The Hidden Costs of War: Veterans and Dementia

A report that recently caught the attention of the American press was that Post Traumatic Stress Syndrome, or PTSD, in our soldiers returning from Iraq and Afghanistan may increase their risk of developing Alzheimer's dementia. Unfortunately, the situation is more alarming than this.

In some cases, the development of Alzheimer's dementia is determined by the presence of certain genes at birth. However, in the majority of cases, the development of Alzheimer's and other forms of dementia is the result of the acquisition of various risk factors throughout life. PTSD is only one of many such risk factors that are seen in increasingly large numbers among our veterans.

In Alzheimer's dementia, the brain becomes clogged with deposits of crystallized protein called amyloid and tangles of another abnormally processed protein called tau. Certain genes predispose individuals to the build up of these substances. However, medical conditions such as diabetes, heart disease, obesity, and sleep apnea substantially increase the likelihood of abnormal processing of these brain substances and the subsequent development of Alzheimer's dementia.

A condition known as Metabolic Syndrome is often the starting point for those conditions. Metabolic Syndrome presents as high blood pressure; high triglycerides; low levels of the good cholesterol, HDL; high fasting blood sugar levels; and pot-bellied, abdominal obesity. Metabolic Syndrome is currently being seen in about 25% of Americans, with substantially higher prevalence among veterans.

Psychiatric conditions, such as Major Depression, further increase the likelihood of Metabolic Syndrome. Major Depression also independently increases the risk of heart disease, diabetes, obesity, and, not surprisingly, Alzheimer's dementia. PTSD is a psychiatric condition that may arise under conditions of extreme stress and horror, such as may be experienced in combat. PTSD presents with constant wariness, anxiety, and inability to relax. There is withdrawal from people, irritability, flashbacks, and nightmares. Relationships fail, jobs are lost, and lives are devastated. Major Depression, substance abuse, and sleep disorders are common co-morbidities.

The relationship to PTSD or war weariness is unclear, but the incidences of Major Depression and substance abuse are increasing among veterans. The recently noted increase in the suicide rate among American soldiers gives grim testimony to this fact. Nearly 43% of veterans with PTSD are also found to develop metabolic syndrome, with the highest prevalence among those with the most severe symptoms of PTSD. It is not clear if PTSD itself increases the risk of dementia, or if the conditions that PTSD leads to are responsible for the increased risk. However, current evidence suggests that having PTSD increases the risk of Alzheimer's dementia by over 30%.

Head trauma, the signature injury of the Iraq and Afghanistan wars, makes its own contribution to dementia. One would expect Traumatic Brain Injury, or TBI, to cause changes in cognitive function. However, it is being found that aside from the immediate effects on brain structure and function, TBI can initiate amyloid deposition and neurofibrillary tangles that are the primary neurodegenerative processes of dementia. In some cases, the risk of Alzheimer's dementia may increase even in the absence of remarkable acute changes in cognition. Depending on the presence of certain genetic features, TBI may as much as double the risk of Alzheimer's dementia.

In view of the accelerating incidence of Metabolic Syndrome, heart disease, diabetes, Major Depression, substance abuse, PTSD, and TBI among our veterans, the VA and the veterans it serves may soon be facing a heart wrenching and extremely expensive epidemic of dementia.

 

Comments

[mamacat]

Our Dad suffered horribly with PTSD from World War II (although they didn't yet call it that), and he was an alcoholic, but he was lucid til the moment he died. Although invited, he refused to go to celebrations of the victories he was involved in - he didn't want to remember. Just saying, dementia doesn't necessarily follow from PTSD and substance abuse.

I would like to point out that our Dad was not a mean drunk. He drank to escape, and as much as we wanted him not to drink, it was pretty hard not to be sympathetic. If ever I need a reminder that war is hell, I just remember the stories my Dad told me.

[SD Mendelson]

Dear Mamacat, Thank you for your thoughtful comment. It is difficult to tell the whole truth about a complicated subject in only a few paragraphs. You are absolutely right, and your point is very important. That is, there are no certain ways to determine if anyone will develop or stay free of dementia. Some people, like your father, have a basic resilliancy that spares them from the degeneration of the brain, even when they have suffered the horrors of war and used alcohol to still the memories. We need to learn what those underlying characteristics are, as they may point the way to treatment. Unfortunately, the opposite is also true. That is, some who would have been spared dementia, go on to develop the illness when their brains are traumatized by war and/or substance abuse. We owe it to these brave men and women to spread the word, and to offer them the best medical and psychiatric treatment available.
Best wishes, Scott D. Mendelson, M.D., Ph.D.

[DreamerWeaver]

Damn!
This is a spirit crushing story -- the conditions of our men and women in the military and what their futures and ours will be like.

I wonder if any of the problems could also be related to the food and water provided by contractors? Their vaccinations and medicines?
I wonder about the significance today, or later, when the psychological impact of the knowledge that they went to war because ...... and they were not protected, because ................
Our military, to defend our way of life .... our freedom. Over there. Makes me cry.

But facts and research and treatment must be attended to.
Thank you for the report.

[SD Mendelson]

Dear Dreamer Weaver, The horrors of war, the suffering of our veterans, and the fact that our nation's memory can be very short when it comes to honoring these brave men and women can indeed be spirit crushing. But, take heart! My "real job" is as a psychiatrist at a VA hospital, and everyday I see first hand the recovery of soldiers whose minds have been shattered by the burden of war. Many of us are spreading the word that the hidden wounds of war are often the most damaging, and efforts are being made at the highest levels of the VA to address these realities. The most important thing is to keep telling the truth, and to insist that our soldiers not be abandoned due to societal ignorance or governmental penny pinching.
I hope your tears dry soon. Best to you,
Scott D. Mendelson, M.D., Ph.D.

[DreamerWeaver]

Dr. Mendelson:
Thank you for your reply. Yes, Americans have been a fickle society. And yet the corporate media makes it very easy not to see war or problems in depth simply by not covering important stories. Just last week, after my discussion with a vet here on one of the blogs, I decided to volunteer at a vet care center. My skill is that I'm a good listener with an empathic spirit. The best way to relieve spirit crushing problems is to jump in and take action. I see in your bio that you are in Roseburg, I'm in Portland. I will be in contact with the VA Hospital at OHSU.
Do you have any suggestions? It is interesting that I only just decided to volunteer in your area of practice and research, and here is your report.
My best wishes to you for success in your important work.
Ms. Weaver