PTSD Series

Prevention and Screening of Post-Traumatic Stress Disorder in Older Adults

Emmanuel Osei-Boamah, MD1,2; Brunhilde J. Pilkins, LCSW-C2; Steven R.Gambert, MD, AGSF, MACP1,2

Affiliations:

1Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Maryland School of Medicine, Baltimore, MD

2University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, Baltimore, MD

Abstract: Post-traumatic stress disorder (PTSD) is underrecognized and underdiagnosed in older persons. Clinicians might mistake the early signs and symptoms of PTSD for other medical disorders or diseases, as side effects of some medications, or as natural conditions associated with aging. However, recognition and treatment of PTSD is important not only for improving quality of life, but also because untreated PTSD has been associated with substance abuse; self-destructive behavior, including suicidal ideation; aggression toward others; and a variety of psychiatric disorders causing physical and/or cognitive impairment. This article, the second in a series on PTSD, reviews the prevalence and risk factors of PTSD among the geriatric population, describes the diagnostic criteria of PTSD, and briefly discusses some of the early interventions that clinicians can use to prevent, reduce, or delay the onset of PTSD in older patients.

Article series summary: This is the second article in a continuing series on post-traumatic stress disorder (PTSD). The first article in the series “Post-Traumatic Stress Disorder: A Historical Perspective of an Evolving Diagnosis” was published in the June issue online. Subsequent articles will discuss how to treat elderly persons who have a PTSD diagnosis, with a focus on biological, pharmacological, and psychological techniques.

Key words: Post-traumatic stress disorder, anxiety disorders, avoidance, traumatic experience, elder abuse, elder neglect.
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Post-traumatic stress disorder (PTSD) has received a great deal of attention in the past decade due to the ongoing conflict in the Middle East and the large number of returning military personnel who have been affected. However, the disorder is not limited to military veterans. It is estimated that 7% to 8% of the US population will have PTSD at some point during their lives, and approximately 5.3 million adults have PTSD in a given year.1 The exact cause of PTSD is not well understood, nor are the reasons why some people develop PTSD but not others; however, it is suspected that numerous physical, psychological, and social factors—and even genetics—play a role in development of PTSD. Symptoms of PTSD typically manifest after witnessing or experiencing an overwhelming traumatic event, such as assault, abuse, natural disaster, terrorism, or war, but symptom onset and severity vary on a person-to-person basis. Patients who experience trauma in their youth may have recurring symptoms that affect their functioning well into adulthood and late-life. New-onset PTSD in the elderly is rare2; however, as the population continues to age, clinicians need to be able to recognize its early warning signs, differentiate these warning signs from natural processes of aging or effects of other medical illness, and be prepared to intervene with treatment as soon as possible.

This article, the second in the continuing series on PTSD in older persons, reviews the risk factors of PTSD in the general population and in the older adult population specifically. It provides an overview of the early signs and symptoms of PTSD in older persons and explains some of the screening tools that clinicians can administer in the primary care setting to identify at-risk patients. The next article in the series will discuss the various approaches to treatment of PTSD in this patient population.

Prevalence of PTSD

According to information from the National Comorbidity Survey (NCS) report,3 the estimated lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to develop PTSD during their lifetime. This represents a small proportion of those who have experienced a traumatic event at one time or another in their lives; 60.7% of men and 51.2% of women reported having at least one traumatic event. The most frequently experienced traumas were: witnessing someone being badly injured or killed; being involved in a fire, flood, or natural disaster; being involved in a life-threatening accident; and combat exposure.3

Further in the NCS report, the majority of persons affected with PTSD experienced two or more types of trauma. More than 10% of men and 6% of women with PTSD reported four or more types of trauma during their lifetimes. The traumatic events most often associated with PTSD in men were rape, combat exposure, childhood neglect, and childhood physical abuse. The most commonly noted traumatic events in women suffering from PTSD were rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse.3

Historically, the rate of PTSD has always been high among military personnel, but the prevalence among this population seems to be increasing. According to the US Department of Veterans Affairs, PTSD is the most common mental health diagnosis (21.5%) among veterans, and based on current deployment rates, healthcare providers anticipate an annual expense of $200 million on PTSD care.4 More recent data estimate that PTSD affects 11% of veterans returning from Afghanistan and 20% of veterans returning from Iraq.5 This is in contrast to the higher rate of PTSD in women overall for non-combat–related trauma, likely due to the more personal nature of these traumatic events, especially in the case of rape. The National Vietnam Veterans Readjustment Study, which studied veterans who experienced combat as well as civilians merely working for the military, reported that 15% of men and 9% of women exposed to combat were affected with PTSD two decades later, with a lifetime prevalence of 18.7%.6

According to a recent poll by the American Psychiatric Association, one-third of Americans report experiencing “extreme levels” of stress, with one in five reporting high levels of stress on 15 days or more per month.7 The Department of Veterans Affairs estimates that between 50% and 72% of women experience a traumatic experience at least once in their lives, predisposing them to later PTSD upon additional traumatic experiences.8,9 Compared with younger persons, older adults are more frequently hospitalized, sustain traumatic injuries from falls and motor vehicle accidents at a higher rate, and encounter a greater number of life stressors that may contribute to the development of PTSD. However, despite the high prevalence of traumatic events in the lives of all men and women, it remains unclear why PTSD develops in only certain individuals and not in others.

Risk Factors for Developing PTSD

While men are at higher risk of exposure to traumatic events, women are at higher risk of developing PTSD (10% women compared with 5% of men).1,3 Age has not been specifically studied as a variable. A history of prior trauma, especially childhood abuse, has been noted to be highly predictive of developing PTSD later in life. Individuals with a family history of anxiety disorders and who have anxiety themselves, emotional lability, poor interpersonal interactions, and an overall “negative” mood are also considered to be at greater risk of developing PTSD following exposure to trauma.

The higher the intensity of trauma, the greater the risk of developing PTSD will be. Intensity in this context encompasses a variety of factors, including duration of the trauma, unpredictability of the event, lack of control over one’s environment, failed attempts to avoid injury, a perceived sense of failure, and actual loss. The more personally involved the individual is in the traumatic event, the greater the risk of PTSD. It is estimated that one-third of all rape victims develop PTSD during their lifetime, and rape victims were 6.2 times more likely to develop PTSD than women who had not been victims of a crime (31% vs 5%).10

Numerous characteristics have been reported to protect against the development of PTSD. Individuals with personality types that express optimism, social support, and humor are less likely to have PTSD following the same trauma. In addition, active instead of avoidant coping mechanisms and an openness to change also appear to be protective. When individuals are able to reframe problems, demonstrate greater flexibility in thinking, and have stronger social support networks, they are considered to be at lower risk of developing PTSD.11

Issues Associated With Diagnosing PTSD in Older Adults

Despite the wealth of information that has accumulated over the years about PTSD, little is known about PTSD in the elderly. The US Department of Veterans Affairs estimates that in the general population of older adults (≥60 years), the prevalence of PTSD may range between 1.5% and 4%, with estimates of subclinical PTSD ranging between 7% and 15%,9 but due to the lack of research and the changing diagnostic criteria of PTSD over the decades (which were reviewed in the first part of this series), these statistics are believed to underrepresent the true prevalence of PTSD in this age group. Since long-term memory is not affected by the normal aging process and is one of the last cognitive changes to occur in late life, even in the setting of dementia, memory of past events can play a dramatic role in how older persons are able to deal with a new traumatic event.

While PTSD has historically been considered an anxiety disorder,2,12 the latest revision to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) categorizes PTSD as a trauma- and stress-related disorder.13 Studies of PTSD have noted similarities between young and old persons in terms of reliving a traumatic event, attempts to avoid situations that remind the individual of the traumatic event no matter how long ago it occurred, and hypervigilant (hyperarousal) behavior.9 It is known that PTSD in the elderly can remain a chronic problem over a lifetime, with intermittent reappearances or exacerbations that affect normal functioning, or only occur later in life as the result of a recent traumatic event that serves as a trigger.

While ageism may play a role in the underdiagnosis of PTSD during later life, coexisting medical and/or psychiatric disorders that are more frequently encountered during later life may also make it harder to diagnose this problem; this often leads to a delay in diagnosis because it is often not even considered as a potential problem. Coexisting anxiety, depression, and dementia may also make it more difficult to obtain an accurate and reliable history while making it difficult to distinguish which signs and symptoms may actually be part of PTSD and not attributable to the underlying psychiatric problems.

Studies show that severe and prolonged trauma or a history of PTSD may place the elderly individual at increased risk of cognitive decline and onset of dementia.9,14 In addition, older adults with both PTSD and cognitive impairment may encounter a range of trauma-related stimuli or “triggers” that may elicit PTSD symptoms and anxiety. These triggers may lower the threshold for response and lead to an increase in behavioral disorders. Normal everyday stimuli may serve as a reminder of a traumatic experience and may include such things as news heard on TV and/or radio, sounds of other individuals in distress/pain, or loud noises. These stimuli may be misinterpreted as trauma-related and the individual may not have the normal ability to place these stimuli into proper context due to their underlying cognitive impairment. In certain cases, even something as minor as waking the older person who has suffered a traumatic event to administer a medication or provide care may result in distress and even a violent reaction. These behaviors may be misinterpreted and lead to the older person being placed in restraints or given unnecessary medications that may increase agitation and delirium. The following list identifies risk factors for the development of PTSD in older adults that healthcare providers should ask about to help screen their patients for PTSD.

Subacute and/or Chronic Trauma
Individuals with symptoms that have not yet become clinically apparent (ie, subclinical PTSD) or have been victims of repeated trauma throughout their lives (chronic trauma) are at increased risk for developing PTSD.9,15 Examples include any prior life-threatening traumatic event; an event that leads to a perception of imminent death; prior combat experience; time spent as a prisoner of war or in a labor camp as a Holocaust survivor; and being a victim of sexual abuse/rape and/or other violent crime.

Recent Traumatic Events

A traumatic event for older adults includes any life-threatening event or event in which they perceive imminent death to themselves or to loved ones. Examples that are common among older adults include losing a spouse or child (within the past 2 years); being a victim of sexual, physical, or mental abuse; experiencing a natural disaster; or being injured in a motor vehicle accident.

Physical and mental abuse. Many elderly persons with PTSD have experienced or may be currently experiencing physical and/or mental abuse and/or neglect. It is important to understand what constitutes these abuses so that there will be an increased awareness and early recognition of PTSD. The different types of elder abuse are explained as follows16:

  • Physical abuse refers to any act of violence that may result in pain, injury, impairment, or disease. Examples include pushing, striking, slapping, or pinching; force-feeding; incorrect positioning; improper use of physical restraints or medications; and sexual coercion or assault.
  • Neglect refers to failure of a caregiver to provide the care, services, or supervision necessary to meet the physical and/or mental needs of their patient and that are necessary for optimal functioning or to avoid harm. Examples include withholding health maintenance care, such as meals, physical therapy, or proper hygiene; failure to provide physical aids, such as eyeglasses, canes/walkers, false teeth, or hearing aids; and leaving the patient alone for long periods of time.
  • Exploitation refers to misuse of the patient’s income and/or resources for the personal benefit of another. Examples include stealing money or possessions; coercing the patient to sign a contract or assign durable power of attorney; purchasing goods; and making changes to a will. Financial or material exploitation can also include failure to use available funds and resources necessary to sustain or restore the health and wellbeing of the patient as a means of personal gain (ie, having money available for personal use, either while the patient is still alive of after his or her death).

The warning signs of possible elder abuse and/or exploitation may include a variety of signals. There may be behavioral signals, such as inconsistencies in money management, unjustified fear, unwarranted suspicion, unreasonable excuses, and unwillingness to talk. There may also be environmental signals, including a history of having inadequate medicine, food, housing, or clothing; evidence of alcohol use and/or abuse; and fecal and/or urine smell on clothes and/or the person. In more extreme cases, there may be physical manifestations, such as unexplained bruises, fractures, burns, or skin disorders; dehydration, malnutrition, and/or sudden weight loss; untreated medical conditions and/or medication abuse; and hyperthermia or hypothermia.

Evaluating Signs and Symptoms of PTSD in the Elderly

Improving recognition of PTSD in elderly patients requires training healthcare professionals to take trauma histories and assess patients for early signs and symptoms of PTSD.The following behaviors, which demonstrate symptoms of reexperiencing, avoidance, and hyperarousal, are early warning signs that the older patient may be developing PTSD. While these may be the result of the traumatic event or some underlying illness, they should trigger a thorough investigation and consideration of acute stress disorder. These warning signs are most commonly diagnosed in the first 30 days after a traumatic event and may lead to PTSD if left untreated:

  • A feeling of intense fear, helplessness, and/or horror17,18
  • A newly identified inability to concentrate19
  • Indecisiveness/procrastination18
  • Persistent anxiety or worrying19
  • Signs of depression and/or despair18
  • Withdrawal from usual activities, hobbies, and contact with family and friends18,19
  • Frequent references to death, dying, and/or suicide18
  • Increased irritability and/or restlessness11
  • Disruptive sleep19
  • New confusion18
  • More talkative than usual (ie, pressure to keep talking while thoughts are racing)20
  • Disheveled appearance, poor hygiene21
  • Language that shifts from past to present tense verbs22

Studies have demonstrated that older individuals who already have been identified as having PTSD exhibit more memory problems, somatization, dissociation, affective changes, and personality changes that may mimic mental disorders as compared with their younger counterparts.9 Beck and Stanley23 noted that anxiety disorders tended to be much more common than affective disorders and major depression in the elderly.

Challenges Associated With Assessment of PTSD in Older Adults

Assessment of PTSD can be difficult in older adults, who may not be likely to discuss traumatic events in a clinical visit or may appear to minimize their importance, especially if the traumatic event occurred years earlier. Therefore, if clinicians recognize any of the aforementioned signs, administration of an assessment tool is merited. As many older adults have some degree of cognitive impairment that may impede accurate history-taking, administration of a full mental status examination, including cognitive screening, is recommended by the 2010 Veterans Affairs/Department of Defense Clinical Practice Guidelines for PTSD in elderly patients.9

There are several validated PTSD assessment measures that have been used in older adults, including the Clinician-Administered PTSD Scale (CAPS),24 which is considered the gold-standard in PTSD assessment, and the self-report PTSD Checklist (PCL).25 As older adults are more likely to report physical concerns or pain rather than emotional difficulties, a tool such as the Primary Care PTSD Screen (PC-PTSD),26 a four-item screening tool designed for use in the primary care setting, may help identify risk of PTSD in elderly persons because it can shed light on mental health issues based upon patients’ physical responses to stress. The PC-PTSD asks the following four questions, each with a yes or no response:

In your life, have you ever had any experiences that were so frightening, horrible, or upsetting that, in the past month, you:

  1. Had nightmares about it or thought about it when you did not want to?
  2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
  3. Were constantly on guard, watchful, or easily startled?
  4. Felt numb or detached from others, activities, or your surroundings?

Individuals who respond “yes” to two or more of these questions should receive further assessment and are considered to be at high risk of developing PTSD following the recent traumatic event. If the patient is unable to provide reliable answers about traumatic exposure or psychiatric distress, family members should be questioned. If necessary and possible, previous medical and/or military service records should also be reviewed.

The CAPS is a 30-item structured interview that corresponds to the diagnostic criteria of PTSD outlined in the DSM-IV.17 CAPS is designed to enable diagnosis of new-onset PTSD (within the past month) or identify a lifetime diagnosis of PTSD.24 In addition to assessing for symptoms of PTSD, the questions assess the impact of symptoms on social and occupational functioning.

The PCL is a 17-item questionnaire that assesses for the presence of the DSM-IV symptoms of PTSD.25 Compared with CAPS, which can take up to an hour to complete, the PCL can be completed by patients in 5 to 10 minutes. The PCL has three versions: military, civilian, and specific. The military and civilian versions ask about symptoms in relation to any stressful experiences, whereas the specific version asks about symptoms in relation to an identified stressful experience.

It is important to note that the criteria of PTSD have been updated with the release of the fifth edition of the DSM (DSM-5) in May 2013. According to the Department of Veterans Affairs, the National Center for PTSD is in the process of updating the PCL, the CAPS, and the PC-PTSD tools to reflect the new DSM-5 criteria.27

Early Interventions to Prevent Early PTSD

If a patient is considered to be at risk of PTSD based on his or her history and the clinical assessment, there are a number of early interventions that may help reduce and/or delay the onset of symptoms of PTSD following a recent traumatic event. It is important to note that the healthcare team should involve multiple disciplines, including geriatricians, social workers, and nurses. Spiritual counseling may also be advisable. Additionally, patients should be referred for psychological or psychiatric counseling when there are changes in behavior, mood (ie, anger, fear, anxiety, guilty), or cognitive functioning that cannot be explained by other aspects of illness.

Early recognition and prompt initiation of a treatment plan is vital. Elderly patients whose PTSD treatment has been delayed tend to have symptoms indicating higher arousal and intrusive thoughts. Clinicians may confuse such symptoms with anxiety related to an illness or another stressor. There are also more sleep disturbances in older persons with PTSD as compared with younger individuals similarly affected, with a preponderance of disturbing dreams and more frequent awakenings.9 Intrusive memories, impairment of trust, and avoidance of things that are viewed as potentially stressful are also more commonly noted. It has been reported that patients are more susceptible to suggestions and less opposed to interventions during the peritraumatic period.28 For this reason, early intervention is advised. Interventions can also help the patient maintain a healthy outlook and avoid triggering past recollections that may precipitate PTSD.

What follows are other actions that clinicians can take to help reduce or delay PTSD onset in their elderly patients:

  1. Communicate with the patient to provide reassurance and hope for a positive recovery; any member of the multidisciplinary care team can do this.
  2. Speak in comforting tones using words that help the patient to relax or calm down. One of the earliest ways to assist a traumatized patient after an injury or accident is to use the “right” vocabulary. Verbally comforting a patient in crisis has been shown to positively alter his or her healing response.29
  3. Use protocols to prevent delirium.30
  4. Establish and foster an active support network. Use family and friends as part of the treatment plan to support the patient through the peritraumatic time period and to ensure proper follow-up and early treatment, if necessary. It is imperative that screening of family and friends be done before initiating their involvement to rule out potential cases of elder abuse, both active and passive. Patients with PTSD have been noted to have more symptoms following the loss of family support. Older individuals more frequently find themselves alone after the death of a spouse or close friend. They may also live far away from their children and/or other family members, increasing their risk of isolation.
  5. Provide frequent orientation, such as to day, time, and place.
  6. Provide comfort measures, including proper nutrition and hydration and ongoing attention to pain control.
  7. Provide detailed explanations of ongoing and future procedures.
  8. Judiciously prescribe anxiolytic agents and sedatives or sleeping medications as necessary.
  9. Use stress reduction techniques, such as relaxation response and meditation.

Conclusion

As the population continues to age, clinicians will undoubtedly encounter many more individuals with PTSD. While many of these cases may be late-life onset, resulting from a recent traumatic event, healthcare providers must not forget that past experiences play a significant role in PTSD development in older persons. In some cases, an older patient may have chronic PTSD resulting from an earlier life event; this may remain an active problem throughout the individual’s entire life, placing him or her at particular risk of exacerbation as life stresses become more prevalent during later life. Although prevention is key, we cannot prevent all traumatic events, and past experiences will continue to predispose to future illness. Therefore, recognition of the early signs and symptoms of PTSD is imperative, and when identified, multidisciplinary interventions should be promptly initiated to reduce the impact of PTSD on the patient’s life and improve his or her quality of life.

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Disclosures: The authors report no relevant financial relationships.

Address correspondence to: Steven R. Gambert, MD, University of Maryland Medical Center, N3E09, 22. S. Greene Street, Baltimore, MD 21201; sgambert@medicine.umaryland.edu