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Although studies have shown posttraumatic stress disorder (PTSD) associated with risk of suicide, the relationship in later life, especially for overdose death, remains unclear. Thus, the aim of the current study was to determine associations between PTSD, suicide, and unintended overdose death in mid- to late-life.A nationwide cohort study integrating Department of Veterans Affairs' (VA) data, Centers for MedicareMedicaid Services data, and national cause-specific mortality data. Participants were US veterans aged ≥50 years with PTSD diagnoses at baseline (2012-2013) and were propensity-matched 1:1 with patients without PTSD based on sociodemographics, Charlson Comorbidity Index, and neuropsychiatric disorders (N = 951,018). Information on suicide attempts and unintended death by overdose through December 31, 2017 was provided by the VA's National Suicide Prevention Applications Network (non-fatal attempts) and Mortality Data Repository (death).Veterans with PTSD (N = 475,509) had increased risk of suicide attempt (Hazard Ratio [HR], 1.59; 95% CI, 1.54-1.65; p 0.001), non-fatal attempt (HR, 1.74; 95% CI, 1.67-1.81; p 0.001), drug overdose death overall (HR, 1.32; 95% CI, 1.22-1.42; p 0.001), and suicide overdose death (HR, 1.44; 95% CI, 1.15-1.80; p = 0.002), even after adjusting for sociodemographics, Charlson comorbidity index, and neuropsychiatric disorders. We found increased risk for overdose death by narcotics (HR, 1.30; 95% CI, 1.15-1.46; p 0.001), antiepileptic/sedative-hypnotics (HR, 1.29; 95% CI, 1.02-1.62; p = 0.032), and for other/unspecified drugs (HR, 1.35; 95% CI, 1.20-1.51; p 0.001), the last category indicative of polydrug. Results remained robust when examined for unintentional, suicide, and undetermined intent for cause-specific death by other/unspecified drugs.PTSD persists throughout mid- to late-life with considerable increased risk for non-fatal suicide attempts and suicide overdose death. These findings suggest the importance of drug-monitoring in preventing late-life suicide.

Older veterans are vastly underrepresented in studies that shape national suicide prevention strategies. This is of great concern because factors that impact younger veterans may not be as robust in later life. Although younger veterans have higher rate of suicide, the highest counts of death by suicide are in older veterans. However, it remains unclear from the extant literature what factors may influence increased or decreased risk of late-life suicide in veterans. The objective of this systematic review was to identify risk and protective factors related to suicide outcomes (i.e., ideation, attempt, death, or suicide-related behavior [SRB]) among older veterans. Furthermore, it offers data regarding future study directions and hypothesis generation for late-life suicide research and for informing potential intervention and prevention efforts in this area. We searched 4 databases from inception up to May 5, 2022. We screened 2,388 abstracts for inclusion and 508 articles required full text review. The final sample included 19 studies published between 2006 and 2022. We found five domains of factors studied (i.e., neuropsychiatric, social determinants of health, aging stereotypes, residential and supportive housing settings, and multifactorial-neuropsychiatric/mental health and physical health) with more risk factors than protective factors reported. Across the three suicide outcomes only neuropsychiatric factors were consistently identified as risk factors. Neuropsychiatric factors also comprised the largest group of risk factors studied. More innovative targets to consider for intervention and more innovative methods to predict suicide in late-life are needed. There is also continued necessity to design suicide prevention interventions for older veterans given lethality trends.

ObjectiveRacial/ethnic disparities in menopause symptoms and hormone therapy management remain understudied among women served by the Veteran's Health Administration, despite the unique racial/ethnic diversity of this population. Thus, we determined racial/ethnic disparities in medical record-documented menopause symptoms and prescribed menopausal hormone therapy among women veterans.MethodsWe conducted cross-sectional analyses of national Veteran's Health Administration electronic health record data from 2014 to 2015. We used logistic regression models to compare medical-record documented menopause symptoms and treatment (eg, vaginal estrogen or systemic hormone therapy) by self-identified race/ethnicity, adjusting for age, body mass index, and depression. Models examining hormone treatment were adjusted for menopause symptoms.ResultsAmong 200,901 women veterans (mean age 54.3, SD 5.4 y; 58% non-Hispanic/Latinx White, 33% non-Hispanic/Latinx Black, 4% Hispanic/Latinx, and 4% other), 5% had documented menopause symptoms, 5% were prescribed vaginal estrogen, and 5% were prescribed systemic hormone therapy. In fully adjusted multivariable models, non-Hispanic/Latinx Black women veterans had lower odds of documented menopause symptoms relative to non-Hispanic/Latinx White women (OR 0.82, 95% CI: 0.78-0.86). Moreover, non-Hispanic/Latinx Black women (OR 0.74, 95% CI: 0.70-0.77), as well as Hispanic/Latinx women (OR 0.68, 95% CI: 0.61-0.77), had lower likelihood of systemic hormone therapy prescription. Hispanic/Latinx women had higher odds of vaginal estrogen prescription (OR 1.12 95% CI: 1.02-1.24) than non-Hispanic/Latinx White women. Non-Hispanic/Latinx Black women had lower likelihood of estrogen use (OR 0.78 95% CI: 0.74-0.81) than non-Hispanic/Latinx White women.ConclusionDespite evidence suggesting higher menopause symptom burden among Black women in community samples, documented menopause symptoms and hormone therapy were less common among Black, compared with White, women veterans. Additionally, Hispanic/Latinx women veterans had lower odds of prescribed systemic menopause therapy and yet higher odds of prescribed vaginal estrogen, despite no difference in documented symptoms. These findings may signal important disparities in symptom reporting, documentation, and/or treatment for minority women veterans.

ImportanceFrailty is associated with reduced physiological reserve, lack of independence, and depression and may be salient for identifying older adults at increased risk of suicide attempt.ObjectivesTo examine the association between frailty and risk of suicide attempt and how risk differs based on components of frailty.Design, Setting, and ParticipantsThis nationwide cohort study integrated databases from the US Department of Veterans Affairs (VA) inpatient and outpatient health care services, Centers for Medicare & Medicaid Services data, and national suicide data. Participants included all US veterans aged 65 years or older who received care at VA medical centers from October 1, 2011, to September 30, 2013. Data were analyzed from April 20, 2021, to May 31, 2022.ExposuresFrailty, defined based on a validated cumulative-deficit frailty index measured using electronic health data and categorized into 5 levels: nonfrailty, prefrailty, mild frailty, moderate frailty, and severe frailty.Main Outcomes and MeasuresThe main outcome was suicide attempts through December 31, 2017, provided by the national Suicide Prevention Applications Network (nonfatal attempts) and Mortality Data Repository (fatal attempts). Frailty level and components of the frailty index (morbidity, function, sensory loss, cognition and mood, and other) were assessed as potential factors associated with suicide attempt.ResultsThe study population of 2 858 876 participants included 8955 (0.3%) who attempted suicide over 6 years. Among all participants, the mean (SD) age was 75.4 (8.1) years; 97.7% were men, 2.3% were women, 0.6% were Hispanic, 9.0% were non-Hispanic Black, 87.8% were non-Hispanic White, and 2.6% had other or unknown race and ethnicity. Compared with patients without frailty, risk of suicide attempt was uniformly higher among patients with prefrailty to severe frailty, with adjusted hazard ratios (aHRs) of 1.34 (95% CI, 1.27-1.42; P P P P Conclusions and RelevanceThis cohort study found that among US veterans aged 65 years or older, frailty was associated with increased risk of suicide attempts and lower levels of frailty were associated with greater risk of suicide death. Screening and involvement of supportive services across the spectrum of frailty appear to be needed to help reduce risk of suicide attempts.

Background Among midlife and older women, menopause symptoms and menopausal hormone therapy have been linked to mental health disorders and other comorbidities related to suicide. However, the role of hormone therapy as a prognostic factor of suicide risk is largely unknown. Objectives To examine associations between menopausal hormone therapy, suicide attempts, and suicide among midlife and older women Veterans. Research design In this longitudinal analysis of national Veterans Health Administration data from women Veterans aged 50 years and above, we used Fine-Gray proportional hazards models to examine associations between menopausal hormone therapy (prescribed in 2012-2013) and incident suicide attempts and suicide (index date-2016). Measures Menopausal hormone therapy and psychoactive medications from pharmacy records; suicide attempts and suicide from national suicide data repositories; demographic variables, medical and psychiatric diagnoses, and substance use disorders from electronic medical record data and International Classification Diagnoses-9-CM codes. Results In this national sample of 291,709 women Veterans (mean age 60.47, SD 9.81), 6% were prescribed menopausal hormone therapy at baseline. Over an average of 4.5 years, 2673 had an incident suicide attempt (93%) or death by suicide (7%). Adjusting for age, race, and medical diagnoses, menopausal hormone therapy was associated with increased risk of suicide attempt (hazard ratio 1.41; 95% confidence interval, 1.22-1.64) and over 2-fold increased risk of death by suicide (hazard ratio 2.47; 95% confidence interval, 1.58-3.87). Associations with death by suicide remained significant after accounting for psychiatric comorbidity and psychoactive medications. Conclusions Menopausal hormone therapy may be an important indicator of suicide risk among midlife and older women.

The objective of this study was to determine the association of traumatic brain injury (TBI) with mortality in military veterans and whether this association differs as a function of TBI severity, timing, and cause of death. This national cohort study used U.S. Department of Veterans Affairs' (VA) data of patients 18 years and older with TBI diagnoses (N = 213,290) and 1:1 propensity-matched comparison random sample of patients without TBI (N = 213,290). The main outcome measure was mortality within 6 months of TBI diagnosis and longer-term (after 6 months). Cox proportional hazards models were used to examine risk of all-cause mortality according to TBI severity and Fine-Gray proportional hazards regression to examine time to cause-specific mortality, accounting for competing risk of other deaths. For patients with moderate-to-severe TBI (compared with no TBI), hazard ratios (HRs) for mortality were highest within first 6 months of injury (fully-adjusted HR: 2.42, 95% CI: 2.32-2.53); for mild TBIs, HRs for mortality were lower and relatively constant over time (fully-adjusted HR within first 6 months: 1.33, 95% CI: 1.26-1.39). Veterans with mild and moderate-to-severe TBI had higher risk of future death over short term for 9 out 10 of the U.S. leading causes of death, with only unintentional injury, stroke, and suicide showing differences by TBI severity. Associations attenuated significantly from within to after 6 months TBI diagnosis. These findings indicate that adults with TBI are at increased risk of majority of leading causes of death, with differential risk by TBI severity and timing of death.

Lung cancer screening (LCS) via low-dose chest computed tomography can prevent mortality through surgical resection of early-stage cancers, but it is unknown whether poor health is associated with screening. Though LCS may be associated with better outcomes for non-Hispanic Black individuals, it is unknown whether racial or ethnic disparities exist in LCS use.To determine whether health status is associated with LCS and whether racial or ethnic disparities are associated with LCS independently of health status.This cross-sectional, population-based study of community-dwelling US adults used data from Behavioral Risk Factor Surveillance System annual surveys, 2017 to 2020. Participants were aged 55 to 79 years, with a less than 30 pack-year smoking history, and were current smokers or those who quit within 15 years. Data were analyzed from August to November 2021.Self-reported health status and race and ethnicity.Self-reported LCS in the last 12 months.Of 14 550 individuals (7802 men [55.5%]; 7527 [55.0%] aged 65-79 years [percentages are weighted]), representing 3.68 million US residents, 17.0% (95% CI, 15.1%-18.9%) reported undergoing LCS. The prevalence of LCS was lower among non-Hispanic Black than non-Hispanic White individuals but not to a significant degree (12.0% [95% CI, 4.3%-19.7%] vs 17.5% [95% CI, 15.6%-19.5%]; P = .57). Health status was associated with LCS: 468 individuals in poor health vs 96 individuals in excellent health reported LCS (25.2% [95% CI, 20.6%-29.9%] vs 7.6% [95% CI, 5.0%-10.3%]; P .001), and those with difficulty climbing stairs were more likely to report LCS than those without this functional limitation. Adjusting for sociodemographic factors, functional status, and comorbidities, self-rated health status remained associated with LCS (adjusted odds ratio, 1.19 per each 1-step decline in health; 95% CI, 1.03-1.38), and non-Hispanic Black individuals were 53% less likely to report LCS than non-Hispanic White individuals (adjusted odds ratio, 0.47; 95% CI, 0.24-0.90). Results were robust in sensitivity analyses in which health was alternatively quantified as number of comorbidities.LCS in the US is more common among those who may be less likely to benefit from screening because of poor underlying health. Furthermore, racial or ethnic disparities were evident after accounting for health status, with non-Hispanic Black individuals nearly half as likely as non-Hispanic White individuals to report LCS despite the potential for greater benefit of screening this population.

BackgroundAccumulating evidence indicates that behaviors in Alzheimer's disease and related dementias could result in incarceration. Yet, the proportion of persons diagnosed with dementia and mild cognitive impairment (MCI) before they were incarcerated is largely unknown. By leveraging a national sample of mid- to late-life adults who were incarcerated, we determined the prevalence of dementia and MCI before their incarceration.MethodsIn this current study, participants were Medicare-eligible U.S. veterans who transitioned from incarceration to the community in mid- to late-life from October 1, 2012, to September 30, 2018, after having been incarcerated for ≤10 consecutive years (N=17,962). Medical claims data were used to determine clinical diagnoses of dementia and MCI up to three years before incarceration. Demographics, comorbidities, and duration of incarceration among those with dementia and MCI were compared to those with neither diagnosis.ResultsParticipants were >97% male, 65% non-Hispanic white, 30% non-Hispanic black, and 3.3% had a diagnosis of either dementia (2.5%) or MCI (0.8%) before their most recent incarceration. Individuals with MCI or dementia diagnoses were older, were more likely to be non-Hispanic white, had more medical and psychiatric comorbidities, and experienced homelessness and traumatic brain injury at higher rates than those with neither diagnosis. Average duration of incarceration was significantly shorter among those with MCI (201.8 [±248.0] days) or dementia (312.8 [±548.3] days), as compared to those with neither diagnosis (497.0 [±692.7] days) (p

Introduction Given minimum sentencing laws, more arrests in later age, and population aging, the US incarcerated population is aging, with adults 50+ projected to account for 1/3 of this population by 2030. As most incarcerated persons are released, the number of those being released in mid- to late-life is growing. Evidence indicates accelerated aging (e.g., higher prevalence of geriatric conditions and ADL disability) among those 50+ with incarceration histories as compared to their never-incarcerated (NI) peers. Moreover, those reentering the community following incarceration are likely to have many risk factors for Alzheimer's disease and related dementias (AD/ADRD), such as PTSD and low education attainment. However, the burden of AD/ADRD, mild cognitive impairment (MCI), and other related diseases in this population is largely unknown. Our objective was to characterize the prevalence of these conditions in the 50+ reentry population using a national sample. Understanding this burden is a crucial first step to developing evidence-based policies that support their healthcare and reentry needs. Methods We estimated the prevalence of dementia (AD/ADRD and MCI) and other related diseases in 28,267 veterans aged 50+, who were Medicare beneficiaries and reentered the community from incarceration between October 1, 2007 and December 31, 2017 (referred to as “reentry veterans”). In addition, we created a 1:5 matched comparison cohort of 141,335 never-incarcerated veterans (referred to as “NI veterans”) matched on age, year of release/Medicare eligibility year, and sex. To create these cohorts, we linked two national databases: (1) Centers for Medicare & Medicaid Services (CMS), for medical claims/diagnoses and incarceration release date; and (2) National Patient Care Database (NPCD), for VA inpatient and outpatient services. To characterize the prevalence of dementia and related diseases, we used ICD-9 clinical diagnosis codes in inpatient and outpatient medical records from October 1, 2007 to September 30, 2015, and ICD-10 codes through study end. The 10-year prevalence of dementia diagnoses include MCI and AD/ADRD diagnoses: Alzheimer's disease, Frontotemporal dementia, Lewy body dementia, vascular dementia, mixed dementia (2+ dementias), dementia associated with Parkinson's disease, senile dementia, dementia not otherwise specified, and dementia associated with HIV/AIDS. The 10-year prevalence of dementia related diseases included Parkinson's disease, Huntington's disease, and multiple sclerosis. Both 10-year prevalence estimates were determined by reentry and NI status across age groups 50-64, 65-74, 75-84, and 85+. Differences between reentry and NI cohorts age groups were evaluated with chi-square tests. We examined the potential differing trend across age groups by statistically testing the interaction of age groups and reentry status for each disorder using logistic regression. Statistical significance was defined as p Results Both cohorts had an average age of 63 (SD 8) and were 97% male. The reentry cohort was 66% white, 30% black, and 4% other. The never incarcerated cohort was 77% white, 18% black, and 4% other. Figure 1 presents the 10-year prevalence of dementia diagnoses according to age group for both reentry and NI cohorts. The reentry cohort had, on average, a 32% higher 10-year prevalence of dementia diagnosis than the NI cohort (Figure 1), with greatest differences at ages 65-74. At ages 65+, 18% of reentry veterans had an AD/ADRD diagnosis, versus 12% in the NI cohort. The estimates go up to >50% for reentry veterans 85+ versus 43% for NI (p-interaction Conclusions These findings indicate that reentering community after incarceration aged 50+ is associated with higher occurrences of AD/ADRD and MCI, but not necessarily with dementia related diseases. Because we did not have access to the reentry group's incarceration medical records, we were unable to obtain diagnoses during incarceration. This is the first study to characterize the burden of AD/ADRD and related diseases among those with a recent history of incarceration. The higher prevalence of AD/ADRD and MCI in the reentry cohort across age groups may indicate accelerated cognitive aging among those with a history of incarceration. Our findings highlight the importance of identifying those with MCI during incarceration so reentry care transition services can be put into place to slow the progression of cognitive decline. Funding This work was supported by RF1 MH117604 from the National Institute of Mental Health (principal investigators: Lisa C. Barry, Ph.D., M.P.H. and Amy L. Byers, Ph.D., M.P.H.).

Approximately 1 in 3 women veterans endorse military sexual trauma (MST) during Veterans Health Administration (VHA) screening. Higher rates have been reported in anonymous surveys.We compared MST identified by VHA screening to survey-reported MST within the same sample and identified participant characteristics associated with discordant responses.Cross-sectional data were drawn from an observational study of women veterans aged 45-64 enrolled in VHA care in Northern California, with data from mail- and web-based surveys linked to VHA electronic health records (EHRs). Between March 2019 and May 2020, participants reported sociodemographic characteristics, current depressive (Patient Health Questionnaire-9) and posttraumatic stress (PTSD checklist for DSM-5) symptoms, and MST (using standard VHA screening questions) in a survey; depression and posttraumatic stress disorder diagnoses (ICD-10 codes) and documented MST were identified from EHRs. Associations between sociodemographic characteristics, mental health symptoms and diagnoses, and discordant MST reports (EHR-documented MST vs. MST reported on survey, not in EHR) were examined with multivariable logistic regression.In this sample of midlife women veterans (n = 202; mean age 56, SD = 5), 40% had EHR-documented MST, and 74% reported MST on the survey. Sociodemographic characteristics, mental health symptoms, and diagnosed depression were not associated with discordant MST responses. Women with an EHR-documented PTSD diagnosis had fivefold higher odds of having EHR-documented MST (vs. survey only; odds ratio 5.2; 95% confidence interval 2.3-11.9).VHA screening may not capture more than half of women who reported MST on the survey. VHA screening may underestimate true rates of MST, which could lead to a gap in recognition and care for women veterans.

ImportanceCannabis has been proposed as a therapeutic with potential opioid-sparing properties in chronic pain, and its use could theoretically be associated with decreased amounts of opioids used and decreased risk of mortality among individuals prescribed opioids.ObjectiveTo examine the risks associated with cannabis use among adults prescribed opioid analgesic medications.Design, Setting, and ParticipantsThis cohort study was conducted among individuals aged 18 years and older who had urine drug screening in 2014 to 2019 and received any prescription opioid in the prior 90 days or long-term opioid therapy (LTOT), defined as more than 84 days of the prior 90 days, through the Veterans Affairs health system. Data were analyzed from November 2020 through March 2022.ExposuresBiologically verified cannabis use from a urine drug screen.Main Outcomes and MeasuresThe main outcomes were 90-day and 180-day all-cause mortality. A composite outcome of all-cause emergency department (ED) visits, all-cause hospitalization, or all-cause mortality was a secondary outcome. Weights based on the propensity score were used to reduce confounding, and hazard ratios [HRs] were estimated using Cox proportional hazards regression models. Analyses were conducted among the overall sample of patients who received any prescription opioid in the prior 90 days and were repeated among those who received LTOT. Analyses were repeated among adults aged 65 years and older.ResultsAmong 297 620 adults treated with opioids, 30 514 individuals used cannabis (mean [SE] age, 57.8 [10.5] years; 28 784 [94.3%] men) and 267 106 adults did not (mean [SE] age, 62.3 [12.3] years; P P Conclusions and RelevanceThis study found that cannabis use among adults receiving opioid analgesic medications was not associated with any change in mortality risk but was associated with a small increased risk of adverse outcomes and that short-term risks were higher among older adults receiving LTOT.

Background Previous research has found that social risk factors are associated with an increased risk of 30-day readmission. We aimed to assess the association of 5 social risk factors (living alone, lack of social support, marginal housing, substance abuse, and low income) with 30-day Heart Failure (HF) hospital readmissions within the Veterans Health Affairs (VA) and the impact of their inclusion on hospital readmission model performance. Methods We performed a retrospective cohort study using chart review and VA and Centers for Medicare and Medicaid Services (CMS) administrative data from a random sample of 1,500 elderly (≥ 65 years) Veterans hospitalized for HF in 2012. Using logistic regression, we examined whether any of the social risk factors were associated with 30-day readmission after adjusting for age alone and clinical variables used by CMS in its 30-day risk stratified readmission model. The impact of these five social risk factors on readmission model performance was assessed by comparing c-statistics, likelihood ratio tests, and the Hosmer-Lemeshow goodness-of-fit statistic. Results The prevalence varied among the 5 risk factors; low income (47 % vs. 47 %), lives alone (18 % vs. 19 %), substance abuse (14 % vs. 16 %), lacks social support (2 % vs. Conclusions While a lack of social support was associated with 30-day readmission in the VA, its prevalence was low. Moreover, the inclusion of some social risk factors did not improve readmission model performance. In an integrated healthcare system like the VA, social risk factors may have a limited effect on 30-day readmission outcomes.

Alzheimer’s disease and related dementias (ADRD) are progressive illnesses characterized by decline in cognitive function that impairs performing daily activities. People with ADRD are at an increased risk of suicide, especially those who have comorbid mental health conditions, have specific types of ADRD, or have been recently diagnosed. The coronavirus disease 2019 (COVID-19) pandemic has increased the distress of people with ADRD, a population also at increased risk of contracting the COVID-19 virus. In this article, we draw on a case study and use the Interpersonal Theory of Suicide to help describe the association between ADRD and suicide risk. Secondly, we call for new strategies to mitigate suicide risk in people living with ADRD during and beyond the current pandemic by using lessons learned from cancer care. Our goal is not to dictate solutions but rather to start the conversation by outlining a framework for future research aimed at preventing death by suicide in people with ADRD. Specifically, we draw on the updated Framework for Developing and Evaluating Complex Interventions to reflect on the complexity of the issue and to break it down into achievable parts to reduce the risk of suicidal behavior (ideation, plans, attempts) in those living with ADRD.

Objective: Evidence guiding suicide-prevention efforts in patients with traumatic brain injury (TBI) is imperative. We evaluated association between TBI and risk of death by drug overdose and firearms, including suicide and unintentional injury.Methods: Cohort study of all patients 18 years and older in Veterans Health Administration databases from October 1, 2001 to December 31, 2014 with TBI diagnosis (N = 230,200), and age-matched 1:1 to random sample of patients without TBI (N = 230,200).Results: After adjusting for demographics, comorbidities, and accounting for competing risk of other deaths, hazard ratios for death by drug overdose were 1.40 (95% CI = 1.21-1.62) for mild TBI and 1.51 (95% CI = 1.31-1.74) for moderate-to-severe TBI, while hazard ratios for death by firearms were 1.09 (95% CI = 0.89-1.33) for mild TBI and 1.33 (95% CI = 1.10-1.60) for moderate-to-severe TBI. Risk of overdose death due to TBI severity was mainly observed for middle and older age groups.Conclusions: Findings suggest that veterans with mild and moderate-to-severe TBI are at increased risk of death by drug overdose and firearms, with overdose risk heightened with age. Data indicate that prevention efforts in patients with TBI include targeted means reduction.

Background Rates of suicide and unintended overdose death are high among midlife and older women, yet there is paucity of data identifying women at greatest risk. Psychoactive medications, commonly prescribed and co-prescribed in this population, may serve as salient indicators of risk for these outcomes. Objective To determine whether long-term psychoactive medications and psychoactive polypharmacy predict risk of suicide and unintended overdose death among midlife and older women Veterans above and beyond other recognized factors. Design Longitudinal cohort study Participants Women Veterans aged ≥ 50 with at least one Veterans Health Administration (VHA) clinical encounter in FY2012–2013. Main Measures Long-term psychoactive medications (opioids, benzodiazepines, sedative-hypnotics, antidepressants, antipsychotics, and antiepileptics, prescribed for ≥ 90/180 days) and psychoactive polypharmacy (overlapping for ≥ 1 day) from VHA pharmacy records; suicide and unintended overdose death through December 31, 2018. Key Results In this national sample of 154,558 midlife and older women Veterans (mean age 63.4, SD 9.3 years), 130 died by suicide and 175 died from unintentional overdose over an average of 5.6 years. In fully adjusted models, long-term opioids (hazard ratio (HR) 2.01, 95% CI 1.21–3.35) and benzodiazepines (HR 2.99, 95% CI 1.82–4.91) were associated with death by suicide; opioids (HR 3.62, 95% CI 2.46–5.34), benzodiazepines (HR 2.77, 95% CI 1.73–4.42), sedative-hypnotics (HR 1.87, 95% CI 1.06–3.29), antidepressants (HR 1.47, 95% CI 1.03–2.12), antipsychotics (HR 1.81, 95% CI 1.02–3.22), and antiepileptics (HR 2.17, 95% CI 1.48–3.19) were associated with unintended overdose death. Women who were co-prescribed ≥ 3 psychoactive medications had over 2-fold increased risk of suicide (HR 2.83, 95% CI 1.65–4.84) and unintended overdose death (HR 2.60, 95% CI 1.72–3.94). Conclusions Long-term psychoactive medications and psychoactive medication polypharmacy were important indicators of risk for death by suicide and death by unintended overdose among midlife and older women Veterans, even after accounting for psychiatric and substance use disorders.

ObjectiveTo test the hypothesis that veterans with traumatic brain injury (TBI) have an increased subsequent risk of sleep disorders, we studied the longitudinal association between TBI and incident sleep disorders in nearly 200,000 veterans.MethodsWe performed a cohort study of all patients diagnosed with a TBI in the Veterans Health Administration system from October 1, 2001, to September 30, 2015, who were age-matched 1:1 to veterans without TBI. Veterans with prevalent sleep disorders at baseline were excluded. Development of sleep disorders was defined as any inpatient or outpatient diagnosis of sleep apnea, hypersomnia, insomnia, or sleep-related movement disorders based on ICD-9 codes after the first TBI diagnosis or the random selection date for those without TBI. We restricted the analysis to those with at least 1 year of follow-up. We used Cox proportional hazards models to examine the association between TBI and subsequent risk of sleep disorders.ResultsThe study included 98,709 veterans with TBI and 98,709 age-matched veterans without TBI (age 49 ± 20 years). After an average follow-up of 5 (1–14) years, 23,127 (19.6%) veterans developed sleep disorders. After adjustment for demographics, education, income, and medical and psychiatric conditions, those who had TBI compared to those without TBI were 41% more likely to develop any sleep disorders (hazard ratio 1.41 [95% confidence interval 1.37–1.44]), including sleep apnea (1.28 [1.24–1.32]), insomnia (1.50 [1.45–1.55]), hypersomnia (1.50 [1.39–1.61]), and sleep-related movement disorders (1.33 [1.16–1.52]). The association was stronger for mild TBIs, did not differ appreciably by presence of posttraumatic stress disorder, and remained after a 2-year time lag.ConclusionIn 197,418 veterans without sleep disorders, those with diagnosed TBI had an increased risk of incident sleep disorders over 14 years. Improved prevention and long-term management strategies for sleep are needed for veterans with TBI.

Objective To compare occurrence of clinically diagnosed psychiatric disorders and suicidal behavior (mental health disorders) across dementia subtypes in the largest healthcare system in the United States. Methods We aggregated two national databases (Department of Veterans Affairs [VA] National Patient Care Database, National Suicide Prevention Applications Network [SPAN]) and estimated 2-year prevalence of mental health disorders across five dementia subtypes during fiscal years 2012–2013. Using VA healthcare systems throughout the United States, the sample included 56,296 older patients (≥50 years) with Alzheimer's disease (AD; n = 30,578), vascular dementia (VD; n = 17,924), frontotemporal dementia (FTD; n = 1,181), Lewy body dementia (LBD; n = 3,194), and mixed dementia (MD; n = 3,419). Mental health disorders were determined by International Classification of Diseases, Ninth Revision, Clinical Modification codes and the National SPAN. Results Roughly 25% of patients had at least one mental health disorder, with 2-year prevalence reaching 30%–45% in FTD, VD, LBD, and MD. Compared with other subtypes, patients with FTD had the highest prevalence of mood (19%), anxiety (20%), and substance use (19%) disorders, as well as suicidal behavior (4%), with nearly 0.5% with a suicidal plan/attempt. Those with VD also showed a high prevalence of these disorders (14%–17%). Although patients with LBD and MD had a slightly lower prevalence of mood and anxiety disorders (12%–15%), they had a much lower prevalence of substance use disorders (9%) and suicidal behavior (2%). Patients with AD had the lowest 2-year prevalence of all mental health disorders ( Conclusion Occurrence of mental health disorders is high and differs across dementia subtypes, highlighting the importance of reducing the burden of mental health disorders in dementia subtypes.

Introduction Late life is often associated with declining health, with an estimated 11-32% of community-dwelling older adults living with frailty. Frailty, a durable phenotype associated with depression, is often measured as an accumulation of physical and mental deficits. This underlying distress may be associated with suicidal thoughts. Frailty has never been assessed as a risk factor for suicide on a national level but may be useful as a prognostic marker. Our primary objective was to determine the relationship of frailty to subsequent risk of suicide attempt and death by suicide across age groups in a large national cohort of veterans aged 50+. With >70% of the veteran population aged 50+ and ∼70% of veteran suicides occurring in older veterans, this study has potential to be highly impactful. Methods We performed a longitudinal cohort study on a national sample of mid to late-life veterans: All veterans aged 50+ who used VA healthcare services during study baseline of fiscal years 2012-2013 (N=5,059,526) with ongoing follow-up through the end of calendar year 2017. We linked four national databases: (1) National Patient Care Database (NPCD), for VA inpatient and outpatient services; (2) Centers for Medicare & Medicaid Services (CMS), for non-VA inpatient and outpatient services; (3) Suicide Prevention Applications Network (SPAN), for information on non-fatal suicide attempts; and (4) Mortality Data Repository (MDR), for cause-specific death information and dates. Demographic information for age, gender, and race/ethnicity was obtained from NPCD and/or CMS records. To study the role of frailty and its connection to late-life suicide-related behaviors, we used a cumulative deficit method and frailty index (FI) developed by Orkaby et al. (2019). This index integrates 31 variables (deficits) from ICD-9/10 diagnoses and procedure codes and HCPCS (Healthcare Common Procedure Coding System) codes from NPCD and CMS data. Variables relate to morbidity (e.g., diabetes), functional status (e.g., use of durable medical equipment), cognition and mood (e.g., depression), sensory loss (e.g., blindness), and other geriatric conditions (e.g., weight loss in the past year). FI scores were calculated at baseline index date of study entry and within two years prior, summing the number of accrued deficits then dividing by 31 (total number of possible deficits), producing scores from 0 to 1. We defined Non-frail as FI≤0.1, Pre-frail as 0.1 0.4. Suicide attempt and death outcomes were derived from SPAN and MDR databases through 2017. Non-fatal suicide attempts were derived from SPAN, based on standardized clinician reports uploaded to the national database. Fatal suicide attempts were derived from MDR with ICD-10 codes X60-X84 and Y87.0. Cumulative incidence of any suicide attempt was plotted by patient age in years across frailty categories. We used Cox proportional hazards regression to examine time to suicide attempt at follow up, with age as the time scale and censoring at end of study. We examined multivariable models adjusted in steps: Model 1, unadjusted; Model 2, adjusted for demographics (race, gender, region); Model 3, Model 2 + adjusted for substance use disorder and PTSD; Model 4, Model 3 + adjusted for Charlson Comorbidity Index (CCI). We did not adjust for depression as it was included in the FI. We adjusted for CCI to examine the FI's robustness as a marker for suicide risk in the context of another global index. Results Our sample's average age was 68 (SD 11), 94% male, 77% white, and 14% black. Fifty-one percent of veterans aged 50+ were non-frail, while 26% were pre-frail, 12% mildly frail, 6% moderately frail, and 4% severely frail. The average FI score was 0.10. There were 29,679 suicide attempts at follow up, with 9,659 fatal attempts. Cumulative incidence rates of suicide attempt were significantly higher for more frail than less frail individuals (Figure 1). Our fully adjusted model (Table 1, Model 4) showed a strong dose-response relationship between frailty severity and risk of suicide attempt (fatal and non-fatal), with hazard ratios (HR) increasing from 1.55 for Pre-frail to 2.50 for Severely frail individuals. An attenuated HR effect was seen for fatal attempts: ranging from 1.29 for Pre-frail to 1.56 for Severely frail individuals. Furthermore, we found a significant interaction of FI by age groups 50-64 and 65+ (p-interaction Conclusions Our findings suggest a cumulative deficit FI may be a strong prognostic marker associated with risk of suicide attempt in young-old to oldest-old beyond other factors such as substance use disorder, PTSD, and CCI. This study provides clinicians with a better understanding of potential frailty-related suicide risk in patients aged 50+. Funding I01 CX001119-05 (PI: Byers) Veterans Administration Clinical Science Research & Development

Introduction Although posttraumatic stress disorder (PTSD) may increase risk of suicide in mid- to late-life, findings have been controversial, in large part, because studies have not accounted for comorbid disorders. Moreover, little is known about association between mid- to late-life PTSD and apparent accidental death by overdose, which could be due to suicidal intent. Thus, we conducted a comprehensive study to examine PTSD and risk of death by suicide, suicide attempt, and unintended death by overdose among veterans in mid- to late-life. Methods This nationwide cohort study included all veterans ≥50 years (N=1,038,980) seen in the Veterans Health Administration starting 2012-2013 (baseline) and followed through December 31, 2017. Veterans with a PTSD diagnosis were propensity-matched 1:1 with patients without PTSD. They were matched on age, gender, race/ethnicity, income, education, homelessness, service connection, Charlson comorbidity index, and neuropsychiatric disorders. Dates of suicide attempt and cause-specific mortality at follow up were defined using the National Suicide Prevention Applications Network and the Mortality Data Repository, respectively. PTSD was identified by two or more ICD-9 codes in electronic medical records at baseline. PTSD and risk of suicide-related outcomes were assessed using multivariable models. Fine-Gray proportional hazards regression was used to examine time to outcome event at follow up. Models were next adjusted in steps, with the final adjustment accounting for sociodemographics, Charlson comorbidity index, and neuropsychiatric diagnoses. Other outcomes examined using similar methods included death by drug overdose (i.e., antiepileptics/sedative-hypnotics, narcotics, and unspecified/other cause-specific drug categories) for suicide, unintentional, and undetermined death. Results Of 1,038,980 patients in our study, 519,490 had PTSD. The mean participant age was 63.56, 59,542 (5.73%) were women, and 765,572 (73.68%) were non-Hispanic White. Although firearms were by far the leading method of suicide death for those with and without PTSD, there was no significant between-group difference related to firearms. However, veterans with PTSD were significantly more likely to die by suicide by drug overdose compared with those without a PTSD diagnosis. As shown in Table 1, after adjusting for sociodemographics, Charlson comorbidities, and neuropsychiatric diagnoses, the hazard ratio for risk of suicide in veterans with PTSD was 1.57 (95% CI, 1.51, 1.63) for any suicide attempt; 1.09 (95% CI, 1.01, 1.19) for death by suicide; 1.43 (95% CI, 1.32, 1.56) for drug overdose death overall; 1.53 (95% CI, 1.21, 1.94) for suicide death by drug overdose. Further analyses explored type of drug involved in overdose and demonstrated that veterans with PTSD had hazard ratios of 1.44 (95% CI, 1.26, 1.65) for narcotics and 1.48 (1.31-1.68) for other /unspecified drugs (Figure 1). We also found that having PTSD increased unintentional death, suicide death, and undetermined intent for narcotics by 1.4 to 2.4 times, and for other/unspecified drugs by 1.4 to 1.8 times. Conclusions The findings suggest that veterans with PTSD aged ≥50 years in VA healthcare, have persistently elevated risk for suicide attempts and suicide death, particularly by drug overdose. This current work may inform clinical practice targeting late-life suicide prevention efforts by promoting improved prescribing and drug-monitoring. Future medication recommendations to treat PTSD may need to consider less risky drugs than narcotics, as well as emphasize inquiring about potential illicit drug use and access, for older adults. More research is needed to elucidate the relationship of PTSD to increased risk of mid- to late-life death by suicide and unintended drug overdose, exploring what other and unspecific drugs do and do not exacerbate this risk. Funding This work was supported by Award Number I01 CX001119 from the Clinical Science Research & Development Service of the U.S. Department of Veterans Affairs (VA) Office of Research and Development (PI: Dr. Byers). Support for the Mortality Data Repository (MDR; previously known as the Suicide Data Repository or SDR) and Suicide Prevention Applications Network (SPAN) is provided by the VA Center of Excellence for Suicide Prevention. Support for VA/CMS data is provided by the Department of Veterans Affairs, VA Health Services Research and Development Service, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004).

Key Points Question What are the sociodemographic characteristics of adults who engage in high-frequency cannabis use? Findings In this survey study including 387 157 US adults residing in 21 states conducted in 2016 through 2019, young, male, Black, and Native American individuals and individuals with low educational attainment and income were more likely to engage in higher frequency cannabis use. Meaning Higher-frequency use among these populations may warrant more attention from policymakers and public health officials in the form of screening, risk stratification, and treatment given the known and emerging adverse health effects of cannabis., This survey study of 21 US states and 2 US territories examines social and demographic characteristics associated with the frequency of cannabis use among adults., Importance Cannabis use has increased, but there are few studies on frequent and daily cannabis use among US adults. Individuals who engage in higher frequency use may suffer more health consequences. Objective To examine frequency of cannabis use and associated factors among US adults. Design, Setting, and Participants This survey study included data from 21 US states and 2 US territories reported in the Behavioral Risk Factor Surveillance System surveys from 2016 to 2019. Cross-sectional data on US adults ages 18 years and older were used to estimate demographic, socioeconomic, and behavioral risk factors for cannabis use, taking into account the survey strata and sampling weights for the 4 years of combined data. Using a multivariable ordinal logistic analysis, the association of demographic, socioeconomic status, and behavioral risk factors with past month cannabis frequency were examined. Exposures Sociodemographic characteristic, ie, age, gender, race and ethnicity, educational attainment, employment status, and annual household income. Main Outcomes and Measures Ordinal categorization of number of days of cannabis use in the past 30 days in terms of nonuse, infrequent use (1-5 days), frequent use (6-29 days), and daily use. Results Among the 387 179 respondents, 58 009 (27.9%) were ages 18 to 34 years, 186 923 (50.3%) were ages 35 to 64 years, and 142 225 (21.8%) were age 65 years or older (mean [SD] age, 48.3 [0.1] years). The sample included 28 345 (9.8%) Black, 36 697 (22.6%) Hispanic, and 292 210 (57.3%) White respondents. Smoking was the most common form of cannabis use. The frequency of cannabis use varied significantly by age, gender, race, marital status, education, and employment. Higher frequency cannabis use was associated with younger age (ages 18-34 years: adjusted odds ratio [aOR], 4.12; 95% CI, 3.63-4.68; ages 35-64 years: aOR, 2.22; 95% CI, 1.98-2.49), Black (aOR, 1.46; 95% CI, 1.33-1.71) and Native American (aOR, 1.25; 95% CI, 1.04-1.52) race, and less educational attainment (high school or less: aOR, 1.09; 95% CI, 1.02-1.17; some college: aOR, 1.27; 95% CI, 1.19-1.35). Being married (aOR, 0.54; 95% CI, 0.51-0.58) or identifying as Asian (aOR, 0.60; 95% CI, 0.51-0.71) or Hispanic (aOR, 0.71; 95% CI, 0.65-0.77) was associated with lower-frequency cannabis use after accounting for other baseline factors. Conclusions and Relevance This nationally based study found that higher-frequency cannabis use is more common among young and racial minority populations, as well as respondents with low socioeconomic status. Given the known and emerging negative health effects of cannabis use, more attention may need to be paid to high-frequency use among underserved populations in the form of screening, risk stratification, and treatment.

Objective Little is known about key factors associated with use of mental health services across the life course. This study determined key socioeconomic, social support, psychiatric, and medical predictors of services use in younger, middle, and older age. Design, Setting, Participants, Measurements The sample included 3,708 adults with DSM-IV–based mood, anxiety, and substance use disorders in the Collaborative Psychiatric Epidemiology Surveys. Key predictors of mental health services use for each age group were systematically determined by multivariable models, and exploratory analyses examining potential effect modification by race–ethnicity and sex were assessed by interaction terms. Statistical analyses included complex design-corrected and weighted logistic regression analyses that provide results generalizable to the United States. Results Psychiatric and medical issues such as prior suicidal behavior, comorbid psychiatric disorders, and perceived cognitive impairment increased odds of mental health services use in younger, middle, and older age. Chronic medical conditions also influenced services use in younger and older age, with their impact on use across age potentially modified by racial–ethnic disparities (p interaction = 0.01). Moreover, socioeconomic factors like marital status influenced use in middle and older age, where being divorced, separated, widowed, or never married encouraged use. The effect of marital status on use across age was also potentially modified by racial–ethnic disparities (p interaction = 0.02). Conclusions Key socioeconomic, social support, psychiatric, and medical predictors uniquely influence use of mental health services across the life course. These findings will help inform efforts to encourage greater services use by adults across the life course in need of care.

Objective To characterize the association between traumatic brain injury (TBI) and chronic pain and pain disability in the context of comorbid conditions, posttraumatic stress disorder (PTSD), and depression to better inform care of combat veterans. Design Retrospective cohort study. Setting Medical centers and community clinics. Participants Combat veterans (N=116,913) who received Veterans Affairs care between October 1, 2007 and March 31, 2015, completed a Comprehensive Traumatic Brain Injury Evaluation, and received a criterion standard diagnosis of TBI (none, mild, or moderate to severe). Interventions Not applicable. Main Outcome Measures Chronic pain defined as ≥2 of the same pain diagnoses ≥90 days apart and pain disability defined as self-reported pain causing moderate to very severe interference with daily functioning. Results Fifty-seven percent received ≥1 chronic pain diagnosis. Compared to those with no TBI, PTSD, or depression, there was an independent risk for chronic pain in veterans with mild TBI, which was higher in veterans with moderate to severe TBI. The risk of chronic pain was additive and highest when all 3 conditions—TBI, depression, and PTSD—were copresent (adjusted relative risk, 1.53 and 1.62 [95% confidence interval, 1.50–1.66] for mild and moderate or severe TBI, respectively, plus other diagnoses). The relation of pain disability to TBI, PTSD, and depression followed a similar additive pattern. Conclusions In combat veterans, chronic pain and pain disability are most commonly associated with TBI in conjunction with PTSD, depression, or both. Integrated models of care that simultaneously address pain in conjunction with TBI, PTSD, and depression will likely be the most clinically effective.

High rates of substance use disorders (SUDs) in persons age 50 and older are concerning. Those reentering the community in later life after incarceration are especially at risk. We determined if later-life prison release increases risk of SUD-related hospitalizations and ED visits in a national sample of veterans (N=7,671) released from prison between 2012 to 2014 and matched never-incarcerated controls (N=7,671). Later-life prison release was associated with increased risk of any SUD-related hospitalization/ED visit (2907.1 vs. 465.0 per 100,000/year; adjusted HR=2.67; 95% CI, 2.11-3.36) and 3-fold risk of hospitalizations/ED visits due to alcohol use disorder (1955.4.1 vs. 282.6 per 100,000/year; adjusted HR=3.04; 95% CI, 2.24-4.13) and drug use disorder (1586.1 vs. 252.0 per 100,000/year; adjusted HR=3.09; 95% CI, 2.23-4.30). Those reentering the community in later life after prison are at higher risk of experiencing SUD-related hospitalizations or ED visits. Prevention and intervention efforts targeting later-life prison-to-community care transitions are needed. Part of a symposium sponsored by the Aging, Alcohol and Addictions Interest Group.

This session will provide information about adverse health outcomes, including suicide, suicide attempts and unintended death, that may be related to polysubstance use and polypharmacy in older adults, particularly older veterans. It will further provide information that will help support late-life suicide prevention and intervention efforts. Older veterans (age50 and older) have the highest number of lives lost to suicide, make up majority of the veteran population, and are highly likely to experience conditions (e.g., chronic pain, sleep disorders, musculoskeletal) associated with commonly prescribed medications that are potential markers for suicide risk (hereafter referred to as “high-risk” drug categories), including benzodiazepines, sedative-hypnotics, opioids, antidepressants, antipsychotics, and antiepileptics. The research presented in this session will highlight important patterns in high-risk drug prescribing and use and related outcomes in late life. The presentations will underscore various groups of older veterans that may be important to consider and, yet, neglected in the polysubstance and polypharmacy and suicide prevention conversation, including those who recently attempted suicide, veterans with late-life posttraumatic stress disorder (PTSD), and older veterans transitioning from prison to community. Drs. Maust and Morin will present findings on prescribing and use of high-risk medications in late life, including an overview of trends in polypharmacy and associations with suicide attempts. Drs. Byers and Barry will speak about older veterans with PTSD and those with a history of incarceration, with information on suicide, unintended death by overdose, and substance use disorder-related emergency department visits and hospitalizations, emphasizing importance of care transition models for prevention. Aging, Alcohol and Addictions Interest Group Sponsored Symposium.

Older veterans have the highest number of lives lost to suicide, make up majority of the veteran population, and are highly likely to experience conditions (e.g., chronic pain, sleep disorders, musculoskeletal) associated with commonly prescribed medications that are potential markers for suicide risk (hereafter referred to as “high-risk” drug categories), including benzodiazepines, sedative-hypnotics, opioids, antidepressants, antipsychotics, and antiepileptics. The research presented in this session will highlight important patterns in high-risk drug prescribing and use and related outcomes in late life. The presentations will highlight various groups of older veterans that may be important to consider and, yet, neglected in the polysubstance and polypharmacy and suicide prevention conversation, including those who recently attempted suicide, veterans with late-life posttraumatic stress disorder (PTSD), and older veterans transitioning from prison to community. Drs. Maust and Morin will present findings on polypharmacy prescribing and use of high-risk medications in late life. First, drawing from the literature and his own research studies, Dr. Maust will provide a big picture overview of trends in polypharmacy among older adults in the U.S., including older veterans. Next, Dr. Morin will describe high-risk profiles of use in the 90 days prior to a first documented suicide attempt among veterans >=65 years who attempted suicide between 2012 and 2014, using Veterans Health Administration (VHA) medical record data. In addition, she will examine associations of these profiles with diagnostic, lethality, and utilization factors. Drs. Byers and Barry will speak about more specific subgroups of older veterans, with recommendations for possible intervention to reduce suicide, unintended death by overdose, and substance use disorder (SUD)-related emergency department (ED) visits and hospitalizations, emphasizing importance of care transition models for prevention. Dr. Byers will present a cohort study of veterans >=50 years seen in VHA. Findings provide evidence that late-life PTSD increases risk of suicide attempts and suicide by overdose (and accidental and undetermined death), independent of comorbid disorders. Furthermore, findings will be presented about the relationship of late-life PTSD to cause-specific high-risk drugs. Finally, Dr. Barry will provide an example of increased risk for SUD-related ED visits and hospitalizations (found in the literature to be strongly associated with suicide attempts) among older veterans transitioning from prison to community. Findings show that those re-entering society following prison sentence are at significantly higher risk for SUD-related ED visit or hospitalization compared to matched controls. These results highlight urgent need for assistance during this vulnerable period of transition.

Objectives To identify comorbidity profiles of older patients last seen in primary care before a suicide attempt and assess attempt and clinical factors (eg, means and lethality of attempt) associated with these profiles. Design Cohort study and latent class analysis using Department of Veterans Affairs (VA) national data (2012-2014). Setting All VA medical centers in the United States. Participants A total of 2131 patients 65 years and older who were last seen by a primary care provider before a first documented suicide attempt. Measurements Fatal suicide attempt and means were identified using the National Suicide Data Repository. Nonfatal attempt was defined using the National Suicide Prevention Applications Network. Medical and psychiatric diagnoses and other variables were determined from electronic medical records. Results Patients (mean age = 74.4 y; 98.2% male) were clustered into five classes based on medical and psychiatric diagnoses: Minimal Comorbidity (23.2%); Chronic Pain-Osteoarthritis (30.1%); Depression-Chronic Pain (22.9%); Depression-Medical Comorbidity (16.5%); and High Comorbidity (7.3%). The patients in the Minimal Comorbidity and Chronic Pain-Osteoarthritis classes were most likely to attempt fatally compared with classes with a higher burden of comorbidities. Overall, 61% of the sample attempted fatally, and 82.5% of suicide decedents used firearms. Conclusion This study provides evidence that most comorbidity profiles (>50%) in primary care patients attempting suicide were characterized by minimal depression diagnoses and fatal attempts, mostly with firearms. These findings suggest that more than a depression diagnosis contributes to risk and that conversations about firearm safety by medical providers may play an important role in suicide intervention and prevention. J Am Geriatr Soc 67:2553-2559, 2019.

IMPORTANCE: Little is known about the association between mild cognitive impairment (MCI) and suicide. Most studies have focused on dementia and suicidal behavior, with inconsistent results. OBJECTIVES: To examine the association between diagnoses of MCI and dementia and suicide attempt and explore potential psychiatric moderators and to assess whether the association differs based on recency of diagnosis. DESIGN, SETTING, AND PARTICIPANTS: This nationwide cohort study integrated 5 national databases from the Department of Veterans Affairs (VA) and Centers for Medicare & Medicaid Services and included all VA medical centers in the US. US veterans 50 years or older with MCI diagnoses at baseline (October 1, 2011, to September 30, 2013) or earlier (October 1, 2007, to September 30, 2011) were propensity matched 1:3 with (1) patients with dementia diagnoses and (2) patients without either diagnosis based on demographic characteristics and the Charlson Comorbidity Index. Diagnoses of MCI or dementia were defined as recent if there were no diagnosis codes before baseline. Data were analyzed from March 16, 2020, to January 15, 2021. MAIN OUTCOMES AND MEASURES: Information on suicide attempts through December 31, 2016, provided by the National Suicide Prevention Applications Network (nonfatal) and Mortality Data Repository (fatal). RESULTS: The study population of 147 595 participants included 21 085 patients with MCI, 63 255 with dementia, and 63 255 in the propensity-matched comparison group. Participants had a mean (SD) age of 74.7 (10.3) years, 143 353 (97.1%) were men, 4242 (2.9%) were women, and 127 065 (86.1%) were non-Hispanic White. A total of 138 patients with MCI (0.7%) and 400 patients with dementia (0.6%) attempted suicide during follow-up, compared with 253 patients without MCI or dementia (0.4%). Exploratory analyses revealed that no psychiatric comorbidity moderated the association between MCI or dementia and suicide attempt. After adjustment for demographic details and medical and psychiatric comorbidities, risk of suicide attempt was consistently highest for patients with a recent MCI or dementia diagnosis, with adjusted hazard ratios (HRs) of 1.73 (95% CI, 1.34-2.22; P

Importance Agent Orange is a powerful herbicide that contains dioxin and was used during the Vietnam War. Although prior studies have found that Agent Orange exposure is associated with increased risk of a wide range of conditions, including neurologic disorders (eg, Parkinson disease), metabolic disorders (eg, type 2 diabetes), and systemic amyloidosis, the association between Agent Orange and dementia remains unclear. Objective To examine the association between Agent Orange exposure and incident dementia diagnosis in US veterans of the Vietnam era. Design, setting, and participants This cohort study included Veterans Health Administration data from October 1, 2001, and September 30, 2015, with up to 14 years of follow-up. Analyses were performed from July 2018 to October 2020. A 2% random sample of US veterans of the Vietnam era who received inpatient or outpatient Veterans Health Administration care, excluding those with dementia at baseline, those without follow-up visits, and those with unclear Agent Orange exposure status. Exposures Presumed Agent Orange exposure documented in electronic health record. Main outcomes and measures Fine-Gray competing risk models were used to compare the time to dementia diagnosis (with age as the time scale) for veterans with vs without presumed Agent Orange exposure (as per medical records), adjusting for demographic variables and medical and psychiatric comorbidities. Results The total sample was 511 189 individuals; after exclusions, 316 351 were included in analyses. Veterans were mostly male (n = 309 889 [98.0%]) and had a mean (SD) age of 62 (6.6) years; 38 121 (12.1%) had presumed Agent Orange exposure. Prevalence of most conditions, including Parkinson disease, diabetes, and amyloidosis, was similar at baseline among veterans with and without Agent Orange exposure. After adjusting for demographic variables and comorbidities, veterans exposed to Agent Orange were nearly twice as likely as those not exposed to receive a dementia diagnosis over a mean (SD) of 5.5 (3.8) years of follow-up (1918 of 38 121 [5.0%] vs 6886 of 278 230 [2.5%]; adjusted hazard ratio: 1.68 [95% CI, 1.59-1.77]). Veterans with Agent Orange exposure developed dementia at a mean of 1.25 years earlier (at a mean [SD] age of 67.5 [7.0] vs 68.8 [8.0] years). Conclusions and relevance Veterans with Agent Orange exposure were nearly twice as likely to be diagnosed with dementia, even after adjusting for the competing risk of death, demographic variables, and medical and psychiatric comorbidities. Additional studies are needed to examine potential mechanisms underlying the association between Agent Orange exposure and dementia.

BACKGROUND: Little is known about the association between trauma exposure and suicidal ideation across racial/ethnic groups. Our study aim was to determine the association between trauma exposure and suicidal ideation in a nationally representative ethnically diverse sample of adults. METHODS: This study included 14,866 White, Hispanic, Black, and Asian participants 18 years and older involved in the Collaborate Psychiatric Epidemiology Surveys (2001-2003), comprised of three nationally representative studies (NCS-R, NSAL, and NLAAS). Lifetime history of suicidal ideation as assessed in the World Health Organization's World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (WMH-CIDI). RESULTS: Of the 81% respondents who reported being exposed to trauma as assessed in the WMH-CIDI, 12.1% endorsed lifetime suicidal ideation. Additionally, of the 19% who did not report trauma, 1.1% endorsed lifetime suicidal ideation. Fully adjusted, multivariable logistic regression models revealed two traumas consistently associated with significantly higher odds for suicidal ideation across all four racial groups examined: Assaultive/interpersonal violence and child maltreatment. Asians, in particular, had the highest likelihood for suicidal ideation in both trauma categories, with a near threefold increased odds for assaultive/interpersonal violence exposure (OR: 2.56; 95% CI: 1.71-3.83) and nearly ninefold increased odds for child maltreatment exposure (OR: 8.43; 95% CI: 4.91-14.49). DISCUSSION: Suicidal ideation in racially/ethnically diverse American adults is strongly associated with assaultive/interpersonal violence and child maltreatment, independent of PTSD, MDD, and substance use. These findings highlight the need for monitoring of suicidal behavior following assaultive/interpersonal trauma and child maltreatment, regardless of the presence of a psychiatric disorder.© 2016 Wiley Periodicals, Inc. Language: en

Objectives To determine if late-life posttraumatic stress disorder (PTSD) is associated with cardiovascular disease in a sample of older veterans, and whether the association is independent of medical and psychiatric comorbities. Design Retrospective cohort study conducted using the Department of Veterans Affairs (VA) National Patient Care Database (2000–2011). Setting VA medical centers in the United States. Participants A total of 138,341 veterans 55 years and older without cardiovascular disease at study baseline (2000–2003). Measurements PTSD and cardiovascular disease (as defined by diagnoses of: cerebrovascular disease [CVD], congestive heart failure [CHF], myocardial infarction [MI], and peripheral vascular disease [PVD]) were identified by ICD-9 codes during study baseline (2000–2003) and follow-up (2004–2011), respectively. Results 3% of veterans (N = 4,041) had a baseline diagnosis of PTSD. Unadjusted increased risk of incidence of CVD was 80%, CHF was 56%, MI was 82%, and PVD was 60% in veterans with PTSD compared with those without PTSD. After adjustment for demographics, medical comorbidities, substance use, and psychiatric comorbidities, veterans with late-life PTSD were at a 45% increased risk for incident CVD, 26% increased risk for incident CHF, 49% increased risk for incident MI, and 35% increased risk for PVD compared with veterans without late-life PTSD. Conclusions Findings highlight the longitudinal impact of PTSD on increasing the incidence of cardiovascular disease in older adults. This study implies the need for greater monitoring and treatment of PTSD in older persons, particularly older veterans, to assist in preventing adverse outcomes, such as cardiovascular disease, over the long term.

Late-life veteran suicide is a public health concern, and may overlap with recent high-risk medication use. We identified use in the 6 months prior to attempt and assessed salient risk factors. 13,872 veterans aged 50 years and older that attempted suicide were compared with demographically-matched controls utilizing VHA healthcare in a similar time period. Medications potentially related to suicide risk were included. Other variables were psychiatric and medical diagnoses, fatality of attempt and means. Compared with controls, veterans who attempted were nearly 3 times more likely to have been prescribed benzodiazepines and opioids, even when controlling for other diagnoses. Those taking 3 or more high-risk medications were between 7 and 11 times more likely to attempt than controls, with a higher risk of death particularly by drug overdose. These findings begin to uncover the complex contribution of prescription medications and polypharmacy to late-life veteran suicide, with implications for prevention. Part of a symposium sponsored by the Aging, Alcohol and Addictions Interest Group.

Very little is known about Alzheimer’s Disease and related dementias (AD/ADRD) and diseases (e.g., Parkinson’s/PD) in older adults returning to community from prison (“older reentry adults”). We utilized a national sample of older veterans to conduct the first study documenting the occurrence (prevalence/incidence) of AD/ADRD and related diseases in older reentry adults. We examined 28,235 reentry veterans who were aged 50 years and older at their most recent release date and Medicare beneficiaries, 2008 through December 31, 2017. AD/ADRD and related diseases were identified by ICD-9/10 codes in the electronic health record from Medicare and inpatient/outpatient Veterans Health Administration data. We examined distributions of AD/ADRD and related diseases across 4 age categories (sample %): 50-64 (55%), 65-74 (37%), 75-84 (7%), and 85+ (0.7%). Of the 28,235 veterans 50 years and older, 17% (n=4,725) had dementia (defined by AD/ADRD based on NIA criteria) or mild cognitive impairment (MCI) and 3% (n=794) had PD. Of those with dementia/MCI, 18% had AD and 26% MCI. Nearly 40% of dementia diagnoses occurred prior to/on most recent release date, and 40% of PD diagnoses occurred prior to/on most recent release date. Differences were significant across age groups (P

Little is known about late-life posttraumatic stress disorder (PTSD) and risk of suicide and apparent accidental death by overdose. We studied 488,044 older veterans (50 and older) with PTSD and propensity-matched comparison group without PTSD (n=488,044), seen in VA 2012-2013 followed to 12/31/2016. There were 5,693 non-fatal and fatal suicide attempts for those with PTSD and 4,310 for those without PTSD (approximately 20% fatal for each group). Those with PTSD had nearly 2-fold increased risk of any attempt [HR=1.55 (95% CI=1.49-1.62)]. While results specific to death by suicide were non-significant, impact of PTSD on method of death (e.g., drug overdose, firearms, hanging) was significant only for drug overdose [HR=1.58 (95% CI=1.22-2.03)]. Intentional and unintentional death by narcotics and such drugs as non-opioid analgesics and autonomic nervous system drugs were most highly associated with late-life PTSD. This study provides important implications for late-life suicide prevention related to PTSD and cause-specific drugs. Part of a symposium sponsored by the Aging, Alcohol and Addictions Interest Group.

The U.S. Veterans Health Administration (VHA) provides depression treatment to veterans with Traumatic Brain Injury (TBI). VHA costs of comorbid TBI-depression were estimated by Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) status over 14 years.VHA-USING veterans with TBI DIAGNOSED IN 2000-2010 were followed through FY2014. TBI severity was determined using the Department of Defense criteria. Depression was identified by the Elixhauser algorithm. Generalized linear and seemingly unrelated regression models were used to estimate the impact of depression on annual per veteran and total VHA inpatient, outpatient, and pharmaceutical costs, by OEF/OIF status.A total of 66.57% of pre-OEF/OIF and 87.46% of OEF/OIF veterans had depression. Depression was estimated to increase annual total ($1,847), outpatient ($1,558), and pharmaceutical ($287) costs for pre-OEF/OIF, and $1,228, $1,685, and $191 for OEF/OIF veterans. However, depression was estimated to lower annual inpatient costs by $648 per OEF/OIF veteran. The annual VHA cost for all veterans with comorbid TBI-depression was estimated at $1,101,329,953.The estimated annual cost for Veterans with comorbid TBI-depression was more than $1 billion. TBI and depression screening/treatment may result in reduced inpatient VHA costs in OEF/OIF veterans exposed to TBI. VHA policymakers should consider screening for TBI and depression in pre-OEF/OIF veterans.

Background The Veterans Health Administration (VA) reports hospital-specific 30-day risk-standardized readmission rates (RSRRs) using CMS-derived models. Objective The aim of this study was to examine and describe the interfacility variability of 30-day RSRRs for acute myocardial infarction (AMI), heart failure (HF), and pneumonia as a means to assess its utility for VA quality improvement and hospital comparison. Research design A retrospective analysis of VA and Medicare claims data using one-year (2012) and three-year (2010-2012) data given their use for quality improvement or for hospital comparison, respectively. Subjects This study included 3,571 patients hospitalized for AMI at 56 hospitals, 10,609 patients hospitalized for HF at 102 hospitals, and 10,191 patients hospitalized for pneumonia at 106 hospitals. Measures Hospital-specific 30-day RSRRs for AMI, HF, and pneumonia hospitalizations were calculated using hierarchical generalized linear models. Results Of 164 qualifying VA hospitals, 56 (34%), 102 (62%), and 106 (64%) qualified for analysis based on CMS criteria for AMI, HF, and pneumonia cohorts, respectively. Using 2012 data, we found that two hospitals (2%) had CHF RSRRs worse than the national average (+95% CI), whereas no hospital demonstrated worse-than-average risk-stratified readmission Rate (RSRR; +95% CI) for AMI or pneumonia. After increasing the number of facility admissions by combining three years of data, we found that four (range: 3.5%-5.3%) hospitals had RSRRs worse than the national average (+95% CI) for all three conditions. Conclusions The Centers for Medicare and Medicaid Services-derived 30-day readmission measure may not be a useful measure to distinguish VA interfacility performance or drive quality improvement given the low facility-level volume of such readmissions.