Late-life Posttraumatic Stress Disorder Research Articles

Home-based primary care providers' perspectives on the unique challenges of working with late life posttraumatic stress disorder within their population of Veterans.

Posttraumatic stress disorder (PTSD) is more prevalent in medically ill older Veterans in Home-Based Primary Care (HBPC) settings than in the general population, raising unique considerations. The aim of this qualitative project was to explore HBPC mental health providers' perceptions of the presentation and treatment of PTSD and trauma-related symptoms in this population of older Veterans, many of whom face additional barriers to treatment due to living in rural settings. Five focus groups and one one-on-one interview were conducted with 23 HBPC mental health providers serving rural or rural/urban mixed communities across the United States. We applied qualitative content analysis to the data. Three themes were found: (1) Presentation of Trauma-Related Symptoms and PTSD in HBPC Population; (2) Treatment Challenges in HBPC; and (3) PTSD Treatment Strategies. Each theme had multiple subthemes which illustrate unique issues in this population. Results of this project contribute to key insights surrounding the unique presentation of PTSD and trauma-related processes and treatment considerations in a medically, cognitively, and psychosocially complex group of veterans. Efforts to improve access to care should consider the specific needs of veterans who are homebound, live in rural settings and identify with rural cultural norms, and have difficulty engaging in specialized PTSD treatment due to the convergence of these factors. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Age differences in peritraumatic and posttraumatic processing.

There is limited research investigating the mechanisms underlying the lower rate of posttraumatic stress disorder (PTSD) in older compared to younger adults. This study examined age differences in peritraumatic and posttraumatic reactions, and the use of two emotion regulation strategies (rumination and positive reappraisal) using a trauma film induction paradigm. Participants (45 older adults and 45 younger adults) watched a trauma film. Eye gaze, Galvanic Skin Response, peritraumatic distress, and emotion regulation were assessed during the film. Participants completed an intrusive memory diary over the next 7 days and follow-up measures of posttraumatic symptoms and emotion regulation. Findings showed no age differences in peritraumatic distress or use of rumination or positive reappraisal during film viewing. Older adults reported lower posttraumatic stress and distress from intrusive memories than younger adults at the 1-week follow-up, despite experiencing a comparable number of intrusions. Rumination was a unique predictor of intrusive and hyperarousal symptoms, after accounting for age. There were no age differences in the use of positive appraisal, and positive reappraisal was not associated with posttraumatic stress. Lower rates of late-life PTSD may relate to decreased use of maladaptive emotion regulation (i.e., rumination), rather than increased use of adaptive emotion regulation strategies (i.e., positive reappraisal). (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Post-Traumatic Stress Disorder and Risk of Degenerative Synucleinopathies: Systematic Review and Meta-Analysis

A systematic review was conducted to answer whether adult-onset post-traumatic stress disorder (PTSD) is associated with increased risk of Parkinson's disease (PD) and related synucleinopathies. A systematic search of Medline (Ovid), Embase (Elsevier), PsycInfo (Ovid), Cochrane Library (Wiley), and Web of Science (Clarivate) was performed using MeSH headings and equivalent terms for PTSD, PD, DLB, and related disorders. No restrictions. Eligible articles were published in peer-reviewed journals, sampled adult human populations, and treated PTSD and degenerative synucleinopathies as exposures and outcomes, respectively. Extracted data included diagnostic methods, sample characteristics, matching procedures, covariates, and effect estimates. Bias assessment was performed with the Newcastle-Ottawa scale. Hazard ratios were pooled using the random effects model, and the Hartung-Knapp adjustment was applied due to the small number of studies. A total of six articles comprising seven unique samples (total n=1,747,378) met eligibility criteria. The risk of PD was reported in three retrospective cohort studies and one case-control study. Risk of DLB was reported in one retrospective cohort, one case-control, and one prospective cohort study. No studies addressed potential relationships with multiple system atrophy or pure autonomic failure. Meta-analysis of hazard ratios from four retrospective cohort studies supported the hypothesis that incident PTSD was associated with PD and DLB risk (pooled HR 1.88, 95% C.I. 1.08-3.24; p=0.035). The sparse literature to-date supports further investigations on the association of mid- to late-life PTSD with Parkinson's and related neurodegenerative disorders.

PTSD, Risk of Suicide, and Unintended Death by Overdose in Mid- to Late-Life

<h3>Introduction</h3> Although posttraumatic stress disorder (PTSD) may increase risk of suicide in mid- to late-life, findings have been controversial, in large part, because studies have not accounted for comorbid disorders. Moreover, little is known about association between mid- to late-life PTSD and apparent accidental death by overdose, which could be due to suicidal intent. Thus, we conducted a comprehensive study to examine PTSD and risk of death by suicide, suicide attempt, and unintended death by overdose among veterans in mid- to late-life. <h3>Methods</h3> This nationwide cohort study included all veterans ≥50 years (N=1,038,980) seen in the Veterans Health Administration starting 2012-2013 (baseline) and followed through December 31, 2017. Veterans with a PTSD diagnosis were propensity-matched 1:1 with patients without PTSD. They were matched on age, gender, race/ethnicity, income, education, homelessness, service connection, Charlson comorbidity index, and neuropsychiatric disorders. Dates of suicide attempt and cause-specific mortality at follow up were defined using the National Suicide Prevention Applications Network and the Mortality Data Repository, respectively. PTSD was identified by two or more ICD-9 codes in electronic medical records at baseline. PTSD and risk of suicide-related outcomes were assessed using multivariable models. Fine-Gray proportional hazards regression was used to examine time to outcome event at follow up. Models were next adjusted in steps, with the final adjustment accounting for sociodemographics, Charlson comorbidity index, and neuropsychiatric diagnoses. Other outcomes examined using similar methods included death by drug overdose (i.e., antiepileptics/sedative-hypnotics, narcotics, and unspecified/other cause-specific drug categories) for suicide, unintentional, and undetermined death. <h3>Results</h3> Of 1,038,980 patients in our study, 519,490 had PTSD. The mean participant age was 63.56, 59,542 (5.73%) were women, and 765,572 (73.68%) were non-Hispanic White. Although firearms were by far the leading method of suicide death for those with and without PTSD, there was no significant between-group difference related to firearms. However, veterans with PTSD were significantly more likely to die by suicide by drug overdose compared with those without a PTSD diagnosis. As shown in Table 1, after adjusting for sociodemographics, Charlson comorbidities, and neuropsychiatric diagnoses, the hazard ratio for risk of suicide in veterans with PTSD was 1.57 (95% CI, 1.51, 1.63) for any suicide attempt; 1.09 (95% CI, 1.01, 1.19) for death by suicide; 1.43 (95% CI, 1.32, 1.56) for drug overdose death overall; 1.53 (95% CI, 1.21, 1.94) for suicide death by drug overdose. Further analyses explored type of drug involved in overdose and demonstrated that veterans with PTSD had hazard ratios of 1.44 (95% CI, 1.26, 1.65) for narcotics and 1.48 (1.31-1.68) for other /unspecified drugs (Figure 1). We also found that having PTSD increased unintentional death, suicide death, and undetermined intent for narcotics by 1.4 to 2.4 times, and for other/unspecified drugs by 1.4 to 1.8 times. <h3>Conclusions</h3> The findings suggest that veterans with PTSD aged ≥50 years in VA healthcare, have persistently elevated risk for suicide attempts and suicide death, particularly by drug overdose. This current work may inform clinical practice targeting late-life suicide prevention efforts by promoting improved prescribing and drug-monitoring. Future medication recommendations to treat PTSD may need to consider less risky drugs than narcotics, as well as emphasize inquiring about potential illicit drug use and access, for older adults. More research is needed to elucidate the relationship of PTSD to increased risk of mid- to late-life death by suicide and unintended drug overdose, exploring what other and unspecific drugs do and do not exacerbate this risk. <h3>Funding</h3> This work was supported by Award Number I01 CX001119 from the Clinical Science Research & Development Service of the U.S. Department of Veterans Affairs (VA) Office of Research and Development (PI: Dr. Byers). Support for the Mortality Data Repository (MDR; previously known as the Suicide Data Repository or SDR) and Suicide Prevention Applications Network (SPAN) is provided by the VA Center of Excellence for Suicide Prevention. Support for VA/CMS data is provided by the Department of Veterans Affairs, VA Health Services Research and Development Service, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004).

PTSD, Risk of Suicide, and Unintended Death by Overdose in Late Life

Little is known about late-life posttraumatic stress disorder (PTSD) and risk of suicide and apparent accidental death by overdose. We studied 488,044 older veterans (50 and older) with PTSD and propensity-matched comparison group without PTSD (n=488,044), seen in VA 2012-2013 followed to 12/31/2016. There were 5,693 non-fatal and fatal suicide attempts for those with PTSD and 4,310 for those without PTSD (approximately 20% fatal for each group). Those with PTSD had nearly 2-fold increased risk of any attempt [HR=1.55 (95% CI=1.49-1.62)]. While results specific to death by suicide were non-significant, impact of PTSD on method of death (e.g., drug overdose, firearms, hanging) was significant only for drug overdose [HR=1.58 (95% CI=1.22-2.03)]. Intentional and unintentional death by narcotics and such drugs as non-opioid analgesics and autonomic nervous system drugs were most highly associated with late-life PTSD. This study provides important implications for late-life suicide prevention related to PTSD and cause-specific drugs. Part of a symposium sponsored by the Aging, Alcohol and Addictions Interest Group.

Adverse Outcomes, Polysubstance Use, and Polypharmacy in Older Veterans

This session will provide information about adverse health outcomes, including suicide, suicide attempts and unintended death, that may be related to polysubstance use and polypharmacy in older adults, particularly older veterans. It will further provide information that will help support late-life suicide prevention and intervention efforts. Older veterans (age50 and older) have the highest number of lives lost to suicide, make up majority of the veteran population, and are highly likely to experience conditions (e.g., chronic pain, sleep disorders, musculoskeletal) associated with commonly prescribed medications that are potential markers for suicide risk (hereafter referred to as “high-risk” drug categories), including benzodiazepines, sedative-hypnotics, opioids, antidepressants, antipsychotics, and antiepileptics. The research presented in this session will highlight important patterns in high-risk drug prescribing and use and related outcomes in late life. The presentations will underscore various groups of older veterans that may be important to consider and, yet, neglected in the polysubstance and polypharmacy and suicide prevention conversation, including those who recently attempted suicide, veterans with late-life posttraumatic stress disorder (PTSD), and older veterans transitioning from prison to community. Drs. Maust and Morin will present findings on prescribing and use of high-risk medications in late life, including an overview of trends in polypharmacy and associations with suicide attempts. Drs. Byers and Barry will speak about older veterans with PTSD and those with a history of incarceration, with information on suicide, unintended death by overdose, and substance use disorder-related emergency department visits and hospitalizations, emphasizing importance of care transition models for prevention. Aging, Alcohol and Addictions Interest Group Sponsored Symposium.

Health Characteristics and Treatment Patterns of VHA Veterans Diagnosed With PTSD in Later Life

Older adults may exhibit symptoms of Post-Traumatic Stress Disorder (PTSD) after a traumatic event, even if they do not meet the criteria for a full diagnosis. This sub-clinical PTSD affects 7-15% of older adults and is associated with elevated depressive symptoms, suicidal ideation, and poorer physical health. Individuals with sub-clinical PTSD often experience worsening symptoms, resulting in a full diagnosis of PTSD, albeit late onset. This evaluation informs the Veterans Health Administration (VHA)’s understanding of the developmental course of PTSD in older Veterans. VHA administrative data were used to examine health characteristics and service utilization in the five years before and five years after the initial VHA documentation of PTSD. We identified a cohort of Veterans (n=27,610), alive and with at least 1 encounter in all evaluation years, with a first PTSD diagnosis documented between ages 50-59, a cohort outside of the average age of diagnosis, but before Medicare eligibility. We compared periods before and after diagnosis across different ages of first diagnosis (50-54, 55-59). Veterans diagnosed at later ages (55-59) had a greater number of mental and physical health conditions. Increasing VHA use preceded a PTSD diagnosis in both groups, but the increase was steeper among those diagnosed at 55-59. Future analyses will compare these patterns to those of Veterans diagnosed at younger ages. Findings from this work may provide a profile of persons at risk for late-life PTSD for use in targeting interventions earlier to reduce the risk of developing worsening PTSD symptoms in late life.

ADVERSE OUTCOMES, POLYSUBSTANCE USE, AND POLYPHARMACY IN OLDER VETERANS

Older veterans have the highest number of lives lost to suicide, make up majority of the veteran population, and are highly likely to experience conditions (e.g., chronic pain, sleep disorders, musculoskeletal) associated with commonly prescribed medications that are potential markers for suicide risk (hereafter referred to as “high-risk” drug categories), including benzodiazepines, sedative-hypnotics, opioids, antidepressants, antipsychotics, and antiepileptics. The research presented in this session will highlight important patterns in high-risk drug prescribing and use and related outcomes in late life. The presentations will highlight various groups of older veterans that may be important to consider and, yet, neglected in the polysubstance and polypharmacy and suicide prevention conversation, including those who recently attempted suicide, veterans with late-life posttraumatic stress disorder (PTSD), and older veterans transitioning from prison to community. Drs. Maust and Morin will present findings on polypharmacy prescribing and use of high-risk medications in late life. First, drawing from the literature and his own research studies, Dr. Maust will provide a big picture overview of trends in polypharmacy among older adults in the U.S., including older veterans. Next, Dr. Morin will describe high-risk profiles of use in the 90 days prior to a first documented suicide attempt among veterans >=65 years who attempted suicide between 2012 and 2014, using Veterans Health Administration (VHA) medical record data. In addition, she will examine associations of these profiles with diagnostic, lethality, and utilization factors. Drs. Byers and Barry will speak about more specific subgroups of older veterans, with recommendations for possible intervention to reduce suicide, unintended death by overdose, and substance use disorder (SUD)-related emergency department (ED) visits and hospitalizations, emphasizing importance of care transition models for prevention. Dr. Byers will present a cohort study of veterans >=50 years seen in VHA. Findings provide evidence that late-life PTSD increases risk of suicide attempts and suicide by overdose (and accidental and undetermined death), independent of comorbid disorders. Furthermore, findings will be presented about the relationship of late-life PTSD to cause-specific high-risk drugs. Finally, Dr. Barry will provide an example of increased risk for SUD-related ED visits and hospitalizations (found in the literature to be strongly associated with suicide attempts) among older veterans transitioning from prison to community. Findings show that those re-entering society following prison sentence are at significantly higher risk for SUD-related ED visit or hospitalization compared to matched controls. These results highlight urgent need for assistance during this vulnerable period of transition.

The Role of Inflammation in Late-Life Post-Traumatic Stress Disorder

There is evidence that immune system dysregulation and inflammation may play a role in the development of post-traumatic stress disorder (PTSD). Previous studies have reported elevated levels of inflammatory markers such as C-reactive protein (CRP) in individuals with PTSD. However, it is unclear whether exacerbation of PTSD symptoms late in life is also associated with elevated inflammation. The purpose of this pilot study was to examine the relationship between inflammation and late-life PTSD. We recruited veterans either diagnosed with PTSD after the age of 55 or with no diagnosis of PTSD. Six veterans did not meet all eligibility criteria, including five who did not meet criteria for PTSD and one with celiac disease. The final sample included a total of 32 male veterans (16 veterans diagnosed with PTSD after 55 and 16 veterans without PTSD). The groups were matched as closely as possible on age, body mass index, and combat exposure. PTSD symptoms were assessed using the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and depressive symptoms were assessed using the Hamilton Rating Scale for Depression. Inflammation was measured using serum CRP level. The two groups did not differ on sample characteristics including age, body mass index, tobacco use, medication use, and military history. CRP level was found to be significantly higher in the PTSD group than in the comparison group (Z = -3.047, p = 0.002), which was also observed after adjusting for depression scores (F(1, 27) = 8.30, p = 0.0077). The results from this pilot study suggest that late-life PTSD may be associated with increased inflammation. Further research in larger samples is needed to corroborate these findings and to clarify the relationship between inflammation and PTSD, which may lead to improved methods of diagnosis and treatment.

PTSD and Risk of Incident Cardiovascular Disease in Aging Veterans

To determine if late-life posttraumatic stress disorder (PTSD) is associated with cardiovascular disease in a sample of older veterans, and whether the association is independent of medical and psychiatric comorbities. Retrospective cohort study conducted using the Department of Veterans Affairs (VA) National Patient Care Database (2000-2011). VA medical centers in the United States. A total of 138,341 veterans 55 years and older without cardiovascular disease at study baseline (2000-2003). PTSD and cardiovascular disease (as defined by diagnoses of: cerebrovascular disease [CVD], congestive heart failure [CHF], myocardial infarction [MI], and peripheral vascular disease [PVD]) were identified by ICD-9 codes during study baseline (2000-2003) and follow-up (2004-2011), respectively. 3% of veterans (N= 4,041) had a baseline diagnosis of PTSD. Unadjusted increased risk of incidence of CVD was 80%, CHF was 56%, MI was 82%, and PVD was 60% in veterans with PTSD compared with those without PTSD. After adjustment for demographics, medical comorbidities, substance use, and psychiatric comorbidities, veterans with late-life PTSD were at a 45% increased risk for incident CVD, 26% increased risk for incident CHF, 49% increased risk for incident MI, and 35% increased risk for PVD compared with veterans without late-life PTSD. Findings highlight the longitudinal impact of PTSD on increasing the incidence of cardiovascular disease in older adults. This study implies the need for greater monitoring and treatment of PTSD in older persons, particularly older veterans, to assist in preventing adverse outcomes, such as cardiovascular disease, over the long term.

The Impact of Late-Life PTSD on Vascular-Related Disorders

Posttraumatic Stress Disorder (PTSD) is common among young veterans returning from Iraq and Afghanistan and has been highly prevalent in veterans across the lifespan and into late life. Although PTSD is associated with poor health outcomes in younger veterans, little is known about late-life PTSD and its association with adverse outcomes such as cerebrovascular disease and other vascular-related disorders. Since the risk of medical comorbidities increases with age, the impact of late-life PTSD on vascular disease may be daunting.

Posttraumatic stress disorder in older adults: an overview of characteristics and treatment approaches

Posttraumatic stress disorder (PTSD) is a common and disabling condition following a traumatic event. Despite its high prevalence rates, relatively little is known about the manifestation and course of the disorder in older adults. Moreover, there has been little evaluation of the efficacy of psychotherapeutic treatment approaches for older patients. This overview aims to summarize available data on the prevalence and symptoms of late-life PTSD and to review the current treatment approaches for older adults. The course and severity of PTSD symptoms in older adults depend on the time the trauma occurred (early versus late life). In the case of acute traumatization, lower prevalence rates and symptom severities are generally observed in older than in younger populations. In the case of early-life traumatization, a decline in PTSD symptom severity can be observed over the life course. Research on treatment approaches has produced promising results, indicating that disorder-specific interventions (i.e., trauma confrontation and cognitive restructuring) can be effectively combined with an age-specific narrative life-review approach. Given the limited empirical evidence, caution is warranted in generalizing the reported findings. Nevertheless, it is possible to draw a number of conclusions concerning the characteristics and treatment of PTSD in older adults. Further research is needed to better understand the various presentations of PTSD in late life and to validate and improve the effectiveness of available treatment approaches.

Grand rounds: ‘I'll knock elsewhere’ – the impact of past trauma in later life

“And when life has no more meaning in old age, the will to meaning is lost; when life no longer seems to be worth living, some people who have experienced disasters and are unable to cope, may throw their lives away.” (Wilson et al, 1988) There continues to be a great deal of interest among psychiatrists, psychologists and sociologists about post traumatic stress disorder (PTSD) related to war crimes and experiences. Twentieth century studies of Holocaust victims and Far East prisoners of war, Korean and Vietnam veterans and the recent experiences of people in Bosnia have honed the diagnosis and increased awareness of the gradations of these disorders. Almost every conceivable variable has been examined in attempts to explore the motivating and resulting behaviours. Initially most studies dealt with the immediate impact of the event, but more recently articles have focused on the longer-term effects on relatives and the next generations of the earlier events (Sigal, 1998). Time has allowed this. The passage of time has also established that post-traumatic stress symptoms can be reactivated as much as half a century after the original trauma (Krasucki et al, 1995). Reactivation of events from 40 or 50 years previously may occur via current stressors such as social isolation and upheaval. Equally perceived helplessness precipitated by the somatic process of ageing could reactivate previous feelings and a delayed onset or exacerbation of clinical PTSD may emerge during the process of ageing. Institutionalisation itself could re-awaken feelings associated with incarceration or victimisation (Aarts &amp; Op den Velde, 1996; Sadavoy, 1997). Late-life PTSD is more often associated with sleep disturbance, nightmares, intrusive ideation and avoidance of reminders of the original events (Kuch &amp; Cox, 1992).