Document Type : Research paper


1 The Florey Institute of Neuroscience and Mental Health, Melbourne, Australia; Department of Molecular Imaging & Therapy, Centre for PET, Austin Health, Melbourne, Australia.

2 Department of Psychiatry, The University of Melbourne, Melbourne, Australia.

3 Department of Molecular Imaging & Therapy, Centre for PET, Austin Health, Melbourne, Australia.

4 Department of Molecular Imaging & Therapy, Centre for PET, Austin Health, Melbourne, Australia; Department of Medicine, The University of Melbourne, Melbourne, Australia.

5 Monash-Epworth Rehabilitation Research Centre, Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia.


Objective:  Since 2000, over 350,000 US military personnel have been diagnosed with a traumatic brain injury (TBI) (VA, 2010). Whilst epidemiological studies report up to a fourfold increased risk for dementia associated with brain injury amongst veterans there is limited controlled research into the long-term neuropsychological burden of injury.
Main aim:  The study aimed to determine whether Australian Vietnam war veterans with service-related TBI were more likely to exhibit cognitive deficits, 30-50 years after injury when compared to healthy veteran controls.
Materials and methods: 69 male veterans 60-85 years old, underwent psychiatric and neuropsychological assessment; 40 with a TBI (mean age = 68.0 ± 2.5) and 29 without (mean age = 70.1 ± 5.3). The TBI cohort included 15 mild, 16 moderate and nine severe TBI.
Results: After adjustment for identified covariates, veterans with moderate-to-severe TBI performed significantly worse than controls on composite measures of memory and learning (M = -0.55 ± 0.69, t(67) = 2.86, p=0.006, d=0.70) and attention and processing speed (M = -0.71 ± 1.08, t(52) = 2.53, p=0.014, d=0.69). There were no differences in cognitive performance between veterans with mild TBI (mTBI) and controls.
Conclusion: Results from this study suggest that amongst ageing veterans, a moderate-to-severe TBI sustained during early adulthood is associated with later-life cognitive deficits in memory and learning, attention and processing speed.


Main Subjects

Aker AT, Ozeren M, Basoglu M, Kaptanoglu C, Erol A, Buran B. Clinician administered post-traumatic stress disorder scale (CAPS) reliability and validity study. Turk Psikiyatri Derg, 1999;10(4), 286-293.
Araki T, Yokota H, Morita A. Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management. Neurol Med Chir (Tokyo). 2017 Feb 15;57(2):82-93. doi: 10.2176/nmc.ra.2016-0191.
Ashman TA, Spielman LA, Hibbard MR, Silver JM, Chandna T, Gordon WA. Psychiatric challenges in the first 6 years after traumatic brain injury: cross-sequential analyses of Axis I disorders. Arch Phys Med Rehabil. 2004 Apr;85(4 Suppl 2):S36-42. doi: 10.1016/j.apmr.2003.08.117.
Barnes DE, Kaup A, Kirby KA, Byers AL, Diaz-Arrastia R, Yaffe K. Traumatic brain injury and risk of dementia in older veterans. Neurology. 2014 Jul 22;83(4):312-9. doi: 10.1212/WNL.0000000000000616.  
Belanger HG, Curtiss G, Demery JA, Lebowitz BK, Vanderploeg RD. Factors moderating neuropsychological outcomes following mild traumatic brain injury: a meta-analysis. J Int Neuropsychol Soc. 2005 May;11(3):215-27. doi: 10.1017/S1355617705050277.
Belanger HG, Vanderploeg RD. The neuropsychological impact of sports-related concussion: a meta-analysis. J Int Neuropsychol Soc. 2005 Jul;11(4):345-57. doi: 10.1017/s1355617705050411.
Butters N, Granholm E, Salmon DP, Grant I, Wolfe J. Episodic and semantic memory: a comparison of amnesic and demented patients. J Clin Exp Neuropsychol. 1987 Oct;9(5):479-97. doi: 10.1080/01688638708410764.  
Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989 May;28(2):193-213. doi: 10.1016/0165-1781(89)90047-4.   
Carroll LJ, Cassidy JD, Peloso PM, Borg J, von Holst H, Holm L, Paniak C, Pépin M; WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. Prognosis for mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2004 Feb;(43 Suppl):84-105. doi: 10.1080/16501960410023859.
Corkin S, Rosen TJ, Sullivan EV, Clegg RA. Penetrating head injury in young adulthood exacerbates cognitive decline in later years. J Neurosci. 1989 Nov;9(11):3876-83. doi: 10.1523/JNEUROSCI.09-11-03876.1989.
Dagher JH, Richard-Denis A, Lamoureux J, de Guise E, Feyz M. Acute global outcome in patients with mild uncomplicated and complicated traumatic brain injury. Brain Inj. 2013;27(2):189-99. doi: 10.3109/02699052.2012.729288. 
Derogatis LR, Unger R. Symptom checklist‐90‐revised. Wiley Online Library. 2010.
Draper K, Ponsford J. Cognitive functioning ten years following traumatic brain injury and rehabilitation. Neuropsychology. 2008 Sep;22(5):618-625. doi: 10.1037/0894-4105.22.5.618.
Elias A, Cummins T, Lamb F, Tyrrell R, Dore V, Williams R, Rosenfeld JV, Hopwood M, Villemagne VL, Rowe CC. Amyloid-β, Tau, and 18F-Fluorodeoxyglucose Positron Emission Tomography in Posttraumatic Stress Disorder. J Alzheimers Dis. 2020;73(1):163-173. doi: 10.3233/JAD-190913.
Ellis KA, Bush AI, Darby D, De Fazio D, Foster J, Hudson P, Lautenschlager NT, Lenzo N, Martins RN, Maruff P, Masters C, Milner A, Pike K, Rowe C, Savage G, Szoeke C, Taddei K, Villemagne V, Woodward M, Ames D; AIBL Research Group. The Australian Imaging, Biomarkers and Lifestyle (AIBL) study of aging: methodology and baseline characteristics of 1112 individuals recruited for a longitudinal study of Alzheimer’s disease. Int Psychogeriatr. 2009 Aug;21(4):672-87. doi: 10.1017/S1041610209009405.
Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975 Nov;12(3):189-98. doi: 10.1016/0022-3956(75)90026-6. 
Frencham KA, Fox AM, Maybery MT. Neuropsychological studies of mild traumatic brain injury: a meta-analytic review of research since 1995. J Clin Exp Neuropsychol. 2005 Apr;27(3):334-51. doi: 10.1080/13803390490520328.
Friedland, DP. Improving the Classification of Traumatic Brain Injury: The Mayo Classification System for Traumatic Brain Injury Severity. Journal of Spine. 2013. doi:10.4172/2165-7939.s4-005
Guskiewicz KM, Marshall SW, Bailes J, McCrea M, Cantu RC, Randolph C, Jordan BD. Association between recurrent concussion and late-life cognitive impairment in retired professional football players. Neurosurgery. 2005 Oct;57(4):719-26; discussion 719-26. doi: 10.1093/neurosurgery/57.4.719.
Guskiewicz KM, McCrea M, Marshall SW, Cantu RC, Randolph C, Barr W, Onate JA, Kelly JP. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. JAMA. 2003 Nov 19;290(19):2549-55. doi: 10.1001/jama.290.19.2549.
Himanen L, Portin R, Isoniemi H, Helenius H, Kurki T, Tenovuo O. Longitudinal cognitive changes in traumatic brain injury: a 30-year follow-up study. Neurology. 2006 Jan 24;66(2):187-92. doi: 10.1212/01.wnl.0000194264.60150.d3.
Hoofien D, Gilboa A, Vakil E, Donovick PJ. Traumatic brain injury (TBI) 10-20 years later: a comprehensive outcome study of psychiatric symptomatology, cognitive abilities and psychosocial functioning. Brain Inj. 2001 Mar;15(3):189-209. doi: 10.1080/026990501300005659.
Kaplan E. The assessment of aphasia and related disorders. Lippincott Williams & Wilkins 1983 (2).
Kaplan E, Goodglass H, Weintraub S. The Boston Naming Test. 2nd. Philadelphia: Lea & Febiger. 1983.
Kaufman AS, Lichtenberger EO. Essentials of WAIS-III assessment: John Wiley & Sons Inc. 1999.
Kaup AR, Peltz C, Kenney K, Kramer JH, Diaz-Arrastia R, Yaffe K. Neuropsychological Profile of Lifetime Traumatic Brain Injury in Older Veterans. J Int Neuropsychol Soc. 2017 Jan;23(1):56-64. doi: 10.1017/S1355617716000849.
Koponen S, Taiminen T, Portin R, Himanen L, Isoniemi H, Heinonen H, Hinkka S, Tenovuo O. Axis I and II psychiatric disorders after traumatic brain injury: a 30-year follow-up study. Am J Psychiatry. 2002 Aug;159(8):1315-21. doi: 10.1176/appi.ajp.159.8.1315.
Levin HS. Neurobehavioural sequelae of closed head injury In P. R. Cooper (Ed.), Head injury: Williams & Wilkins. 1993.
Lund M, Foy D, Sipprelle C, Strachan A. The Combat Exposure Scale: a systematic assessment of trauma in the Vietnam War. J Clin Psychol. 1984 Nov;40(6):1323-8. doi: 10.1002/1097-4679(198411);2-i. 
Management of Concussion/mTBI Working Group. VA/DoD Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain Injury. J Rehabil Res Dev. 2009;46(6):CP1-68.
McCrea M, Guskiewicz K, Randolph C, Barr WB, Hammeke TA, Marshall SW, Powell MR, Woo Ahn K, Wang Y, Kelly JP. Incidence, clinical course, and predictors of prolonged recovery time following sport-related concussion in high school and college athletes. J Int Neuropsychol Soc. 2013 Jan;19(1):22-33. doi: 10.1017/S1355617712000872.
McLellan AT, Luborsky L, Woody GE, O’Brien CP. An improved diagnostic evaluation instrument for substance abuse patients. The Addiction Severity Index. J Nerv Ment Dis. 1980 Jan;168(1):26-33. doi: 10.1097/00005053-198001000-00006.
Meyers JE, Meyers KR. Rey Complex Figure Test and recognition trial professional manual: Psychological Assessment Resources. 1995.
Millis SR, Rosenthal M, Novack TA, Sherer M, Nick TG, Kreutzer JS, High WM Jr, Ricker JH. Long-term neuropsychological outcome after traumatic brain injury. J Head Trauma Rehabil. 2001 Aug;16(4):343-55. doi: 10.1097/00001199-200108000-00005.
Nasreddine Z, Collin I, Chertkow H, Phillips N, Bergman H, Whitehead V. Sensitivity and specificity of the Montreal Cognitive Assessment (MoCA) for detection of mild cognitive deficits. Can J Neurol Sci, 2003. 30(2), 30.
Navarro D. Learning statistics with R: A tutorial for psychology students and other beginners. (Version 0.5). University of Adelaide, R package 0.5. 2015.  
Ommaya AK, Goldsmith W, Thibault L. Biomechanics and neuropathology of adult and paediatric head injury. Br J Neurosurg. 2002 Jun;16(3):220-42. doi: 10.1080/02688690220148824.
Plassman BL, Havlik RJ, Steffens DC, Helms MJ, Newman TN, Drosdick D, Phillips C, Gau BA, Welsh-Bohmer KA, Burke JR, Guralnik JM, Breitner JC. Documented head injury in early adulthood and risk of Alzheimer’s disease and other dementias. Neurology. 2000 Oct 24;55(8):1158-66. doi: 10.1212/wnl.55.8.1158. PMID: 11071494.
Ponsford JL, Downing MG, Olver J, Ponsford M, Acher R, Carty M, Spitz G. Longitudinal follow-up of patients with traumatic brain injury: outcome at two, five, and ten years post-injury. J Neurotrauma. 2014 Jan 1;31(1):64-77. doi: 10.1089/neu.2013.2997.
Reitan RM. Validity of the Trail Making Test as an Indicator of Organic Brain Damage. Perceptual and Motor Skills. 1958; 8(3), 271-276. doi:10.2466/pms.1958.8.3.271
Rey A. L’examen clinique en psychologie [The clinical psychological examination]. Paris: Presses Universitaires de France. 1964.
RStudio Team. R: A Language and Environment for Statistical Computing: R Foundation for Statistical Computing. 2016. Retrieved from
Schretlen DJ, Shapiro AM. A quantitative review of the effects of traumatic brain injury on cognitive functioning. Int Rev Psychiatry. 2003 Nov;15(4):341-9. doi: 10.1080/09540260310001606728.
Senathi-Raja D, Ponsford J, Schönberger M. Impact of age on long-term cognitive function after traumatic brain injury. Neuropsychology. 2010 May;24(3):336-344. doi: 10.1037/a0018239.
Shiekh J. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clinical gerontology: a guide to assessment and intervention, 1986;165-173.
Spitz G, Bigler ED, Abildskov T, Maller JJ, O’Sullivan R, Ponsford JL. Regional cortical volume and cognitive functioning following traumatic brain injury. Brain Cogn. 2013 Oct;83(1):34-44. doi: 10.1016/j.bandc.2013.06.007. 
Thomsen IV. Late outcome of very severe blunt head trauma: a 10-15 year second follow-up. J Neurol Neurosurg Psychiatry. 1984 Mar;47(3):260-8. doi: 10.1136/jnnp.47.3.260.
VA. National survey of veterans, active duty service members, demobilized national guard and reserve members, family members, and surviving spouses. Washington DC. 2010.
Vargha A, Delaney HD. A Critique and Improvement of the CL Common Language Effect Size Statistics of McGraw and Wong. Journal of Educational and Behavioral Statistics. 2000;25(2):101-132. doi:10.3102/10769986025002101.
Venegas J, Clark E. Wechsler Test of Adult Reading. In Kreutzer JS, DeLuca J, Caplan B (Eds.), Encyclopedia of Clinical Neuropsychology 2011; 2693-2694. New York, NY: Springer New York.
Wechsler, D. Wechsler memory scale-revised. The Psychological Corporation. 1987.
Wickham H. Reshaping data with the reshape package. Journal of Statistical Software, 2007; 21(12), 1-20.
Wickham H. ggplot2: Elegant Graphics for Data Analysis. New York: Springer-Verlag 2009.
Wickham H. The split-apply-combine strategy for data analysis. Journal of Statistical Software, 2011;40(1), 1-29.
Wood RL, Rutterford NA. Long-term effect of head trauma on intellectual abilities: a 16-year outcome study. J Neurol Neurosurg Psychiatry. 2006 Oct;77(10):1180-4. doi: 10.1136/jnnp.2006.091553.