Serving Those Who Served: Dementia in Veterans

This Veteran’s Day, my thoughts turn to the more than 19 million living U.S. military veterans and their families.

(For our Canadian friends, I also want to express my gratitude for your nearly 630,000 veterans this Remembrance Day.)

First and foremost, I am sincerely grateful for their service to protect our country. But I also wonder how many of them have suffered physical and emotional impacts from their experience—some of which may last a lifetime.

Due to the nature of combat, soldiers are at a high risk of developing traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). As a result of these physical and emotional impacts, could there be at greater risk for dementia in veterans?

We know one risk factor for developing dementia is increased age. Of the 19 million veterans in the U.S. today, 37% are over 65 so they have at least one risk factor already. Let’s take a closer look at these two diagnoses to see how they may increase the probability of dementia in veterans.

Traumatic Brain Injury (TBI)

TBI is a disruption in the normal function of the brain that can be caused by a blow, bump or jolt to the head, the head suddenly and violently hitting an object or when an object pierces the skull and enters brain tissue. Soldiers experience explosions and are exposed to shrapnel and bullets, all of which can increase their risk of developing a TBI.

The Defense and Veterans Brain Injury Center (DVBIC) reported nearly 414,000 TBIs among U.S. service members worldwide between 2000 and late 2019. More than 185,000 Veterans who use VA for their health care have been diagnosed with at least one TBI.

Studies have indicated that TBI in early to midlife is related to two to four times the risk of dementia in late life. This risk appears to be much higher in people with several TBIs.

Post-Traumatic Stress Disorder (PTSD)

PTSD is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape, or who have been threatened with death, sexual violence, or serious injury. Unfortunately, our soldiers may experience one or more of these in the course of their service.

In a 2014 study involving 3,157 United States veterans, 87% reported exposure to at least one potentially traumatic event. On average, veterans reported 3.4 potentially traumatic events during their lifetime.

A study in JAMA Psychiatry found that in a predominantly male veteran cohort, those diagnosed as having PTSD were at a nearly 2-fold-higher risk of developing dementia compared with those without PTSD.

Due to the nature of their job, these veterans were unable to avoid these risks. So how can we help them now?

• If you or family members are seeing signs of dementia in veterans, document the signs and notify their health care provider so they can get a neurological assessment to determine if they might have a reversible or irreversible dementia or something else causing the symptoms being seen.
• If you diagnose dementia in veterans, share resources your community has on how to keep them healthy and active, arrange for therapy to evaluate the safety of their living environment within your community, and work with the veteran and their family to create a plan for the future.
• Share information about what dementia is, the stages of dementia, and how your community can support them throughout their journey.
• Educate staff in Dementia Capable Care, which will help them adapt the world for the veteran at each stage and help prevent distress behaviors which may be associated with the traumas they’ve experienced.

How to Support the Veteran at Each Stage of the Journey with Dementia

People in the early stages of dementia depend on structure and familiar routines for security and more autonomy, as they help the person know what to expect and how to act. Incorporating their familiar routines and preferences into their care plan will allow them to maintain a good level of independence for activities for daily living (ADLs) as well as leisure activities. People at this stage of the disease may require set-up support or reminders of events but will be able to participate and thrive in community life.

As the disease progresses to the middle stage, people with dementia can still perform familiar actions with familiar objects and the support of one person for initiation and cues to participate in an activity. Attention is becoming significantly impaired, so shorter activities (30-45 minutes) are preferable. The person’s verbal abilities are beginning to decline so they may communicate more with behaviors than words. Incorporating their favorite traditions, songs, and foods into celebrations will trigger long-term memory and will allow them to participate to their best ability. People at this stage of the disease need more time to process what is happening, so we as caregivers need to slow down our communication and give one-step-at-a-time cues so they can participate in familiar activity.

In the late stage of the disease, the person’s best ability is making gross motor movements. Their ability to process information and cues in the environment is much slower, so they need more time between stimuli and a quieter setting to participate in a familiar activity. People at this stage of the disease can become easily overwhelmed in noisy, busy spaces. If they also have PTSD or TBI this may be even more pronounced at this stage. Therefore, smaller group gatherings in a quiet area with simple, familiar activities allow them to experience calm and well-being, and engage in activities at their best ability.

At the end stage of dementia, a person’s best ability is responding to stimulation with all five senses, and they still feel love, can laugh, and communicate through facial expressions. Creating sensory stimulation experiences around their interests that include meaningful sights, sounds, tastes, and touches allows the person to engage in activities, and experience relationships with their friends and family members who may otherwise not visit because they feel their loved one is not “in there” anymore.

Ask your therapy and activity team members to collaborate in creating a sensory stimulation kit from the person’s interests and preferences. Family and friends can be trained by your staff on how to use the items safely and effectively for meaningful visits.

Long-term and procedural memories are strengths for all people with dementia. Using familiar traditions, routines, and objects allow the person with dementia greater ability to participate in activities.

Special Considerations: Distress Behaviors

A distress behavior is not a symptom of dementia, yet many associate the diagnosis of dementia with behavioral problems. Alzheimer’s disease and other dementias can cause challenges in processing stimuli, feelings of fear, and insecurity for the person with dementia and could lead to distress behaviors. When you consider dementia in veterans, a history of trauma or brain injury can exacerbate those behavioral and psychological symptoms.

How can your community help?

• Complete assessments that give your team information on past traumas, emotional history, and any psychological diagnoses the veteran may have.
• Consider using the STAR-VA tool. Studies support the feasibility and effectiveness of STAR-VA for managing challenging dementia-related behaviors in veterans in real-world, nursing home settings.
• Educate staff in Dementia Capable Care, which will help them learn how to prevent and respond to calm distress behaviors. No matter the root cause of the distress behavior, whether it be combat traumas, injuries, or the effects of dementia, this can give staff the skills they need to respond compassionately and effectively to distress behaviors.

When they were young, these men and women answered the call to defend our country from harm and protect our freedoms. Through no fault of their own they may have been exposed to the kinds of factors that lead to an increased risk of dementia in veterans.

How lucky are we that we now get a chance to show our gratitude for their service to these veterans through our skilled care and compassionate hearts?

Sharon Host, OTR/L, is a Senior Consultant and Global Professional Instructor with Dementia Care Specialists at Crisis Prevention Institute. Specializing in geriatrics, Sharon has over 20 years of experience in the long-term care setting, the home health care industry, and as a dementia care consultant.

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