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Anica Pless Kaiser, PhD, Jennifer Schuster Wachen, PhD, Carrie Potter, BA, Jennifer Moye, PhD, & Eve Davison, PhD, with the Stress, Health, and Aging Research Program (SHARP)
Barbara Hermann, PhD
Age-related factors can interact with posttraumatic stress symptoms and associated problems and carry implications for research and clinical care. It is important for health care professionals to be well-informed regarding appropriate interventions based upon patient age as well as the broader context of aging processes.
A full Mental Status Examination, including a cognitive screening, is recommended by the 2010 VA/DoD Clinical Practice Guideline (CPG) for PTSD when assessing the elderly patient (1). Most older adults do not have cognitive impairment. However, for an older patient who is inattentive to appearance, a poor historian, or forgetful during the interview, cognitive screening using a standardized instrument is warranted. If the clinician suspects dementia, the patient should be referred for a comprehensive diagnostic evaluation. In addition, if delirium is suspected, or there is a question about medication interactions, the individual should be referred for medical evaluation.
Assessment of trauma and related symptoms should be routine. Older patients may not spontaneously report traumatic experiences or they may minimize their importance, especially if the event(s) occurred a long time ago.
Older patients may talk about problems or respond to questions differently than younger people. For example, older individuals (Veterans and non-Veterans) may be more likely to report physical concerns or pain, sleep difficulties, gastrointestinal issues, cognitive difficulties, or use a general term like "stress." They are less likely to describe emotional difficulties, like depression or anxiety, and may describe "issues" or "concerns" rather than report "problems" (2). Older adults may present to primary care clinics with these complaints rather than seek mental health services. Providers, particularly primary care doctors, should follow up reports of physical issues with questions about changes in mood and activities. Additionally, it is important to consider potentially adaptive strategies that older adults may have developed over a lifetime and encourage use of these coping resources.
Many trauma and PTSD assessment measures have been used validly with older adults (3). This includes the Clinician-Administered PTSD Scale (CAPS; 4), the gold standard in structured diagnostic interviews, and the self-report PTSD Checklist (PCL; 5). Importantly, a lower cut-off score with older adults is recommended for many of these measures. For example, although a score of 50 on the PCL has typically been used to signify clinically significant PTSD symptoms, a cutoff score of 42 has been shown to optimally differentiate older adults with and without PTSD (6).
Suicide assessment is particularly important in older patients. Older (and younger) Veterans are at greater risk for completed suicide than are middle-aged Veterans (7).
To date, no evidence exists that older patients cannot benefit from Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE), or that modifications to the treatment protocols are universally necessary due to older age. Providers should consider specific needs of each individual and apply the treatment in the most beneficial manner. There are no randomized controlled trials currently published on the efficacy of PTSD treatment in older adults. However, a recent pilot study (8) demonstrated that conducting PE with older Veterans is both feasible and efficacious.
Providers specifically considering trauma-focused treatment should also know whether the patient has any significant cardiac or respiratory problems. The 2010 VA/DoD CPG for PTSD suggests that mental health providers seek consultation from other healthcare professionals when considering trauma-focused techniques for patients with these conditions (1). Trauma-focused techniques may lead to increased autonomic arousal and decreased cognitive performance. If, after consultation and discussion with the patient, it is decided that trauma-focused treatment is feasible, mental health providers can proceed with caution and should closely monitor patients at greater risk from high arousal. Several trials of exposure treatments for other anxiety disorders (for example, panic disorder) have indicated they are efficacious and well-tolerated among older adults (9).
The presence of cognitive decline may impact memory, learning, attention, or concentration. The provider may want to repeat material, present information in various ways, and focus on one topic at a time (1).
Beyond modifying treatment administration and seeking consultation, treatment providers working with older patients with cognitive or physical impairments may want to engage caregivers, informal and formal. Caregivers can often play a critical role within a treatment plan for an older adult with physical or cognitive issues by providing additional support, helping reinforce information presented in therapy, and assisting with transportation to treatment (1).
The majority of medication studies for PTSD have not included older adults, so results may not generalize to this segment of the population. Per the 2010 VA/DoD CPG for PTSD, first-line medications for the treatment of PTSD include selective serotonin reuptake inhibitors (SSRIs) and selective neuroepinephrine reuptake inhibitors (SNRIs). There is also some evidence to suggest that the blood pressure medication Prazosin reduces nightmares (1).
Older adults are often more sensitive to medication side effects, and are often managing more co-occurring medical problems and multiple medications than are younger people. As a result, it may be important to start with a low dose when introducing a new medication and make adjustments as needed. Prescribers should assess for any confusion about medication use or poor adherence among older patients who take multiple medications. In addition, the 2010 VA/DoD CPT for PTSD warns against the use of benzodiazapines as a first-line treatment for any patient with PTSD (1).
Author Note: SHARP is co-directed by Avron Spiro, PhD, and Eve Davison, PhD, and is coordinated by Anica Pless Kaiser, PhD. SHARP is supported by the Behavioral Science Division of the VA National Center for PTSD and the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System.
U.S. Department of Veterans Affairs/Department of Defense. (2010). VA/DoD clinical practice guideline for management of post-traumatic stress. Retrieved from http://www.healthquality.va.gov/ptsd/ptsd-sum_2010a.pdf (PDF)
Aldwin, C. M., Sutton, K. J., Chiara, G. & Spiro III, A. (1996). Age differences in stress, coping, and appraisal: Findings from the Normative Aging Study. Journals of Gerontology: Psychological Sciences, 51B, 179-188.
Thorp, S. R., Sones, H. M., & Cook, J. M. (2011). Posttraumatic stress disorder among older adults. In K. H. Sorocco & S. Lauderdale (Eds.), Cognitive Behavior Therapy with Older Adults: Innovations Across Care Settings. Springer Publishing Company.
Blake, D., Weathers, F., Nagy, L., Kaloupek, D., Gusman, F., Charney, D., et al. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8, 75-90.
Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993, October). The PTSD Checklist: Reliability, validity, and diagnostic utility. Paper presented at the annual meeting of the International Society for Traumatic Stress Studies, San Antonio, TX.
Cook, J.M., Thompson, R., Coyne, J.C., & Sheikh, J. (2003). Algorithm versus cut-point derived PTSD in ex-prisoners of war. Journal of Psychopathology and Behavioral Assessment, 25, 267-271.
Zivin, K., Kim, H. M., McCarthy, J. F., Austin, K. L., Hoggatt, K. J., Walters, H. M., Valenstein, M. (2007). Suicide mortality among individuals receiving treatment for depression in the VA health system: associations with patient and treatment setting characteristics. American Journal of Public Health, 97(12), 2193-2198.
Thorp, S. R., Stein, M. B., Jeste, D. V., & Wetherell, J. L. (2012). Prolonged Exposure therapy for older Veterans with posttraumatic stress disorder: A pilot study. American Journal of Geriatric Psychiatry, 20, 276-280.
Swales, P. J., Solfvin, J. F., & Sheikh, J. I. (1996). Cognitive-behavioral therapy in older panic disorder patients. American Journal of Geriatric Psychiatry, 4, 46-60.
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