Hit by Dementia on the Battlefield

Last year, I reported on the correlation between traumatic brain injury and dementia.  Specifically, I linked to a study that found that those with a TBI had a 4.5 percent greater risk of dementia (in some studies, this percentage is a bit lower).  While terrible, that was not a complete surprise, when one is referring to moderate and severe brain injuries.  (The report that found that mild TBI is not so mild for the elderly is upsetting, but not unbelievable.)  However, since that time, government-funded studies, as well as other studies, have broadened that research and discovered that even a mild brain injury without loss of consciousness (loc) can more than double one’s chance of developing dementia, no matter what age that person is when that mTBI occurs.  A study of more than 350,000 veterans found that those who had a mild TBI, a single jolt to the head, without loc had a 2.36 percent greater risk of developing dementia.  For those in the study who had a mild TBI with loc, there was a 2.51 percent higher risk of developing dementia, not that much higher.

“One working theory is that somehow these injuries either cause an overproduction of normal waste proteins, or make it impossible to clear these proteins,” notes the study.  However, this is just a working theory because no one fully understands how the brain works, or rather why and how it stops working.  Responding to the above studies results, the director of the Army’s traumatic brain injury program questioned, “”Is blast exposure hurting service members or soldiers?  And if it is… how can we modify our equipment or the way we operate to prevent injury?”

Beyond the military, why is the risk of dementia higher after a TBI for working age adults, in general?  Additionally, the NCBI sponsored a nationwide study that found that, “the risk of dementia diagnosis decreased over time after TBI… [but] it was still evident >30 years after the trauma.”  Based on this information, how can we modify our diet, our physical activity, etc., during our TBI recovery and after, to prevent this?  As of now, research on cognitive decline, mild cognitive impairment, and dementia prevention has been “encouraging but inconclusive”.  However, the assumed prevention tactics of cognitive training, blood pressure management (for those with hypertension), and increased physical activity are beneficial regardless.

Trump Gives Credit to Caregivers

Trump donates his presidential paycheck to VA caregivers,” read the headline on The Military Times website yesterday, May 17, 2018.   Specifically, the President’s quarterly paycheck of $100,000 is the first check that the President has donated to the VA (earmarked for the caregivers) and the fifth paycheck that he has donated to various governmental departments.  “President Trump understands the critical role of caregivers,” said Acting VA Secretary Robert Wilkie of this quarter’s donation. Apart from financial support, caregivers support the health and healthcare of dependents and provide much needed social interaction.

Earlier this year, the “Trump tax cut”, H.R. 1, that passed in March, states that, “The [tax] credit [for caregivers]… shall be increased by $500 for each dependent of the taxpayer.”  A dependent is a relative who lives with the caregiver, earns less than $4,050 annually and that the caregiver financially supports.  This is a description that applies to many brain-injured individuals.

Menopause Increases Stroke Risk – Part 2

by Caitlin D.

Whether you consider a cerebrovascular disease, commonly known as a stroke, a traumatic brain injury in and of itself or simply the effect of a tbi (a stroke is an acquired brain injury), the negative effects of it do not lessen.  If one has an ischaemic stroke, as opposed to a haemorrhagic stroke, they then have a 25% – 30% higher chance of either developing vascular cognitive impairment (VCI) or vascular dementia (VaD), collaboratively known as VCID.  Strokes may not always be the cause of VCID, but strokes and VCID do have similar risk factors.  (For this reason, a stroke may co-occur with a VCID, but not be directly caused by it.)  And, just like a stroke, “symptoms of vascular dementia and VCI can begin suddenly…. [but they] worsen or improve over time.”

Vascular dementia is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain.”  Because of their similar effects, vascular dementia is often confused with Alzheimer’s disease.  However, the difference is that vascular dementia is caused by the blockage of blood through the brain, whereas the cause of Alzheimer’s disease is not fully understood.  For this reason, “Currently, no specific biomarkers have been proven to robustly discriminate vulnerable patients (‘at risk brains’) from those with better prognosis or to discriminate Alzheimer’s disease dementia from [vascular dementia].”

A relatively newly named condition, vascular cognitive impairment, “refers to the contribution of vascular pathology to any severity of cognitive impairment, ranging from subjective cognitive decline and mild cognitive impairment to dementia.”  It is not an age-restricted condition, though the vast amount of those who are inflicted are elderly.

Last year, the National Heart, Lung and Blood Institute funded a study that proved that exercise helps prevent against vascular dementia.    However, beyond that, little research has been done on how to prevent or cope with vascular dementia or vascular cognitive impairment.  As the government noted, in 2015, “there are limited treatment options to improve cognition and function in VCI.”  That still seems to be accurate.  Since strokes are often the cause of vascular cognitive impairment and vascular dementia and since vascular dementia seems to mirror the effects of Alzheimer’s disease, research on how to cope with and later deal with strokes and Alzheimer’s would be beneficial.

While it is true that America is aging, as the world’s population is living longer, stroke and dementia should not be as much of a concern for those who live a healthy lifestyle.  Thirty years ago, a person who was injured through a traumatic injury or a person who developed an acquired brain injury had almost no hope of survival.  Now many such people can survive and even thrive.  Hoping for that type of result for dementia in the same timetable seems very realistic.

Menopause Increases Stroke Risk – Part 1

Rebecca M.

As covered in-depth by the NIH, women that are through menopause, who have a different hormonal make-up than younger women, have a higher risk of stroke, an acquired brain injury.  This is due to changes in hormones, especially those linked to estrogen, which drops significantly after menopause.  Stroke was once thought to be primarily a male disease, but the number of women that are having strokes has been increasing.  Although men still have a greater risk of stroke overall, the risk of stroke for women between the ages of 50 and 60 (the median menopause age is 51) is greater than that of men at that age.  This is true for women of all races.  (As stress also contributes to stroke rates, I wonder if women with stressful jobs that have been through menopause might be at an even higher risk, as there is evidence that higher stress is contributing to more strokes in younger people.

Currently, legislation does not appear to address strokes or heart disease in any way, but it is addressed by the executive branch of the federal government.  Sometime between the years 2003 and 2005, statistical data was ordered by George W. Bush’s first Secretary of Health and Human Services Tommy Thompson.  The following report called for strengthening the nation’s public health capacity at the state and federal levels. The plan, though created nationally, required community level action to catch risk factors for stroke and heart disease and make changes accordingly, especially those changes that could be implemented through environmental change.  (Environmental change is what a federal agency or legislation would be able to focus on, not on biologically predetermined risks.)  There was also a call for more research in all areas, including the genetic area, so that individuals could be properly tracked and helped before they suffered any risks.   At the time of the report, heart disease and stroke required 3% of the U.S. budget to address and that number was expected to rise as more “baby boomers” reached old age.

It is a bit surprising that there has not been a follow-up on statistics since 2010.  The surprise is not so much based on inaction in the Trump Presidency, which has been less than a year and a half, but during the Obama Presidency, when healthcare was such a signature issue, especially in his first term. There was no continuity from the Bush years.

Though this report focuses on heart disease, as well as on stroke, it is noted early on that the public health burden from stroke has grown at a faster rate, possibly because disability resulting from stroke requires long-term care.  The goal of the report was to strengthen programs that allow for early detection of the two types of disease and thus ensure strong and economically-sound responses to the epidemics.  The hope was that better models for detection and for treatment could be developed nationally and by the international CDC that would be used at the community level. I did not, however, find more up-to-date reports like this, which was issued roughly 14 years ago.  At the time of the report, heart disease was the #1 cause of death in all people in the U.S. over 65, and stroke was the #1 cause of disability.

Illegal Immigrants and Brain Injury

A hot topic in the past few decades, illegal immigration has now come to the forefront because of America’s current president and his border wall.  (For the past 10 years, the estimated number of illegal immigrants in America has stayed relatively stable at about 11 million.  During the presidencies of Bill Clinton and George W. Bush, it was steadily rising.)  As for brain injury and undocumented residents, there are many cause-and-effect questions that, when answered, are quite sobering.

To begin, what if the illegal immigrant is the culprit?  What if the illegal immigrant causes someone to have a brain injury, either intentionally or inadvertently?  First, the police or whomever is pursuing the case must find them.  Since illegal immigrants are largely undocumented, this can be a hard task.  For better or worse, depending on your political ideology, a number of states are now allowing an illegal immigrant to legally obtain a driver’s license and register their car.  In January 2015, for example, California signed into law AB60, which, “requires the [DMV] to issue an original driver’s license to an applicant who is unable to submit satisfactory proof of legal presence in the United States.”  New Jersey, with the support of Governor Phil Murphy, is now preparing for a similar bill, Assembly Bill No. 1738, to pass.  If this bill passes, it will make New Jersey the 13th state, plus the District of Columbia, to allow this.  (What the consequences are for an illegal immigrant who inflicts injury on another person, such as through a car accident and even if they are legally licensed, is unclear.  They are subject to criminal charges, but civil action may be more difficult.  As they are illegal, and many do not submit tax returns, which would show their yearly income, monetary consequences to cover such things as rehabilitation costs are not possible.)

More so, the government does not seem to account for the economic costs of brain injury:  For the victim, there will be a lose of future wages as, even if the victim is able to return to work, they will be away for a bit.  Additionally, when returning to work, a brain injured individual may have to pursue a career that is less cognitively and/or physically demanding and often less lucrative than their previous occupation.  For the Internal Revenue Service (IRS), this means less taxable dollars are earned.  Also, the brain injured individual may stay longer or indefinitely on Medicare and/or Medicaid.  The government then is required to help pay for their doctors’ visits, their medication, etc.

But, how about when the illegal immigrant is the victim?  No one wants to see a person, legal or not, suffer or even die due to lack of medical care.  All told, the government is financing about $18.5 billion a year for medical care of unauthorized immigrants.  Of this total, “federal taxpayers provided $11.2 billion in subsidized care to unauthorized immigrants in 2016.”  (“A relatively small number of undocumented immigrants, perhaps in the tens of thousands, obtain health insurance through private employers,” states a 2016 article.)  However, a page on the NIH website, written by an individual who had authored other pages on ethics, as it relates to illegal immigrants, notes that, “the Patient Protection and Affordable Care Act of 2010 ignored the health care of undocumented immigrants and will not provide relief to undocumented patients with catastrophic illness like ESRD, cancer, or traumatic brain injuries.”

There are local health clinics, hospital emergency rooms and free medical school clinics that must treat everyone, regardless of legality.*  Additionally, some doctors will treat undocumented immigrants, off the record.  Treatment for brain injury though, requires more than a brief trip to the doctor.  As an article from 2009, when illegal immigrants were treated differently by the government than now, is titled, “Struggling to find post-acute care for undocumented and uninsured immigrants.”  Should ethics trump legality, no pun intended?

*Another article recounts the story of an illegal man, without insurance, who suffered a stroke.  Though the hospital legally had to treat him, his care would be uncertain the second he stepped out of the hospital grounds.  Would receiving care for his stroke result in a “medical deportation”?  Ultimately, the hospital was able to find the man’s family in Mexico, but the trip to return him to his family cost $50,000 and was paid entirely by the government.

Note: The above post is not a personal comment on illegal immigration.

Investigators Question America’s Football Crisis

People now see football and brain injury as a definite cause-and-effect.  Parents are much more hesitant to allow their school-aged children join the school football team.  In January, for example, laws related to youth football were proposed in Illinois and New York, both named after former NFL players who suffered the effects of CTE (chronic traumatic encephalopathy).  In Illinois, HB4341 was named after Dave Duerson, a former Chicago Bears player who committed suicide in 2011 and whose autopsy showed that he had a brain injury.  Officially known as the CTE Prevention Act (HB4341), the last action on the Duerson Act was on April 27, 2018 when it was referred the Rules Committee.  In New York, A1269A is named after former Baltimore Colts tight-end John Mackey, who showed signs of brain injury prior to his death at age 69.  The John MacKey Youth Football Protection Act is also still in Committee in the State Assembly.  (Notably, the MacKey Act only prevents children 11 years and younger from playing tackle football, not 12 or 13 years as other proposed laws restrict.)

In Maryland, a bill was introduced by Delegate Terri Hill, and failed, that would have changed the rules for youth soccer, lacrosse, hockey and [tackle] football.  (“I really did not expect it to pass, but I think it’s a conversation we have to have and I don’t think the conversation is over,” Hill said.)  In New Jersey, A3760 was introduced by Assemblywoman Valerie Huttle on April 5, 2018 to prohibit children under the age of 12 from participating in tackle football.  After its introduction, it was referred to the Assembly Women and Children Committee, where it sits now.  Last week, AB-2108 failed in the California Assembly, “but before the outrage and the mudslinging and the ‘Save Youth Football’ rallies, [the] resolution pass[ed] unanimously, with 69 co-authors.”

Many proponents of safer/more restrictive youth football cite a recent Boston University study that showed that hits to the head, not concussions, cause CTE.  Hits to the head are thought to be simply a means of defense in football, not just the residual effect of defense, like a concussion.  Therefore, it’s harder to eliminate them while keeping the competitive edge of the sport.  (Getting rid of the tackle part of professional football would be more difficult, but it is still difficult in youth football, without allowing it to become touch football.)

What the safety rules of youth football should be is a good discussion to have, especially now that a Court-appointed Special Investigator has shown that some NFL players who have claimed brain injury did not, if fact, have such neurological problems.  The Investigator found, for example, that a law firm shared by dozens of NFL players purportedly coached the players on how to fail a neurological test.  A review of the post-NFL lives of some players who claimed themselves to be too cognitively impaired to work did, in fact, work – as motivational speakers, coaches, bankers, etc.

However, no one is fully certain about the effects of football on the brain. In April 2018, former 19-year NFL player Brett Favre spoke of whether his forgetfulness was because of he is aging, as he is 48, or, “do I have [the] early stages of CTE?  I don’t know.”  Research and news have made brain injury and football seem to always coincide, so Favre’s personal questioning is understandable.  Just as was noted in this website’s article related to Shaken Baby Syndrome though, the horrific easy answer isn’t always correct.  Whether or not the news about the CTE-football connection affects a state’s or a school district’s decision on whether to continue to offer football, whether schools stricken their football rules, and whether a parent chooses to allow their child to play the sport rests solely on them.

May is… National Stroke Awareness Month. Join the conversation!

A stroke, the stop of blood flow to the brain, is a common brain injury: occurring every 40 seconds in America.  While strokes are more common in the 65+ age range, they can happen to anyone and at any time.  By Presidential Proclamation, National Stroke Awareness Month has been recognized in May since 1989, as a time to explain the symptoms of stroke, which requires immediate medical help, and to highlight ways of stroke prevention.

“In observance of National Stroke Awareness Month, NINDS (National Institute of Neurological Disorders and Stroke), Million Hearts, American Academy of Neurology (AAN), and the American Stroke Association are co-hosting a Twitter chat to discuss stroke risk factors, the importance of keeping your brain healthy, and the latest stroke research. #BrainforLife will take place Wednesday, May 2, from 1-2 p.m. ET.  Medical experts, including NINDS Director Dr. Walter Koroshetz and AAN President Dr. Ralph L. Sacco, will be on hand to answer questions.”

AVs: Salvation or Hazard

Getting an extra 30 minutes of sleep while you’re on the road… finishing yesterday’s homework while you’re on your way to your senior year of high school… caring for your baby while you’re breezing through the highway.  All of these scenarios seemed too good to be true a few years ago, but now America is on the cusp of the age of autonomous vehicles (AVs).  As it is, in 2016, 87.5 percent of people ages 16+ had their driver’s license and spent, on average, a total of 17,600 minutes on the road a year.  The idea of a car that could do the tedious and time-consuming duties of driving is a dream that is quickly becoming a reality.

For the disabled, the benefits of autonomous cars are even greater – if nothing else, it allows for increased independence.  It means the legally blind, for example, will finally be able to safely operate a car by themselves.  A 2012 video of a legally blind man stopping at the Taco Bell drive-thru prompted much positive excitement.  The means with which to allow the blind to safely drive is still in actuality in development, but spokesmen do say, “At Waymo, Google’s self-driving car company that was launched nearly a decade ago, officials say visually impaired employees contribute to design and research. While no specific system for blind riders has been completed, the company says it’s developing a mobile app, Braille labels and audio cues.”  As Americans gets older, a self-driving car could help those who have a, “loss [of] flexibility, vision and hearing,” and delayed reaction time.  Of course, these are some of the same impairments suffered by those with brain injuries.

However, this may seem too good to be true because it is just that.  Car fatalities have been on an almost steady decline, from a high of more than 50,000 in the 1970s to the low to medium 30,000s this decade.  (“An additional 2.35 million are injured or disabled.”)  Though this is still an extremely high number, how will fully autonomous or semi-autonomous cars affect this?  Beyond testing, no one knows if or by how much this will decrease with the use of self-driving cars.

Cars don’t have the same “sense” that people do.  Only a month ago, on March 20, 2018, in Arizona, a homeless woman became the first pedestrian fatality to be attributed to this new technology. “If there is any real-world scenario where it would be seemingly safe to operate in an automated mode, this should have been it. Something went seriously wrong,” said an urban planning professor after the incident.  (The car that caused the fatality was a self-driving Uber.  Uber has since suspended it’s self-driving car tests.)  In Mountain View, CA, headquarters to self-driving car company Waymo, Walter Huang was killed after the sun glare got into his eyes when his Tesla noted that it needed him to take the wheel, resulting in his vehicle driving straight into a highway median.  Two years ago, in Florida, a man was killed when he failed to take the wheel after numerous notifications from a self-driving car.  (The National Transportation Safety Board released a report of findings about the incident.)

In a horrifying test, reported by Psychology Today this month, “some recent demonstrations have shown that a few black stickers on a stop sign can fool the algorithm into thinking that the stop sign is a 60 mph sign.”  As far as accidents go, in Pittsburgh, PA in late February, a “Woman claim[ed a] self-driving Uber struck her car, left the scene.”  Did that driver choose not to stop or did the car leave on its own?

The above are just a few examples of accidents or possible accidents resulting from problems with autonomous cars.  (I am not sure how many more examples there are, if any.)  Tesla said in 2016, “Autopilot is by far the most advanced such system on the road, but it does not… allow the driver to abdicate responsibility.”  Presumably the technology has gotten much safer in the past 2 years because California just legalized testing of fully-autonomous vehicles on public roads.  Nationally, H.R. 3388 passed the House unanimously.  The bill’s subtext says that its intent is, “to provide for information on highly automated driving systems to be made available to prospective buyers.”  Further reading though, one finds that the goal of the bill is, “encouraging the testing and deployment of such vehicles.”  (Read also: California proposes new rules for self-driving cars to pick up passengers.)

Self-driving cars have already been tested in multiple states with positive results.  For example, in California, the state with the most drivers in America and the state that is testing AVs the most, Waymo just applied to the state to do what the above law indicates: test self-driving cars without a back-up driver on public roads.  (Besides California, many other states already have laws or proposed laws on the legality of self-driving cars.) Six months ago, GM announced its plan to start testing its Chevy Bolt EV in Manhattan later in 2018.  In Connecticut, Governor Daniel P. Malloy created a pilot program, which will soon launch, to test fully-automated cars.  And this month, the Pentagon announced that it intends to become the next big AV developer, as it soon plans to use self-driving vehicles in combat.  As Michael Griffin, the undersecretary of defense for research and engineering, states, “52 percent of casualties in combat zones can been attributed to military personnel delivering food, fuel and other logistics.”  Removing humans from this equation will save many lives.

Since there has been no final determination of the safety or legality of self-driving cars for the general population or for the disabled, no conclusion can be made on this post.  Some car manufacturers are addressing the public’s worries about fully autonomous cars by making them just not really that.  For example, one company, Phantom Auto, has developed a remote control car system, in which the car is “driven” remotely by an employee miles away.

But perhaps the worry about autonomous cars is similar to that which arose when America changed from horse-and-buggy to modern cars?  The concern and the extreme testing are understandable, but some states realize that the testing must stop at some point.  Is that time now?  In addition, should we allow those who are currently hindered from driving by their age or disability to get a key?

* Another issue that some have with self-driving cars is that, “AVs will record everything that happens in and around them. When a crime is committed, the police will ask nearby cars if they saw anything.”  For car accidents and other such physical and/or vehicular traumas this is a plus.  However, while a person or their family may want to know what vehicle caused their child’s car accident, do they want to give the government the ability to know exactly when they left for work, went to Walmart, refilled their gas tank, etc.?  Will self-driving cars be the means for social control?