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Late Onset PTST
Late Onset PTST
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Late-Onset Posttraumatic
Stress Disorder
Abstract
Posttraumatic stress disorder (PTSD) is derrecognized and undertreated disorder
a complex psychological response to a that can result in psychosocial disability,
perceived life-threatening trauma that in- substance use, and other negative health
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cludes re-experiencing the trauma, avoid- outcomes. This article examines the range
ance, intrusive thoughts, hyperarousal, and of symptoms related to PTSD in older adults
dissociation. Exposure to trauma in early and expands on health care provider sensi-
adulthood increases the potential for fur- tivity to the interrelationship of mental and
ther psychological threats throughout life. physical health when addressing the needs
In older adult populations, PTSD is an un- of older adults with this disorder.
tury, the average life research surrounding trauma and ing or detachment.
span has increased responses to trauma has been pri- l Reduced awareness of sur-
by 37%, with many people liv- marily inclusive of male veteran roundings.
ing well into their 80s and 90s. It populations. However, several l Derealization, depersonal-
is estimated that by 2030, more studies do address trauma-related ization, or dissociative amnesia.
than 15 million older adults will issues for civilian older adult fe- These symptoms block processing
experience a mental illness. The male populations. An area of re- of traumatic memories and adap-
aging of the Baby Boomer cohort cent interest is the reoccurrence tation. Interestingly, individuals
and greater longevity is responsi- of trauma-related stress symp- who develop PTSD do not always
ble for this statistic (U.S. Depart- toms in later life. report Cluster B symptoms (Bry-
ment of Health and Human Ser- ant, 2003). It is proposed that
vices [USDHHS], Office of the Acute Stress Disorder both individuals who experience
Surgeon General, 1999). The es- The majority of individuals all symptoms and those who ex-
timated prevalence rate for anxi- exposed to an acute stress epi- perience all but Cluster B symp-
ety disorders in adults age 55 and sode will recover in the months toms can be at risk for developing
older is approximately 11%. This following the traumatic event PTSD (Bryant, 2003). Symptoms
percentage is greater than that of and will not require formal inter- can abate and resurface over
any other disorder associated with vention. These individuals fall months or years and can reoccur
older adults (USDHHS, Office of within the diagnostic categories in full force if the person is retrau-
the Surgeon General, 1999). In outlined in the Diagnostic and matized. While survivor symp-
particular, posttraumatic stress Statistical Manual of Mental Dis- toms can persist as an individual
disorder (PTSD) in older adults orders, fourth edition, text revi- ages into older adulthood, how
is an underrecognized and under- sion (American Psychiatric As- these symptoms are expressed is
treated disorder that can result in sociation, 2000) for acute stress very individual and may depend
psychosocial disability, substance disorder (ASD) (Bryant, 2003). on genetic and epigenetic fac-
use, and other negative health Symptoms related to ASD occur tors, premorbid personality traits,
outcomes. For this reason, the within a month of a traumatic early life experiences, and social
purpose of this article is to exam- event. Symptoms are categorized support (Weintraub & Ruskin,
ine this disorder as it relates to into six areas: 1999). Consistent findings report
older adults and increase health l Cluster A—fearful re- that delayed onset of PTSD is rare
care provider sensitivity to the sponse after a traumatic event. when no prior exposure to trauma
interrelationship of mental and l Cluster B—three dissocia- has occurred (Andrews, Brewin,
physical health when addressing tive symptoms. Philpott, & Stewart, 2007).
the needs of older adults with l Cluster C—re-experienc-
this disorder. ing symptoms. Predictive Factors
l Cluster D—marked avoid- for PTSD
Differential Diagnosis ance. Age can offer a protective
of PTSD l Cluster E—marked anxiety. shield against the effects of a trau-
As Americans live longer, l Cluster F—evidence of sig- matic event through the passage
the psychological stressors some nificant distress or impairment in of time and successful life expe-
individuals sustained at earlier everyday task completion. riences. Factors that seem to be
life stages can become deterrents associated with resilience against
to successful aging (USDHHS, PTSD the development of PTSD in-
Office of the Surgeon General, Disturbance in all six areas clude marriage, social support,
1999). This is especially true identified for ASD must last a increased socioeconomic sta-
for individuals who are exposed minimum of 2 days and a maxi- tus, and religion (Weintraub &
to trauma related to combat, mum of 4 weeks before the diag- Ruskin, 1999). Across studies, no
ravages of war, sexual abuse, or nosis of PTSD can be assigned. agreement has been reached on
events a person conceptualizes as Three Cluster B symptoms of dis- the symptom combination that is
catastrophic, and when available sociation need to be present for a predictive of PTSD, and for this
coping mechanisms fail (Murray, diagnosis of ASD: reason, increased attention has
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been directed toward biological ened declarative memory sug- tive responses are demonstrated
indicators (Bryant, 2003). gestive of hippocampal involve- through persistent negative ap-
ment; impairment in working praisal of the traumatic event
Biological Indicators memory suggestive of prefrontal, and subsequent events through
The connection between the cingulated, temporal, and pari- disturbance in memory that is
basal ganglia, limbic system, and etal cortexes; and neurotransmit- characterized by “poor elabo-
prefrontal cortex brain structures ter systems associated with dopa- ration and contextualization,
are well supported in the litera- mine and serotonin (Grossman strong associative memory, and
ture. This connection seems to et al., 2006). strong perceptual priming” (Bry-
include processing of both so- Increases in these measures ant, 2003, p. 792).
cial and emotional information seem to reflect a preexisting vul- As the traumatic event is pro-
(Flannelly, Koenig, Galek, & El- nerability trait that heightens cessed, understanding and mean-
lison, 2007). The basal ganglia, the risk for developing PTSD fol- ing are attributed to the event
although primitive, provides an lowing a traumatic event. Func- within the contexts of social and
autonomic system for threat as- tional brain images for patients cultural environments. Studies
sessment. The basal ganglia and who have had PTSD reflect sig- indicate the level of psychologi-
the limbic system operate in pre- nificant activation in the ventral cal impact of the trauma experi-
consciousness for both language frontoparietal network and left ence on the individual depends
and emotional arousal. For this hippocampal area, which are heavily on pretrauma function-
reason, in the case of PTSD, as-
sessment of threat is excessive and
sometimes in error, as the person
perceives a threat when there is
Opportunity exists for primary care and
none. All three brain components psychiatric nurses to come together and shape a
(basal ganglia, limbic system, and
prefrontal cortex) rely on sensory system of care that is responsive to patient needs.
input from the prefrontal cortex
and amygdala for their assessment
information regarding a threat, connected with visual attention ing. Preexisting depression and
as well as past experience and and memory (Bryant, 2003). As anxiety and multiple trauma
memories. Judgments regarding a result, even slight traumatic exposures seem to increase an
threat potential seem to be routed stimuli can initiate flashbacks individual’s vulnerability to the
primarily through emotional pro- in the presence of poor concen- stressors related to trauma, with
cessing rather than through cog- tration and attention. It seems the highest rates of PTSD as-
nitive reasoning and, as a result, this traumatic stimulus becomes sociated with violent or sexual
are unconscious, rapid, and auto- associated with arousal and sub- trauma (Nakell, 2007).
matic, with the response outcome sequent development of fear
not necessarily within a person’s conditioning that can trigger fur- POPULATIONs at risk
conscious awareness (Flannelly et ther conditioning. Mechanisms Veteran Survivors
al., 2007). for this sensitization are unclear, Veterans who meet criteria
Another area of biological but it does seem evident that re- for PTSD also report symptoms
investigation is research that ad- petitive activation of traumatic of major depression, generalized
dresses the relationship between memories increases sensitivity anxiety disorder, panic disorder,
increased glucocorticoid levels within the limbic system (Bry- and alcohol abuse. Older vet-
and PTSD symptoms. On the ba- ant, 2003). erans seen in primary care who
sis of peripheral and neuroendo- reported depression and symp-
crine studies of individuals with Psychological Indicators toms of PTSD also reported more
PTSD symptoms, Grossman et Development and continued suicidal ideation, smoking, and
al. (2006) reported greater sensi- experience of acute and chronic negative perceptions of their
tivity in the central brain to glu- symptoms of PTSD are mediated health than did those who did
cocorticoids. This phenomenon by cognitive responses to the not report these symptoms. These
was expressed through height- traumatic event. These cogni- symptoms contributed to difficul-
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terioration in physical health are
evident in older women who expe- KE Y P OINTS
rienced early and repeated trauma,
especially interpersonal, during 1. Older adults exposed to trauma earlier in their lives can experience reactivation
their lifetime (Franco, 2007). of posttraumatic stress disorder (PTSD) symptoms.
Recognition and optimal treat-
2. Primary care is a point of entry into the health care system for older adults and
ment of PTSD in primary care,
offers opportunity for early recognition of PTSD.
however, presents a challenge
because symptoms are vague and 3. Integration of physical and behavioral health services allows optimal treatment
complex and reflect intense dis- for older adults who experience PTSD reactivation.
tress (Nakell, 2007). In a 5-year
follow-up study of mental disorder Do you agree with this article? Disagree? Have a comment or questions?
recognition in primary care, Jack- Send an e-mail to Karen Stanwood, Executive Editor, at kstanwood@slackinc.com.
son, Passamonti, and Kroenke We’re waiting to hear from you!
(2007) reported that 29% of the
sample was identified at baseline
as having a mental disorder, 26% health care—and general health primary care and psychiatric nurs-
of which had more than one dis- care—depends upon the effective es to come together and shape a
order. Across the 5 years, the per- collaboration of all mental, sub- system of care that is responsive
centage diagnosed with a disorder stance-use, general health care, to patient needs. Because of their
increased to 33%. Symptoms that and other human service provid- holistic approach to patient care,
persisted over time were more ers in coordinating the care of nurses are uniquely prepared to
likely to be diagnosed. their patients. (p. 210) integrate both physical and men-
Comprehensive assessments While collaboration among tal health care and can assume
that include life histories are im- mental health and general health leadership within a collaborative
perative for PTSD and other co- care practitioners is essential, ex- interdisciplinary team.
morbid mental disorders. Several isting separation of mental and Collaboration between prima-
brief PTSD assessment scales are substance use health care from ry care and mental health provid-
available and can be used within general health care makes it dif- ers can expand available clinical
primary care settings. Breslau’s ficult (IOM, 2006). Although resources. Traditional treatment
7-item screening tool for PTSD much work is needed to actual- approaches for PTSD are either
is designed especially for use in ize delivery of integrated health pharmacology or psychotherapy.
primary care (Breslau, Peterson, care, several models already ex- Selective serotonin reuptake in-
Kessler, & Schultz, 1999). The ist. Four service delivery models hibitors have been shown to be
scale demonstrates good reliabili- for integrated care have been at- the most effective pharmacologi-
ty compared with the widely used tempted (Alfano, 2005): cal approach to address PTSD
17-item Clinician-Administered l Embedding primary care symptoms (Stein, Ipser, & Seed-
PTSD Scale (CAPS) (Blake et providers within mental health at, 2005). Primary care providers
al., 1995). Breslau’s tool offers a programs. are trained in the medical model
time-efficient and reliable meth- l Unified programs that offer of care that relies heavily on
od for assessment in primary care both mental health and primary medications, treatments, and ad-
(Kimerling et al., 2006). care under a single administration. vice. Although medication offers
l Initiatives to improve col- great opportunity for the treat-
Integrated Health Care laboration between independent, ment of mental disorders, there is
Integration of physical and be- office-based primary care and strong evidence that an effective
havioral health services can offer mental health providers. therapeutic alliance and formal
optimal treatment outcomes for l Co-location of behavioral psychotherapy are also important
older adults with PTSD. A 2006 health providers in primary care components of treatment.
report from the Institute of Med- offices. Initiation of a therapeutic al-
icine (IOM) states that: Integrated approaches are in liance with older adults can be
improving the quality of men- their infancy, but with these ini- forged by primary care or mental
tal health and substance abuse tial steps, opportunity exists for health providers. However, aug-
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