Le vieillissement traumatique

Abstract

With the increase in life expectancy and dementia, the clinical question of post-traumatic stress disorder (PTSD) in the elderly is a major public health issue. PTSD is structured or restructured in old age according to several psychodynamic variants, which can be a reaction to a psychic trauma that is presented de novo; PTSD can also develop at a young age to later become chronic in old age. PTSD can thus be diagnosed very remotely, in time, from the event that was once the cause. The clinical presentation of PTSD is not constant but fluctuates over time: Following the apogee during the acute phase, the psychotraumatic symptoms decrease for a few years or even decades before increasing again at the start of old age. If traumatic or stressful life events that occur during old age can be isolated from a previously structured PTSD, the themes of the suffering experienced within the life history overlap. The symptoms of PTSD can evolve through absence, fluctuating over time to be updated in the elderly person through an organic pathology, sensory deficiency disorders, a cognitive decline or an institutionalization. Over time, the specific symptoms (reexperiencing, avoidance and hypervigilance) decrease in favor of nonspecific symptoms (asthenia, depression, use of psychoactive substances). The somatic presentation of PTSD is a fundamental aspect of the request for treatment in elderly patients: A somatic illness can lead to a PTSD de novo or cause old psychological psychotraumatic pain to reappear. With age the revivifications wane in favor of hypervigilance and avoidance strategies. The latter are at the forefront of “post-fall syndrome”, a syndrome considered as a psychotraumatic picture specific to the elderly person that develops into a normal aging process or dementia. In the face of a potentially traumatogenic situation, the integrity of the cognitive abilities is primordial to ensure a non-pathological psychological resolution. The difficulty in inhibiting traumatic memories will lead to their update. Likewise, PTSD is the locus of a decline in cognitive functions: recent or prolonged stress precedes the development of dementia in 80% of cases, playing the role of a triggering factor or facilitator. As revivifications are expressed more clinically due to neurocognitive disorders, it can be feared that the appearance or the exacerbation of a latent PTSD is the sign of the onset of dementia. Hypocampal atrophy with relative conservation of the amygdala is a biological support for dementia such as PTSD: pathological compensatory mnemic mechanisms could be at work here favoring productions that do not reflect real memories but thoughts guided by semantic knowledge. The absence of possibility of symbolizing death beyond life can fix thoughts on an ancient, unresolved confrontation where this death has already imposed itself. Far from a trivialization or a fatalistic vision of psychotraumatic disorders in elderly people, we wished to highlight research prospects, which open up the way to multidisciplinary questions notably including anthropological determinants. A dementia process can associate, at clinical level, hypo- and hypermnesic affections. It is thus fitting to assert the interest of considering dementia not only from a deficiency point of view but also according to its productive aspects. At an advanced stage of dementia it is difficult to establish a diagnosis of PTSD, all the more so as the emotional memory is affected.