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Late-Onset Posttraumatic Stress Disorder
AbstrAct Posttraumatic stress disorder (PTSD) is a complex psychological response to a perceived life-threatening trauma that includes re-experiencing the trauma, avoidance, intrusive thoughts, hyperarousal, and dissociation. Exposure to trauma in early adulthood increases the potential for further psychological threats throughout life. In older adult populations, PTSD is an underrecognized and undertreated disorder that can result in psychosocial disability, substance use, and other negative health outcomes. This article examines the range of symptoms related to PTSD in older adults and expands on health care provider sensitivity to the interrelationship of mental and physical health when addressing the needs of older adults with this disorder.
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Marsha Snyder, PhD, PMHCNS, BC
Journal of Psychosocial nursing • Vol. 46, no. 11, 2008 39

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ithin the last century, the average life span has increased by 37%, with many people living well into their 80s and 90s. It is estimated that by 2030, more than 15 million older adults will experience a mental illness. The aging of the Baby Boomer cohort and greater longevity is responsible for this statistic (U.S. Department of Health and Human Services [USDHHS], Office of the Surgeon General, 1999). The estimated prevalence rate for anxiety disorders in adults age 55 and older is approximately 11%. This percentage is greater than that of any other disorder associated with older adults (USDHHS, Office of the Surgeon General, 1999). In particular, posttraumatic stress disorder (PTSD) in older adults is an underrecognized and undertreated disorder that can result in psychosocial disability, substance use, and other negative health outcomes. For this reason, the purpose of this article is to examine this disorder as it relates to older adults and increase health care provider sensitivity to the interrelationship of mental and physical health when addressing the needs of older adults with this disorder. DifferentiAl DiAgnosis of PtsD As Americans live longer, the psychological stressors some individuals sustained at earlier life stages can become deterrents to successful aging (USDHHS, Office of the Surgeon General, 1999). This is especially true for individuals who are exposed to trauma related to combat, ravages of war, sexual abuse, or events a person conceptualizes as catastrophic, and when available coping mechanisms fail (Murray, 40

2005). In the case of older adults, research surrounding trauma and responses to trauma has been primarily inclusive of male veteran populations. However, several studies do address trauma-related issues for civilian older adult female populations. An area of recent interest is the reoccurrence of trauma-related stress symptoms in later life.
Acute stress Disorder

The majority of individuals exposed to an acute stress episode will recover in the months following the traumatic event and will not require formal intervention. These individuals fall within the diagnostic categories outlined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (American Psychiatric Association, 2000) for acute stress disorder (ASD) (Bryant, 2003). Symptoms related to ASD occur within a month of a traumatic event. Symptoms are categorized into six areas: l Cluster A—fearful response after a traumatic event. l Cluster B—three dissociative symptoms. l Cluster C—re-experiencing symptoms. l Cluster D—marked avoidance. l Cluster E—marked anxiety. l Cluster F—evidence of significant distress or impairment in everyday task completion.
PtsD

l Subjective sense of numbing or detachment. l Reduced awareness of surroundings. l Derealization, depersonalization, or dissociative amnesia. These symptoms block processing of traumatic memories and adaptation. Interestingly, individuals who develop PTSD do not always report Cluster B symptoms (Bryant, 2003). It is proposed that both individuals who experience all symptoms and those who experience all but Cluster B symptoms can be at risk for developing PTSD (Bryant, 2003). Symptoms can abate and resurface over months or years and can reoccur in full force if the person is retraumatized. While survivor symptoms can persist as an individual ages into older adulthood, how these symptoms are expressed is very individual and may depend on genetic and epigenetic factors, premorbid personality traits, early life experiences, and social support (Weintraub & Ruskin, 1999). Consistent findings report that delayed onset of PTSD is rare when no prior exposure to trauma has occurred (Andrews, Brewin, Philpott, & Stewart, 2007).

Disturbance in all six areas identified for ASD must last a minimum of 2 days and a maximum of 4 weeks before the diagnosis of PTSD can be assigned. Three Cluster B symptoms of dissociation need to be present for a diagnosis of ASD:

PreDictive fActors for PtsD Age can offer a protective shield against the effects of a traumatic event through the passage of time and successful life experiences. Factors that seem to be associated with resilience against the development of PTSD include marriage, social support, increased socioeconomic status, and religion (Weintraub & Ruskin, 1999). Across studies, no agreement has been reached on the symptom combination that is predictive of PTSD, and for this reason, increased attention has JPnonline.com

been directed toward biological indicators (Bryant, 2003).
biological indicators

The connection between the basal ganglia, limbic system, and prefrontal cortex brain structures are well supported in the literature. This connection seems to include processing of both social and emotional information (Flannelly, Koenig, Galek, & Ellison, 2007). The basal ganglia, although primitive, provides an autonomic system for threat assessment. The basal ganglia and the limbic system operate in preconsciousness for both language and emotional arousal. For this reason, in the case of PTSD, assessment of threat is excessive and sometimes in error, as the person perceives a threat when there is none. All three brain components (basal ganglia, limbic system, and prefrontal cortex) rely on sensory input from the prefrontal cortex and amygdala for their assessment information regarding a threat, as well as past experience and memories. Judgments regarding threat potential seem to be routed primarily through emotional processing rather than through cognitive reasoning and, as a result, are unconscious, rapid, and automatic, with the response outcome not necessarily within a person’s conscious awareness (Flannelly et al., 2007). Another area of biological investigation is research that addresses the relationship between increased glucocorticoid levels and PTSD symptoms. On the basis of peripheral and neuroendocrine studies of individuals with PTSD symptoms, Grossman et al. (2006) reported greater sensitivity in the central brain to glucocorticoids. This phenomenon was expressed through height-

ened declarative memory suggestive of hippocampal involvement; impairment in working memory suggestive of prefrontal, cingulated, temporal, and parietal cortexes; and neurotransmitter systems associated with dopamine and serotonin (Grossman et al., 2006). Increases in these measures seem to reflect a preexisting vulnerability trait that heightens the risk for developing PTSD following a traumatic event. Functional brain images for patients who have had PTSD reflect significant activation in the ventral frontoparietal network and left hippocampal area, which are

tive responses are demonstrated through persistent negative appraisal of the traumatic event and subsequent events through disturbance in memory that is characterized by “poor elaboration and contextualization, strong associative memory, and strong perceptual priming” (Bryant, 2003, p. 792). As the traumatic event is processed, understanding and meaning are attributed to the event within the contexts of social and cultural environments. Studies indicate the level of psychological impact of the trauma experience on the individual depends heavily on pretrauma function-

Opportunity exists for primary care and psychiatric nurses to come together and shape a system of care that is responsive to patient needs.
connected with visual attention and memory (Bryant, 2003). As a result, even slight traumatic stimuli can initiate flashbacks in the presence of poor concentration and attention. It seems this traumatic stimulus becomes associated with arousal and subsequent development of fear conditioning that can trigger further conditioning. Mechanisms for this sensitization are unclear, but it does seem evident that repetitive activation of traumatic memories increases sensitivity within the limbic system (Bryant, 2003).
Psychological indicators

ing. Preexisting depression and anxiety and multiple trauma exposures seem to increase an individual’s vulnerability to the stressors related to trauma, with the highest rates of PTSD associated with violent or sexual trauma (Nakell, 2007). PoPUlAtions At risk
veteran survivors

Development and continued experience of acute and chronic symptoms of PTSD are mediated by cognitive responses to the traumatic event. These cogni-

Veterans who meet criteria for PTSD also report symptoms of major depression, generalized anxiety disorder, panic disorder, and alcohol abuse. Older veterans seen in primary care who reported depression and symptoms of PTSD also reported more suicidal ideation, smoking, and negative perceptions of their health than did those who did not report these symptoms. These symptoms contributed to difficul41

Journal of Psychosocial nursing • Vol. 46, no. 11, 2008

ty concentrating, worry, feelings of worthlessness, and depressed mood (Rauch, Morales, Zubritsky, Knott, & Oslin, 2006). Although intrusive thoughts, hyperarousal, avoidance, and dissociation are associated with PTSD, veterans reported that over time they experienced a decline in intrusive thoughts and survivor guilt. However, these survivors reported that avoidance symptoms and estrangement from others were symptoms that lingered into advanced age (Nakell, 2007). The relationship between PTSD and alcohol abuse is reflected inconsistently in data (Rauch et al., 2006). War veterans seem to be at increased risk for reactivation of PTSD symptoms in later life. In an extensive review of case studies and group studies literature, Andrews et al. (2007) suggested the delay in onset of PTSD symptoms is likely due to reactivation of prior symptoms rather than delay in onset of the disorder. In midlife, these veterans did not report symptoms related to any stress disorder, but later in advancing years, they began to reminisce about combat-related thoughts and feelings (Andrews et al., 2007). Persistence of PTSD symptoms has been linked to premorbid personality traits or experiences, as shown in older male combat veterans who were exposed to highly stressful events either in their childhood or in combat as young adults (Weintraub & Ruskin, 1999). The chronic nature of PTSD increases victims’ vulnerability to threats throughout life, especially from midlife through old age. The experience of loss generally associated with the aging process, retirement, physical changes, and recognition of one’s own mortality stimulate memory in later 42

years. As levels of activity shift from productivity to introspection—in combination with losses in daily structure and routine, selfesteem, status, and social interaction—usual coping mechanisms are threatened and challenged (Weintraub & Ruskin, 1999).
older female survivors

Older women are at higher risk for PTSD than are older men due to higher rates of sexual and domestic physical abuse experienced by women. Although they are at higher risk, older women are underdiagnosed for PTSD and are given diagnoses related to depression, anxiety, or poor health. As a result, women may seek help more frequently, but they do not always receive appropriate intervention or treatment (Franco, 2007). Older women who sustained repeated physical assault at an early age report more negative emotional responses to the event than do those who reported being sexually assaulted (Acierno et al., 2007). Women who sustained a sexual assault up to 50 years prior to current symptom expression report autonomic arousal and avoidance symptoms associated with PTSD (Acierno et al., 2007). The impact of early and repeated trauma on current symptoms is critical when treating older women and must be considered an integral part of a health assessment (Franco, 2007). imPlicAtions for PrActice Many older adults will attempt to live with multiple symptoms of PTSD before seeking professional help. The reason for treatment avoidance may be related to shame and embarrassment regarding symptoms, as well as events surrounding the trauma, the need to be tough and

not a coward, or fear of having a serious physical or mental disorder (Murray, 2005). Initially, avoidance behaviors serve to insulate the individual from trigger situations, but when the ability to meet everyday needs is interrupted because of the inability to focus on anything other than the triggers, older adults may be motivated to seek help (Murray, 2005). When older adults eventually do seek help, it is because they feel unsafe or have physical symptoms. Seeking psychiatric help for their difficulties is generally not a serious consideration.
Primary care and older Adults

Due to feelings of stigma associated with seeking mental health treatment, older adults will most likely seek help within primary care. Primary care settings offer the option of community-based services that are convenient and affordable. Within primary care, mental disorders in older adults can be both identified and treated (USDHHS, Office of the Surgeon General, 1999). Co-occurrence of psychiatric problems with medical disorders can significantly affect the trajectory of a medical disorder (Nakell, 2007). Sleep disturbance, a symptom associated with both aging and PTSD, can be further compromised by posttraumatic nightmares and flashbacks, which can lead to increased psychiatric complaints. Nakell (2007) reported that individuals with depression who also screened positive for PTSD reported more severe depression and poorer prognosis, lower levels of social support, and more frequent medical visits, and were more likely to report suicide ideation than those with a single diagnosis of major depressive disorder. Complaints related to deJPnonline.com

terioration in physical health are evident in older women who experienced early and repeated trauma, especially interpersonal, during their lifetime (Franco, 2007). Recognition and optimal treatment of PTSD in primary care, however, presents a challenge because symptoms are vague and complex and reflect intense distress (Nakell, 2007). In a 5-year follow-up study of mental disorder recognition in primary care, Jackson, Passamonti, and Kroenke (2007) reported that 29% of the sample was identified at baseline as having a mental disorder, 26% of which had more than one disorder. Across the 5 years, the percentage diagnosed with a disorder increased to 33%. Symptoms that persisted over time were more likely to be diagnosed. Comprehensive assessments that include life histories are imperative for PTSD and other comorbid mental disorders. Several brief PTSD assessment scales are available and can be used within primary care settings. Breslau’s 7-item screening tool for PTSD is designed especially for use in primary care (Breslau, Peterson, Kessler, & Schultz, 1999). The scale demonstrates good reliability compared with the widely used 17-item Clinician-Administered PTSD Scale (CAPS) (Blake et al., 1995). Breslau’s tool offers a time-efficient and reliable method for assessment in primary care (Kimerling et al., 2006).
integrated Health care

k e Y P o i n t s
1. 2. 3. Older adults exposed to trauma earlier in their lives can experience reactivation of posttraumatic stress disorder (PTSD) symptoms. Primary care is a point of entry into the health care system for older adults and offers opportunity for early recognition of PTSD. Integration of physical and behavioral health services allows optimal treatment for older adults who experience PTSD reactivation.
Do you agree with this article? Disagree? Have a comment or questions? Send an e-mail to Karen Stanwood, Executive Editor, at kstanwood@slackinc.com. We’re waiting to hear from you!

health care—and general health care—depends upon the effective collaboration of all mental, substance-use, general health care, and other human service providers in coordinating the care of their patients. (p. 210)

Integration of physical and behavioral health services can offer optimal treatment outcomes for older adults with PTSD. A 2006 report from the Institute of Medicine (IOM) states that:
improving the quality of mental health and substance abuse

While collaboration among mental health and general health care practitioners is essential, existing separation of mental and substance use health care from general health care makes it difficult (IOM, 2006). Although much work is needed to actualize delivery of integrated health care, several models already exist. Four service delivery models for integrated care have been attempted (Alfano, 2005): l Embedding primary care providers within mental health programs. l Unified programs that offer both mental health and primary care under a single administration. l Initiatives to improve collaboration between independent, office-based primary care and mental health providers. l Co-location of behavioral health providers in primary care offices. Integrated approaches are in their infancy, but with these initial steps, opportunity exists for

primary care and psychiatric nurses to come together and shape a system of care that is responsive to patient needs. Because of their holistic approach to patient care, nurses are uniquely prepared to integrate both physical and mental health care and can assume leadership within a collaborative interdisciplinary team. Collaboration between primary care and mental health providers can expand available clinical resources. Traditional treatment approaches for PTSD are either pharmacology or psychotherapy. Selective serotonin reuptake inhibitors have been shown to be the most effective pharmacological approach to address PTSD symptoms (Stein, Ipser, & Seedat, 2005). Primary care providers are trained in the medical model of care that relies heavily on medications, treatments, and advice. Although medication offers great opportunity for the treatment of mental disorders, there is strong evidence that an effective therapeutic alliance and formal psychotherapy are also important components of treatment. Initiation of a therapeutic alliance with older adults can be forged by primary care or mental health providers. However, aug43

Journal of Psychosocial nursing • Vol. 46, no. 11, 2008

mentation of pharmacotherapy with psychotherapy falls within the expertise of mental health providers. The literature discusses multiple psychotherapy approaches for PTSD: traumafocused cognitive-behavioral therapy, stress management, eye movement desensitization and reprocessing, hypnosis, group cognitive-behavioral therapy, and family therapy (Murray, 2005). Choice of therapeutic interventions for older adults with PTSD is largely dependent on individual clinician and patient preferences, as limited research evidence supports use of these approaches with older adults. Along with continued work toward collaborative models of care for older adults, further research is needed that addresses assessment of and intervention for anxiety disorders in this population, particularly in older women. The long-term impact of the biology of PTSD on physical and mental health is another area that requires further investigation. sUmmArY Reemergence of PTSD in later years can challenge older adults’ coping resources and affect their physical and mental health. Primary care serves as a point of entry into the health care system for older adults and can provide initial screening and treatment of noncomplex mental health needs in this population. Older adults with physical and mental health disorders may also experience complex symptoms related to late-onset PTSD. These individuals can benefit from integrated primary and mental health services. Integrated care can provide the existing mental health system with a way to meet the needs of 44

these older adults and improve not only their health but also their quality of life. references
Acierno, R., Lawyer, S.R., Rheingold, A., Kilpatrick, D.G., Resnick, H.S., & Saunders, B.E. (2007). Current psychopathology in previously assaulted older adults. Journal of Interpersonal Violence, 22, 250-258. Alfano, E. (2005, February). Integration of primary care and behavioral health. Report on a roundtable discussion of strategies for private health insurance. Retrieved May 28, 2008, from the Bazelon Center for Mental Health Law Web site: http:// www.bazelon.org/issues/general/publications/RoundtableReport.pdf American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Rev.). Washington, DC: Author. Andrews, B., Brewin, C.R., Philpott, R., & Stewart, L. (2007). Delayed-onset posttraumatic stress disorder: A systematic review of the evidence. American Journal of Psychiatry, 164, 1319-1326. Blake, D.D., Weathers, F.W., Nagy, L.M., Kaloupek, D.G., Gusman, F.D., Charney, D.S., et al. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8, 75-90. Breslau, N., Peterson, E.L., Kessler, R.C., & Schultz, L.R. (1999). Short screening scale for DSM-IV posttraumatic stress disorder. American Journal of Psychiatry, 156, 908-911. Bryant, R.A. (2003). Early predictors of posttraumatic disorder. Biological Psychiatry, 53, 789-795. Flannelly, K.J., Koenig, H.G., Galek, K., & Ellison, C.G. (2007). Beliefs, mental health, and evolutionary threat assessment systems in the brain. Journal of Nervous and Mental Disease, 195, 9961003. Franco, M. (2007). Posttraumatic stress disorder and older women. Journal of Women & Aging, 19, 103-117. Grossman, R., Yehuda, R., Golier, J., McEwen, B., Harvey, P., & Maria, N.S. (2006). Cognitive effects of intravenous hydrocortisone in subjects with PTSD and healthy control subjects. Annals of the New York Academy of Sciences, 1071, 410-421. Institute of Medicine. (2006). Improving the quality of health care for mental and substance-use conditions. Retrieved

September 18, 2008, from the National Academies Press Web site: http://www.nap.edu/catalog.php? record_id=11470 Jackson, J.L., Passamonti, M., & Kroenke, K. (2007). Outcome and impact of mental disorders in primary care at 5 years. Psychosomatic Medicine, 69, 270276. Kimerling, R., Ouimette, P., Prins, A., Nisco, P., Lawler, C., Cronkite, R., et al. (2006). Brief report: Utility of a short screening scale for DSM-IV PTSD in primary care. Journal of General Internal Medicine, 21, 65-67. Murray, A. (2005). Recurrence of post traumatic stress disorder. Nursing Older People, 17(6), 24-30. Nakell, L. (2007). Adult post-traumatic stress disorder: Screening and treating in primary care. Primary Care, 34, 593610. Rauch, S.A., Morales, K.H., Zubritsky, C., Knott, K., & Oslin, D. (2006). Posttraumatic stress, depression, and health among older adults in primary care. American Journal of Geriatric Psychiatry, 14, 316-324. Stein, D.J., Ipser, J.C., & Seedat, S. (2005). Pharmacotherapy for post traumatic stress disorder (PTSD) (Article No. CD002795). Cochrane Database of Systematic Reviews, Issue 4. U.S. Department of Health and Human Services, Office of the Surgeon General. (1999). Older adults and mental health. In Mental health: A report of the Surgeon General (pp. 336-401). Retrieved August 27, 2008, from http://www.surgeongeneral.gov/library/ mentalhealth/pdfs/c5.pdf Weintraub, D., & Ruskin, P.E. (1999). Posttraumatic stress disorder in the elderly: A review. Harvard Review of Psychiatry, 7, 144-152. Dr. Snyder is Clinical Assistant Professor, University of Illinois at Chicago, Department of Health Systems Science, Chicago, Illinois. The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. Address correspondence to Marsha Snyder, PhD, PMHCNS, BC, Clinical Assistant Professor, University of Illinois at Chicago, Department of Health Systems Science, 845 South Damen Avenue, Chicago, IL 60612-7350; e-mail: snyderm@uic.edu.

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