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PTSD

Traumatic exposure and related subsequent problems, including post-traumatic stress disorder (PTSD), may be under-recognized and under-treated in older individuals. Lack of recognition of the effects of trauma or misattribution of its symptoms to other psychiatric or medical problems may have negative implications for older adults’ treatment and recovery, including the design of inadequate treatment plans, administration of poorly focused or inappropriate psychotherapy, medication or other medical intervention (Allers, Benjack, & Allers, 1992).

Much less known is known about trauma and its potential consequences in older as opposed to younger and middle-aged adults. Until recently, epidemiological studies did not include older adult participants or their numbers were too small to examine age effects. Over the past decade, several large epidemiological studies utilizing representative samples have found the prevalence rates of trauma and PTSD to be significantly lower in the older adult population compared to other adult age groups. Nonetheless, PTSD can and does occur in older individuals. One epidemiological study found the prevalence of PTSD amongst individuals 60 and over was 2.5% (Kessler, Berglund, Demler, Merikangas, & Walkters, 2005). This is fairly consistent with other investigations including epidemiological studies in other countries. Sub-threshold or partial PTSD (where all but one or two of the criterion are met) appears as a clinically significant issue in later adulthood. For example, in another large epidemiological study, partial PTSD was estimated at 13.1% in older individuals (de Vries & Olff, 2009).

The course of PTSD appears variable, with some survivors remaining symptom-free, others being continuously troubled, and many having waxing and waning of symptoms across the lifespan. It is unclear what predicts this ebb and flow of symptoms but clinical lore suggests that occurrence or reactivation of trauma-related symptoms may be due in part to aging-related life events such as illness, decrements in functional status, and bereavement. Although delayed-onset of PTSD has been empirically verified, it is unusual in the absence of any prior mental health symptoms. Thus delayed-onset could be viewed as sub-threshold PTSD that worsens over time and may be more correctly viewed as delayed recognition (Andrews, Brewin, Philpott, & Stewart, 2007).

To date, much of the literature on the treatment of PTSD in later life has involved single case studies (for review, see Cook & O’Donnell, 2005). There are several trauma processing type therapies including Prolonged Exposure (PE; Foa, Hembree, & Rothbaum, 2007), Cognitive Processing Therapy (CPT; Resick & Schnicke, 1993), and Eye Movement Desensitization and Reprocessing (Shapiro, 2001) that have been found effective in the general adult population. Data from one randomized controlled trial of female sexual assault survivors with PTSD provides some indication how “older” adults may do in trauma processing therapies. Women in the sample who were older did better in PE and younger women did better in CPT (Rizvi, Vogt, & Resick, 2009). At present, one randomized clinical trail is underway, at the San Diego VA Health Care System under the direction of Dr. Steven Thorp, comparing two behavioral interventions, PE and relaxation training, in older veterans with PTSD (Department of Veterans Affairs, 2013).

Cognitive impairment can complicate and negatively affect older adults with PTSD. For example, these individuals may experience a flooding of emotional “triggers” that elicit PTSD symptoms and in turn lower the threshold for emotional processing and disinhibit subsequent problem behaviors (Cook, Ruzek & Cassidy, 2004). Many interventions of PTSD are learning-based making them more difficult for older adults with cognitive impairment to grasp and therefore lowering their response to treatment.

Although in recent years there has been significant advancement in research in the intersection between geropsychology and traumatic stress fields, it is important to note that there are still limitations, particularly the typical exclusion of the least healthy and perhaps most vulnerable older adults, those who are physically or emotionally impaired, homebound, or long-term care residents from our research investigations.

Written by Joan Cook, PhD and Vanessa Simiola, MA, Yale School of Medicine

 

GENERAL

Kessler, R., Berglund, P., Demler, O., Jin, R., Merikangas, K. & Walters, E. (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.

Kessler, R., Berglund, P., Demler, O., Jin, R., Merikangas, K. & Walters, E. (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.

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de Vries, G. J., & Olff, M. (2009). The lifetime prevalence of traumatic events and posttraumatic stress disorder in the Netherlands. Journal of traumatic stress, 22, 259-267.

de Vries, G. J., & Olff, M. (2009). The lifetime prevalence of traumatic events and posttraumatic stress disorder in the Netherlands. Journal of traumatic stress, 22, 259-267.

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Andrews, B., Brewin, C., Philpott, R., & Stewart, L. (2007). Delayed-onset posttraumatic stress disorder: a systematic review of the evidence. American Journal of Psychiatry, 164, 1319-1326.

Andrews, B., Brewin, C., Philpott, R., & Stewart, L. (2007). Delayed-onset posttraumatic stress disorder: a systematic review of the evidence. American Journal of Psychiatry, 164, 1319-1326.

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Allers, C. T., Benjack, K. J., & Allers, N. T. (1992). Unresolved childhood sexual abuse: Are older adults affected? Journal of Counseling & Development, 71, 14-17.

Allers, C. T., Benjack, K. J., & Allers, N. T. (1992). Unresolved childhood sexual abuse: Are older adults affected? Journal of Counseling & Development, 71, 14-17.

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Böttche, M., Kuwert, P., & Knaevelsrud, C. (2012). Posttraumatic stress disorder in older adults: an overview of characteristics and treatment approaches. International Journal of Geriatric Psychiatry, 27, 230–239.

Böttche, M., Kuwert, P., & Knaevelsrud, C. (2012). Posttraumatic stress disorder in older adults: an overview of characteristics and treatment approaches. International Journal of Geriatric Psychiatry, 27, 230–239.

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Ogle, C.M., Rubin, D.C., & Siegler, I.C. (2013). The Impact of the Developmental Timing of Trauma Exposure on PTSD Symptoms and Psychosocial Functioning Among Older Adults. Developmental Psychology, doi:10.1037/a0031985

Ogle, C.M., Rubin, D.C., & Siegler, I.C. (2013). The Impact of the Developmental Timing of Trauma Exposure on PTSD Symptoms and Psychosocial Functioning Among Older Adults. Developmental Psychology, doi:10.1037/a0031985.

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Maschi, T., Baer, J., Morrissey, M., & Moreno, C. (2013). The Aftermath of Childhood Trauma on Late Life Mental and Physical Health: A Review of the Literature. Traumatology, 19, 49-64.

Maschi, T., Baer, J., Morrissey, M., & Moreno, C. (2013). The Aftermath of Childhood Trauma on Late Life Mental and Physical Health: A Review of the Literature. Traumatology, 19, 49-64.

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Wolitzky-Taylor, K.B., Castriotta, N., Lenze, E.J., Stanley, M.A., Craske, M.G. (2010). Anxiety disorders in older adults: A comprehensive review. Depression and Anxiety, 27 (2):190-211. PMID: 20099273

Wolitzky-Taylor, K.B., Castriotta, N., Lenze, E.J., Stanley, M.A., & Craske, M.G. (2010). Anxiety disorders in older adults: A comprehensive review. Depression and Anxiety, 27 (2):190-211. PMID: 20099273

Posted in reference | Tagged , , , | Comments Off on Wolitzky-Taylor, K.B., Castriotta, N., Lenze, E.J., Stanley, M.A., Craske, M.G. (2010). Anxiety disorders in older adults: A comprehensive review. Depression and Anxiety, 27 (2):190-211. PMID: 20099273

Seignourel, P.J., Kunik, M.E., Snow, L., Wilson, N., & Stanley, M.A. (2008). Anxiety in dementia: A critical review. Clinical Psychology Review , 28(7):1071-1082. PMCID: PMC2575801

Seignourel, P.J., Kunik, M.E., Snow, L., Wilson, N., & Stanley, M.A. (2008). Anxiety in dementia: A critical review. Clinical Psychology Review , 28(7):1071-1082. PMCID: PMC2575801

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Gum, A. M., King-Kallimanis, B., & Kohn, R. (2009). Prevalence of mood, anxiety, and substance-abuse disorders for older Americans in the National Comorbidity Survey?Replication. American Journal of Geriatric Psychiatry, 17, 769-781.

Gum, A. M., King-Kallimanis, B., & Kohn, R. (2009). Prevalence of mood, anxiety, and substance-abuse disorders for older Americans in the National Comorbidity Survey: Replication. American Journal of Geriatric Psychiatry, 17, 769-781.

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Cook, J. (2011). Aging and PTSD , Free online course. http://www.ptsd.va.gov/professional/ptsd101/course-modules/Aging-PTSD.asp

Cook, J. (2011). Aging and PTSD , Free online course. http://www.ptsd.va.gov/professional/ptsd101/course-modules/Aging-PTSD.asp

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Cook, J. M., & Elmore, D. L. (2009). Disaster mental health in older adults: Symptoms, policy and planning. In Y. Neria, S. Galea, & F. Norris, (Eds.), Mental Health Consequences of Disasters , (pp.233-263). New York: Cambridge University Press.

Cook, J. M., & Elmore, D. L. (2009). Disaster mental health in older adults: Symptoms, policy and planning. In Y. Neria, S. Galea, & F. Norris, (Eds.), Mental Health Consequences of Disasters , (pp.233-263). New York: Cambridge University Press.

Posted in reference | Tagged , , | Comments Off on Cook, J. M., & Elmore, D. L. (2009). Disaster mental health in older adults: Symptoms, policy and planning. In Y. Neria, S. Galea, & F. Norris, (Eds.), Mental Health Consequences of Disasters , (pp.233-263). New York: Cambridge University Press.

Cook, J. M., Dinnen, S., & O’Donnell, C. (2011). Older women survivors of interpersonal violence: A systematic review of the quantitative literature. Journal of Women’s Health, 20 , 1075-1081.

Cook, J. M., Dinnen, S., & O’Donnell, C. (2011). Older women survivors of interpersonal violence: A systematic review of the quantitative literature. Journal of Women’s Health, 20 , 1075-1081.

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ASSESSMENT OF POST TRAUMATIC STRESS DISORDER IN LATER LIFE

Cook, J. M., & O’Donnell, C. (2005). Assessment and psychological treatment of Posttraumatic Stress Disorder in older adults. Journal of Geriatric Psychiatry and Neurology, 18, 61-71.

Cook, J. M., & O’Donnell, C. (2005). Assessment and psychological treatment of Posttraumatic Stress Disorder in older adults. Journal of Geriatric Psychiatry and Neurology, 18, 61-71.

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Kaiser, A.P., Wachen, J.S., Potter, C., Moye, J., & Davison, E. (2013). PTSD Assessment and Treatment in Older Adults. Information provided by the Stress, Health, and Aging Research Program (SHARP).

Kaiser, A.P., Wachen, J.S., Potter, C., Moye, J., & Davison, E. (2013). PTSD Assessment and Treatment in Older Adults.  Information provided by the Stress, Health, and Aging Research Program (SHARP) of the National Center for PTSD.  

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Pietrzak, R.H., Van Ness, P.H., Fried, T.R., Galea, S., & Norris, F. (2012). Diagnostic utility and factor structure of the PTSD Checklist in older adults. International Psychogeriatrics, 24, 1684-1696. doi:10.1017/S1041610212000853.

Pietrzak, R.H., Van Ness, P.H., Fried, T.R., Galea, S., & Norris, F. (2012). Diagnostic utility and factor structure of the PTSD Checklist in older adults. International Psychogeriatrics, 24, 1684-1696. doi:10.1017/S1041610212000853.

Posted in Uncategorized | Tagged , | Comments Off on Pietrzak, R.H., Van Ness, P.H., Fried, T.R., Galea, S., & Norris, F. (2012). Diagnostic utility and factor structure of the PTSD Checklist in older adults. International Psychogeriatrics, 24, 1684-1696. doi:10.1017/S1041610212000853.

King, L.A., King, D.W., Vickers, K., Davison, E.H., & Spiro, A. (2007). Assessing late-onset stress symptomatology among aging male combat veterans. Aging and Mental Health, 11 (2), 175-19.

King, L.A., King, D.W., Vickers, K., Davison, E.H., & Spiro, A. (2007). Assessing late-onset stress symptomatology among aging male combat veterans. Aging and Mental Health, 11 (2), 175-19.

Posted in reference | Tagged , , | Comments Off on King, L.A., King, D.W., Vickers, K., Davison, E.H., & Spiro, A. (2007). Assessing late-onset stress symptomatology among aging male combat veterans. Aging and Mental Health, 11 (2), 175-19.

Feldman, D. B. & Periyakoil, V. S. (2006). Posttraumatic stress disorder at end of life. Journal of Palliative Medicine, 9 (1), 213-218.

Feldman, D. B. & Periyakoil, V. S. (2006). Posttraumatic stress disorder at end of life. Journal of Palliative Medicine, 9 (1), 213-218.

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Edelstein, B., Woodhead, E., Segal, D., Heisel, M., Bower, E., Lowery, A., & Stoner, S. (2008). Older adult psychological assessment: Current instrument status and related considerations. Clinical Gerontologist, 31 , 1-35.

Edelstein, B., Woodhead, E., Segal, D., Heisel, M., Bower, E., Lowery, A., & Stoner, S. (2008). Older adult psychological assessment: Current instrument status and related considerations. Clinical Gerontologist, 31 , 1-35.

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MEASURES OF POST TRAUMATIC STRESS DISORDER IN LATER LIFE

Look at the extensive assessment database of geriatric measures from the University of Alabama’s Alabama Research Institute on Aging! Register for access to the database HERE.

Also, check out the National Center for PTSD list of measures

 

TREATMENT OF POST TRAUMATIC STRESS DISORDER IN LATER LIFE

Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing, Basic Principles, Protocols and Procedures. (2nd ed.). New York: The Guilford Press.

Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing, Basic Principles, Protocols and Procedures. (2nd ed.). New York: The Guilford Press.

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Rizvi, S. L., Vogt, D. S., & Resick, P. A. (2009). Cognitive and affective predictors of treatment outcome in cognitive processing therapy and prolonged exposure for posttraumatic stress disorder. Behaviour Research and Therapy, 47, 737-743.

Rizvi, S. L., Vogt, D. S., & Resick, P. A. (2009). Cognitive and affective predictors of treatment outcome in cognitive processing therapy and prolonged exposure for posttraumatic stress disorder. Behaviour Research and Therapy, 47, 737-743.

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Resick, P.A., & Schnicke, M. (1996). Cognitive Processing Therapy for Rape Victims: A Treatment Manual. Newbury Park: Sage Publications.

Resick, P.A., & Schnicke, M. (1996). Cognitive Processing Therapy for Rape Victims: A Treatment Manual. Newbury Park: Sage Publications.

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Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide. New York, NY: Oxford University Press.

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide. New York, NY: Oxford University Press.

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Department of Veterans Affairs. Treatment of older veterans with chronic posttraumatic stress disorder. In ClinicalTrails.gov [Internet]. San Diego (CA): National Library of Medicine (US). 2000- [cited 2013 Aug 28]. Available from: http://clinicaltrials.gov/ct2/show/NCT00539279 NLM Identifier: NCT00539279

Department of Veterans Affairs. Treatment of older veterans with chronic posttraumatic stress disorder. In ClinicalTrails.gov [Internet]. San Diego (CA): National Library of Medicine (US). 2000- [cited 2013 Aug 28]. Available from: http://clinicaltrials.gov/ct2/show/NCT00539279 NLM Identifier: NCT00539279

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Cook, J. M., & O’Donnell, C. (2005). Assessment and psychological treatment of Posttraumatic Stress Disorder in older adults. Journal of Geriatric Psychiatry and Neurology, 18, 61-71.

Cook, J. M., & O’Donnell, C. (2005). Assessment and psychological treatment of Posttraumatic Stress Disorder in older adults. Journal of Geriatric Psychiatry and Neurology, 18, 61-71.

Posted in Uncategorized | Tagged , , | Comments Off on Cook, J. M., & O’Donnell, C. (2005). Assessment and psychological treatment of Posttraumatic Stress Disorder in older adults. Journal of Geriatric Psychiatry and Neurology, 18, 61-71.

Böttche, M., Kuwert, P., & Knaevelsrud, C. (2012). Posttraumatic stress disorder in older adults: an overview of characteristics and treatment approaches. International Journal of Geriatric Psychiatry, 27, 230–239.

Böttche, M., Kuwert, P., & Knaevelsrud, C. (2012). Posttraumatic stress disorder in older adults: an overview of characteristics and treatment approaches. International Journal of Geriatric Psychiatry, 27, 230–239.

Posted in Uncategorized | Tagged , , | Comments Off on Böttche, M., Kuwert, P., & Knaevelsrud, C. (2012). Posttraumatic stress disorder in older adults: an overview of characteristics and treatment approaches. International Journal of Geriatric Psychiatry, 27, 230–239.

Kaiser, A.P., Wachen, J.S., Potter, C., Moye, J., & Davison, E. (2013). PTSD Assessment and Treatment in Older Adults. Information provided by the Stress, Health, and Aging Research Program (SHARP).

Kaiser, A.P., Wachen, J.S., Potter, C., Moye, J., & Davison, E. (2013). PTSD Assessment and Treatment in Older Adults.  Information provided by the Stress, Health, and Aging Research Program (SHARP) of the National Center for PTSD.  

Posted in Uncategorized | Tagged , , | Comments Off on Kaiser, A.P., Wachen, J.S., Potter, C., Moye, J., & Davison, E. (2013). PTSD Assessment and Treatment in Older Adults. Information provided by the Stress, Health, and Aging Research Program (SHARP).

Clapp, J.D., & Beck, J.G. (2012). Treatment of PTSD in Older Adults: Do Cognitive-Behavioral Interventions Remain Viable? Cognitive and Behavioral Practice, 19, 126–135.

Clapp, J.D., & Beck, J.G. (2012). Treatment of PTSD in Older Adults: Do Cognitive-Behavioral Interventions Remain Viable?  Cognitive and Behavioral Practice, 19, 126–135.

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Thorp, S. R., Stein, M. B., Jeste, D. V., Patterson, T. L., & Wetherell, J. L. (accepted for publication). Prolonged exposure therapy for older veterans with posttraumatic stress disorder: Pilot study. American Journal of Geriatric Psychiatry.

Thorp, S. R., Stein, M. B., Jeste, D. V., Patterson, T. L., & Wetherell, J. L. (accepted for publication). Prolonged exposure therapy for older veterans with posttraumatic stress disorder: Pilot study. American Journal of Geriatric Psychiatry.

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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 (pp. 189-217). New York, NY: Springer Publishing Company.

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 (pp. 189-217). New York, NY: Springer Publishing Company.

Posted in reference | Tagged , , , , | Comments Off on 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 (pp. 189-217). New York, NY: Springer Publishing Company.

Cook, J. M., Ruzek, J. I., & Cassidy, E. L. (2003). Possible association of posttraumatic stress disorder with cognitive impairment among older adults. Psychiatric Services, 54 , 1223-1225.

Cook, J. M., Ruzek, J. I., & Cassidy, E. L. (2003). Possible association of posttraumatic stress disorder with cognitive impairment among older adults. Psychiatric Services, 54 , 1223-1225.

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