with chronic (≥3 months) insomnia disorder. Participants engaged in five sessions of manual-based CBT-I in individual or group format within one Department of Veterans Affairs healthcare system, provided by non-clinician "sleep coaches" who had weekly telephone supervision by behavioral sleep medicine specialists. Insomnia symptoms (Insomnia Severity Index), perceived sleep quality (Pittsburgh Sleep Quality Index), fatigue (Flinder's Fatigue Scale), daytime sleepiness (Epworth Sleepiness Scale), and perceived pain severity (items from the Geriatric Pain Measure) were assessed at 4 time points: baseline, one-week posttreatment, 6-month follow-up, and 12-month follow-up. Mixed effects models with time invariant and time varying predictors were employed for analyses. CBT-I improved insomnia symptoms, perceived sleep quality, fatigue, and daytime sleepiness among older veterans with chronic insomnia. Participant-reported pain was associated with greater improvements in insomnia symptoms following CBT-I. Pain did not affect improvements in other sleep-related outcomes (-0.38 ≤ b ≤ 0.07, p > 0.05). Between-subjects differences in pain, but not within-subject changes in pain over time, appeared to play a central role in insomnia symptom improvement at posttreatment, with individuals with higher-than-average pain showing greater insomnia symptom improvement (ISI score reduction; -0.32 ≤ b ≤ -0.28, p ≤ 0.005). Pain did not meaningfully hinder the effects of CBT-I on sleep outcomes. Among older veterans with chronic insomnia disorder, individuals with higher pain exhibited slightly greater improvement in insomnia than those with lower levels of pain. These findings suggest that experiencing pain does not impair treatment response and should not preclude older adults with insomnia from being offered CBT-I.

Protocol for the development of a vaping cessation intervention for young adult veterans

The use of e-cigarettes (“vaping”) by young adults has increased substantially in the past decade. Although health risks of long-term e-cigarette use remain unknown, there is evidence of acute physiological harms. Most young adults who vape report intent to quit, but little is known about effective interventions. This protocol paper reports on the development and design of a pilot trial of a vaping intervention for young military Veterans.Young adult Veterans accessing VA healthcare (n = 20) who vape daily and have been referred for cessation services will be enrolled. To maximize accessibility the intervention will be delivered virtually; participants will be randomized to receive behavioral counseling by telephone or by video telehealth. The intervention was adapted from an existing program targeting young adult cigarette smokers and will include 6 individual counseling sessions delivered over 8 weeks. Assessment visits will occur at baseline, at end-of-treatment, and 4 weeks later.Analyses will evaluate feasibility and acceptability of the intervention overall, and will compare telephone and video telehealth modalities. Longitudinal regression will be used to evaluate changes in vaping behavior and in nicotine dependence over time.This study will provide assessment of a novel intervention adapted for Veterans who vape nicotine. The comparison of two modalities of virtual intervention delivery will increase knowledge and the potential to disseminate across VA and other healthcare systems. Findings from this pilot trial will inform the design of future, larger studies of vaping cessation interventions for younger Veterans.

Community Participation Trajectories over the 5 Years after Traumatic Brain Injury in Older Veterans: A U.S. Veterans Affairs Model Systems Study

Background: Given the aging of the overall U.S. population, the resulting changes in healthcare needs especially among veterans, and the high prevalence of traumatic brain injury (TBI) among older adults, additional research is needed on community participation after TBI in older veterans. The current study examined predictors of community participation trajectories over the 5 years after TBI in veterans who were 55 years of age or older upon injury. Method: This study included data from 185 participants in the U.S. Department of Veterans Affairs TBI Model System national study who had sustained a TBI at age 55 or older and had completed at least one of each Participation Assessment with Recombined Tools-Objective (PART-O) subscale scores at one or more follow-up time points (1, 2, and 5 years post-TBI). Results: PART-O Productivity, Social, and Out and About scores remained constant over time. Lower PART-O Productivity trajectories were seen among participants who were unemployed at the time of injury (p = 0.023). Lower PART-O Social trajectories were seen among participants who had a lower education level (p = 0.021), were unmarried at injury (p &lt; 0.001), and had private insurance coverage (p &lt; 0.033). Conclusion: These findings add to the growing body of literature on TBI and community participation by focusing on an older adult veteran population. There is an urgency to understand the needs of this group, many of whom are aging with service-connected disabilities including TBI. Veterans with characteristics identified herein as being associated with lower community participation trajectories would be prime candidates for interventions that aim to increase community and social engagement after later-life TBI.

0737 Retirement, Health-Related Quality of Life, and Sleep in Older Adult Veterans

0737 Retirement, Health-Related Quality of Life, and Sleep in Older Adult Veterans

AGING IN THE RIGHT PLACE: HOUSING AND SOCIAL SUPPORTS FOR OLDER ADULTS EXPERIENCING HOMELESSNESS

Abstract The Aging in the Right Place (AIRP) framework recognizes that secure housing for older adults should support one’s unique vulnerabilities and lifestyles. Applying the AIRP framework to older people experiencing homelessness (OPEH) reveals limited access to the types of living environments and supportive services that promote dignity, health, and inclusion in later life. This symposium aims to use the AIRP framework to examine the places, meanings, and opportunities experienced by diverse groups of OPEH striving to secure housing and promote their well-being. The first paper uses photovoice interviews and thematic analysis to broaden the current conceptualization of AIRP by exploring how feelings, actions, and place inform the meaning of AIRP for older adult residents of one temporary housing program in Vancouver, CA. The second examines the housing and support needs of older adult veterans in Calgary, CA residing in temporary congregate housing through a multi-methods approach involving document reviews, environmental audits, and in-depth interviews. The third paper uses interviews with OPEH and service providers in Columbus, OH to look across the continuum of housing occupied by older adults before, during, and after an episode of late-life homelessness and to investigate the mechanisms that allow OPEH to identify and access the housing they consider optimal. Finally, the discussion positions AIRP for OPEH within the broad context of Age-Friendly ecosystems to highlight the role of coordination between housing providers, government leaders, health services, university researchers, and residents to ensure that AIRP is achievable for precariously housed older persons.

25 The Relationship between Judgment and Cognitive Performance in a Mixed-Clinical Older Adult Veteran Sample

Objective:Judgment, defined as the capacity to make decisions carefully after consideration of available information, which may entail a variety of sources, has come to be regularly assessed within neuropsychology, and impairment of judgment has been demonstrated across multiple disorders (Rabin, Borgos, &amp; Saykin, 2008). This study aimed to re-examine the relationship between judgment and performance on measure of cognitive functioning including (memory, attention, language, visuospatial abilities, speed, and aspects of executive functioning) in a mixed-clinical sample of older adult veterans.Participants and Methods:Data for this study was collected from the Cognitive Functioning in Older Adult Veteran’s database repository (CFOAV) at a large Veteran Affairs Healthcare System (VAHCS). Participants were veterans seeking treatment in the Neuropsychology Assessment Clinic. Inclusion criteria were that participants must have answered the nine questions from the TOP-J and received a score based on the specific criteria. Participants were excluded if they appeared to lack adequate test engagement or had a serious mental illness. The final sample for the current study consisted of 83 veterans (73% male, n = 76), ranging from 50 to 89 years (m = 72.01, SD = 9.70), with and average of 13 years of education (SD = 3.21). Of the sample, 75% reported that they were White, 7% African American/Black, and 1% Latino/Hispanic, and ICD-10 diagnoses ranged from age-related cognitive decline, mild cognitive impairment, vascular dementia, and dementia in other disease classified.Results:Using SPSS (Version 27), Pearson correlations were conducted to examine the relationship between the TOP-J raw score, demographic variables, and measures of cognitive functioning, including the WTAR, the RBANS index scores, WAIS-DS, TMT A, TMT B, COWAT, and ANT. Missing data were excluded pairwise in the analyses. Correlation analyses revealed a significant small-to-medium correlation between the TOP-J and the. There were small to medium correlations between the TOP-J, WTAR (r = .31, p = .01), TMT A (r = .27, p = .02), WAIS DS (r = .30, p = .01), and RBANS Attention index (r = .35, p = .04). There was a significant large relationship between the TOP-J and the RBANS Immediate Memory index (r = .52, p = .002). There were no significant associations between the TOP-J, demographic variables (e.g., biological sex, age, and education), TMT-B, COWAT, or ANT.Conclusions:The study supported previous decision making research (Moye, Karel, Gurrera &amp; Asar, 2006) that has found the ability to attend to and immediately retain information to be an important foundational component. While the present study did not fully replicate previous findings that the Top-J was correlated to measures of executive functioning, strong correlations did emerge with verbal memory and a measure of crystalized verbal abilities similar to Rabin et al. (2007). Such research informs the assessment practical judgment. It also indicates that one’s ability to acquire and encoded unstructured and contextual verbal information, as well as pre-morbid verbal abilities, may provide potential targets to improve or compensate from decrements in overall practical judgement. This is certainly an areas for future research.

Early onset adolescent binge drinking is associated with reduced white matter integrity in post-9/11 adult veterans.

Adolescence represents a critical period of neural development during which binge drinking (BD) is prevalent. Though prior work has shown that white matter (WM) integrity is susceptible to damage from excessive alcohol intake in adults, the effect of early adolescent BD on WM health in adulthood remains unknown. Veterans with a history of BD onset before age 15 [n = 49; mean age = 31.8years; early-onset adolescent binge drinkers (EBD)] and after age 15 [n = 290; mean age = 32.2years; late-onset adolescent binge drinkers (LBD)] were studied with diffusion tensor imaging. Group differences in fractional anisotropy (FA; movement of water molecules along the WM) and mean diffusivity (MD; average movement of water molecules) were examined as indices of WM integrity using FreeSurfer and FMRIB Software Library (FSL) processing streams. Lower FA and higher MD are thought to represent degradations in WM integrity. A reference group (RG) of social drinkers with no history of BD (n = 31) was used to provide comparative normative data. We observed widespread decreased FA and increased MD in EBDs, compared to LBDs, as well as decreased FA in the pars triangularis, lateral orbitofrontal cortex, superior frontal cortex, isthmus cingulate, and genu and splenium of the corpus callosum EBDs also had lower WM integrity compared to the RG. Adults who initiated BD during early adolescence demonstrated decreased FA and increased MD throughout the frontostriatal circuits that mediate inhibitory control and thus may result in impulsive behavior and a predisposition for developing alcohol use disorder during adulthood.

Incidence of Venous Thromboembolism Among Commonly Prescribed Second-Generation Antipsychotics

Background: Second-generation antipsychotics (SGAs) are commonly prescribed medications used to treat a variety of mental health conditions. Recent data has correlated antipsychotic medications with venous thromboembolism (VTE). SGAs have diverse side effect profiles, which may contribute to differences in incidence of VTE. It is unknown which SGAs confer the most risk, and what the mechanism of increased risk is. Objective: Determine incidence of VTE in Veterans at Veterans Affairs North Texas Health Care System (VA-NTX HCS) between SGAs aripiprazole, olanzapine and risperidone. Methods: Retrospective chart review of adult Veterans at VA-NTX HCS between October 2015 to December 2019 prescribed aripiprazole, olanzapine, or risperidone. Results: Of 823 Veterans, incidence of VTE was lowest in aripiprazole group at .4%, increased to 1.7% in the olanzapine group, and was highest at 2.5% in the risperidone group. However, differences in incidence of VTE between SGAs were not statistically different, indicating no between-group differences. Conclusion: There was no difference in the incidence of VTE between risperidone, olanzapine, or aripiprazole. Given multiple limitations with this study, higher-powered studies should be conducted to investigate the possibility of differences in the incidence of VTE between the SGAs.

Pilot Study: The Effects of a Mountain Wilderness Experience on Combat Veteran Psychosocial Wellness

The purpose of this quasi-experimental pilot study was to evaluate the efficacy of a 3.5 day outdoor wilderness program (Huts for Vets, HFV) for reducing psychological distress, PTSD symptoms, and improving positive mood states. It was hypothesized that participation in the HFV program would predict improvements in psychosocial well-being in addition to reductions in PTSD symptomatology relative to a waiting-list control group. Participants included 51 adult veterans diagnosed with PTSD and/or some other combat-related disability (Mage = 36.8, SD = 8.19). The experimental group (n = 32) participated in the HFV program, which included hiking and group discussions. Data collection via psychosocial scale administration took place two weeks prior to the HFV trip, on the last day of the trip, and at a 6 week follow up. Participants in the control group (n = 19) underwent the psychosocial assessments on the same schedule, however, they did not participate in the outdoor program. Results indicated significant and sustained reductions in depression, anxiety, somatic stress, negative affect, and PTSD symptoms among program participants, alongside acute improvements in positive moods, relative to the control group. The current findings suggest that therapeutic recreation offers promising benefits as a complementary intervention for combat veterans.

Examining the Efficacy of a Brief Cognitive-Behavioral Therapy for Chronic Pain (Brief CBT-CP) Group Delivered via VA Video Connect (VVC) Among Older Adult Veterans

ABSTRACT Objectives To evaluate the effectiveness of a Brief CBT-CP Group delivered via VA Video Connect (VVC) among different age groups of Veterans with chronic noncancer pain being seen in primary care. A secondary aim was to evaluate participant characteristics of patients who completed vs. did not complete the group. Methods Single-arm treatment study in which outcomes were evaluated by comparing self-reported symptom levels pre- and post-treatment. Dependent variables included generalized anxiety, quality of life, disability, physical health, and pain outcomes. Results Following a 2 × 3 mixed-model ANCOVA, a main effect of time was found for all outcome variables, demonstrating significant improvements in disability rating, physical health, quality of life, generalized anxiety, and pain outcomes from pre- to post-treatment. There were no significant main effects for age group for any outcome variable, suggesting that patients of all ages reported improvements. Conclusions Accommodations and adaptations to telehealth treatment for older adults are proposed and discussed. Clinical Implications The Brief CBT-CP Group via VVC is an effective and accessible treatment for older adults with chronic noncancer pain who are being managed in the primary care setting. Certain Veterans are less likely to complete the Brief CBT-CP Group via VVC.

Abstract P595: Low Serum Cholesterol and Coronary Heart Disease Mortality in Veterans

Background: The lipid hypothesis postulates that lower blood cholesterol is associated with reduced coronary heart disease (CHD) risk, which has been challenged by recent studies that observed a U-shaped relation between cholesterol and mortality. The effect of low cholesterol and CHD risk among Veterans is unclear. Methods: This prospective cohort study included Veterans greater than 18 years of age with baseline outpatient visits from 2002 to 2007 and follow-up to December 30, 2018 in the Veterans Health Administration electronic health record system. Veterans were followed to assess CHD mortality risk in relation to outpatient blood cholesterol levels. We used Cox proportional hazard regression to estimate the hazard ratio (HR) and 95% confidence interval (CI) of CHD mortality associated with total cholesterol (TC). Results: Among 4,467,942 Veterans, 381,871 CHD deaths were recorded. We observed a V-shaped relation between TC and age-, sex, race and smoking-adjusted risk of CHD mortality. The association became U-shaped after adjustment for statin use, body mass index, hypertension, and diabetes. When further adjusted for high-density lipoprotein level, 11 baseline diseases, and applying a 2-year lag analysis, the relation to CHD mortality was J-shaped--flat for TC&lt;180 mg/dL and greater risk was present at higher cholesterol levels. Compared to Veterans with TC between 180-199 mg/dL, risk for CHD mortality (HR (95%CI)) was 1.03 (1.02-1.04), 1.07 (1.06-1.09), 1.15 (1.13-1.18), 1.25 (1.22-1.28) and 1.45 (1.42-1.49) times greater among Veterans with TC (mg/dL) of 200-219, 220-239, 140-259, 260-279 and ≥280, respectively. Transition of the TC- CHD mortality patterns were J-J-J, V-U-J and L-U-J among young, middle, and older veterans (P for interaction between TC and age group &lt; 0.001). Similar J-shaped but weaker relations were observed in statin users at baseline. Conclusions: Based on prospective data for almost 4.5 million adult Veterans, CHD mortality risk steadily increased for TC ≥200mg/dL after adjustment for a range of health conditions. Our results support the lipid hypothesis that lower blood cholesterol is associated with reduced CHD risk and lower prevalence of multimorbidity, mental health disorders, nutritional deficits, and other risk factors for CHD. Furthermore, the hypothesis remained true when TC was low due to use of statins or other lipid-lowering medication. The changes in risk for CHD mortality by TC groups observed in our study (L- to U- to J-shape) highlights the importance of fully adjusting for the presence of multimorbidity and HDL-C to avoid misleading conclusions.

Social Work Staffing and Use of Palliative Care Among Recently Hospitalized Veterans

Palliative care improves quality of life for patients and families but may be underused. To assess the association of an intervention to increase social work staffing in Veterans Health Administration primary care teams with use of palliative care among veterans with a recent hospitalization. This cohort study used differences-in-differences analyses of the change in palliative care use associated with implementation of the Social Work Patient Aligned Care Team (PACT) staffing program, conducted from October 1, 2016, to September 30, 2019. The study included 71 VA primary care sites serving rural veterans. Participants were adult veterans who received primary care services from a site enrolled in the program and who received inpatient hospital care. Data were analyzed from January 2020 to August 2022. The PACT staffing program was a clinic-level intervention that provided 3-year seed funding to Veterans Health Administration medical centers to hire 1 or more additional social workers in primary care teams. Staggered timing of the intervention enabled comparison of mean outcomes across sites before and after the intervention. The primary outcome was the number of individuals per 1000 veterans who had any palliative care use in 30 days after an inpatient hospital stay. The analytic sample included 43 200 veterans (mean [SD] age, 65.34 [13.95] years; 37 259 [86.25%] men) and a total of 91 675 episodes of inpatient hospital care. Among the total cohort, 8611 veterans (9.39%) were Black, 77 069 veterans (84.07%) were White, and 2679 veterans (2.92%) were another race (including American Indian or Alaskan Native, Asian, and Native Hawaiian or other Pacific Islander). A mean of 14.5 individuals per 1000 veterans (1329 individuals in all) used palliative care after a hospital stay. After the intervention, there was an increase of 15.6 (95% CI, 9.2-22.3) individuals per 1000 veterans using palliative or hospice care after a hospital stay, controlling for national time trends and veteran characteristics-a 2-fold difference relative to the mean. This cohort study found significant increases in use of palliative care for recently hospitalized veterans whose primary care team had additional social work staffing. These findings suggest that social workers may increase access to and/or use of palliative care. Future work should assess the mechanism for this association and whether the increase in palliative care is associated with other health or health care outcomes.