Exposure to trauma and related subsequent mental health difficulties, including posttraumatic 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).
Less known is known about trauma and its potential consequences in older as opposed to younger and middle-aged adults. Prior to the past 15 years, epidemiological studies did not typically include older adults at all or in sufficient numbers to examine age effects. In addition, fine-grained analyses on young-old (65–74 years), middle-old (75–84 years) and old-old (85 years and older) were not done to advance understanding of trauma and aging. More recently, 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 65 and over was 3.2% (Goldstein et al., 2016). This is consistent with other epidemiological studies in other countries. Sub-threshold or partial PTSD (where all but one or two of the criteria are met) seems to be more prevalent and a clinically significant problem in older adults (Pietrzak et al., 2012).
The after-trauma exposure the development and 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 (Marmar et al., 2015). 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, isolation, loneliness 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 may be better viewed as sub-threshold PTSD that worsens over time, or as delayed recognition (Andrews, Brewin, Philpott, & Stewart, 2007).
It is also important to note that PTSD in older adults has been linked to impaired physical health, functional impairment, suicidal ideation, cognitive impairment, accelerated aging, and increased healthcare utilization (for review see Cook & Simiola, 2020).
There are challenges for assessing the extent to which trauma may have impacted an older individual especially related to the compounding potential negative health consequences in older adults, including cognitive, sensory, and functional impairments that may affect the experience, impact, or reporting of trauma-related symptoms, and unfamiliarity with or reluctance to engage in discussion of mental health issues. Thorp and colleagues (2011) provide general guidance for conducting psychological assessment with older adults, as well as specific recommendations for conducting PTSD-related assessment with older trauma survivors. Thorp and colleagues provide a useful summary of PTSD measures with established psychometrics applicable to older adults. Specific recommendations for assessing trauma and PTSD in older adults with cognitive impairment and at end of life are reported elsewhere (Cook, Elhai, Cassidy, Ruzek, Ram, & Sheikh, 2005; Glick, Cook, Moye, & Pless Kaiser, 2018).
In a systematic review, Dinnen, Simiola and Cook (2015) examined reports of psychological treatment for trauma-related problems, primarily PTSD, in studies with samples of at least 50% adults aged 55 and older. Of the 20 studies that met review criteria, there were 13 case studies or series, three uncontrolled pilot studies, two randomized clinical trials (RCTs), one non-randomized concurrent control study and one post hoc effectiveness study. A more recent update indicates that a few more RCTs (e.g., Böttche et al., 2016) have been conducted (McCarthy, Cook, & Thorp, 2020), however most of them are not conducted on the three most commonly recommended evidence-based psychotherapies (EBP) for PTSD: Prolonged Exposure (PE; Foa, Hembree, Rothbaum, & Rauch, 2019), Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2017), and Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 2017). Preliminary evidence suggests that these EBPs are acceptable and at least somewhat efficacious in older adults with varied trauma histories and a considerable range of time since traumas. The findings from the first randomized controlled trial of PE for older adults indicate that while helpful, likely longer duration of treatment or supplemental interventions are needed (Thorp et al., 2019). That is, veterans who received PE and those who received the comparison condition, relaxation therapy, both experienced significant declines in PTSD symptoms. But many symptom gains were lost during six-month follow-up. Another suggested EBP PTSD treatment, narrative exposure therapy (NET; Schauer, Neuner, & Elbert, 2011), which approaches treatment from a lifespan perspective including imaginal trauma exposure and meaning making in life, has preliminary evidence that it may be effective and well-tolerated in older adults (Lely et al. 2019), however, given the report of interpersonal and relational difficulties in older adults with PTSD, these areas of functioning may warrant additional alternative interventions.
Cognitive impairment can complicate and negatively affect older adults with PTSD (Lohr et al, 2015). 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. Similarly end of life issues can make it difficult to participate in an EBP. A stepwise psychosocial approach to addressing distress for older adults with PTSD in a palliative care setting is recommended (e.g., Feldman, 2017).
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 research investigations.
Written by Joan Cook, PhD Yale School of Medicine, Vanessa Simiola, PsyD, Kaiser Permanente, and Elissa McCarthy, PhD VA National Center for PTSD
GENERAL
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.
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.
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.
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., & Simiola, V. (2020). Traumatic stress disorders in older adults. In D. Sloan & J. G. Beck (2nd Eds.), The Handbook of Traumatic Stress Disorders. New York: Oxford University Press.
Cook, J. M., & Simiola, V. (2020). Traumatic stress disorders in older adults. In D. Sloan & J. G. Beck (2nd Eds.), The Handbook of Traumatic Stress Disorders. New York: Oxford University Press.
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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., 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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Davison, K. M., Hyland, C. E., West, M. L., Lin, S. L., Tong, H., Kobayashi, K. M., & Fuller-Thomson, E. (2021). Post-traumatic stress disorder (PTSD) in mid-age and older adults differs by immigrant status and ethnicity, nutrition, and other determinants of health in the Canadian Longitudinal Study on Aging (CLSA). Social psychiatry and psychiatric epidemiology, 1-18. https://doi.org/10.1097/JGP.0b013e3181cc0366
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Goldstein, R. B., Smith, S. M., Chou, S. P., Saha, T. D., Jung, J., Zhang, H., … & Grant, B. F. (2016). The epidemiology of DSM-5 posttraumatic stress disorder in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Social Psychiatry and Psychiatric Epidemiology, 51, 1137-1148.
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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.
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.
Lohr, J. B., Palmer, B. W., Eidt, C. A., Aailaboyina, S., Mausbach, B. T., Wolkowitz, O. M., Thorp, S. R., & Jeste, D. V. (2015). Is post-traumatic stress disorder associated with premature senescence? A review of the literature. American Journal of Geriatric Psychiatry, 23(7), 709 725.
Lohr, J. B., Palmer, B. W., Eidt, C. A., Aailaboyina, S., Mausbach, B. T., Wolkowitz, O. M., Thorp, S. R., & Jeste, D. V. (2015). Is post-traumatic stress disorder associated with premature senescence? A review of the literature. American Journal of Geriatric Psychiatry, 23(7), 709-725.
Marmar, C. R., Schlenger, W., Henn-Haase, C., Qian, M., Purchia, E., Li, M., Corry, N., Williams, C. S., Ho, C. L., Horesh, D., Karstoft, K., Shalev, A., & Kulka, R. A. (2015). Course of posttraumatic stress disorder 40 years after the Vietnam war: Findings from the National Vietnam Veterans Longitudinal Study. JAMA: Psychiatry, 72, 875-881.
Marmar, C. R., Schlenger, W., Henn-Haase, C., Qian, M., Purchia, E., Li, M., Corry, N., Williams, C. S., Ho, C. L., Horesh, D., Karstoft, K., Shalev, A., & Kulka, R. A. (2015). Course of posttraumatic stress disorder 40 years after the Vietnam war: Findings from the National Vietnam Veterans Longitudinal Study. JAMA: Psychiatry, 72, 875-881.
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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.
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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.
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.
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.
Glick, D. M., Cook, J. M., Moye, J., & Pless Kaiser, A. (2018). Assessment and treatment considerations for posttraumatic stress disorder at end of life. American Journal of Hospice and Palliative Medicine, 35, 1133-1139.
Glick, D. M., Cook, J. M., Moye, J., & Pless Kaiser, A. (2018). Assessment and treatment considerations for posttraumatic stress disorder at end of life. American Journal of Hospice and Palliative Medicine, 35, 1133-1139.
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.
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.
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.
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
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.
Böttche, M., Kuwert, P., Pietrzak, R. H., & Knaevelsrud, C. (2016). Predictors of outcome of an internet-based cognitive-behavioural therapy for post-traumatic stress disorder in older adults. Psychology and Psychotherapy: Theory, Research and Practice, 89(1), 82-96.
Böttche, M., Kuwert, P., Pietrzak, R. H., & Knaevelsrud, C. (2016). Predictors of outcome of an internet-based cognitive-behavioural therapy for post-traumatic stress disorder in older adults. Psychology and Psychotherapy: Theory, Research and Practice, 89(1), 82-96.
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.
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.
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.
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
Dinnen, S., Simiola, V., & Cook, J. M. (2015). Trauma and posttraumatic stress disorder in older adults: A systematic review of the psychotherapy treatment literature. Aging and Mental Health, 19, 144-150.
Dinnen, S., Simiola, V., & Cook, J. M. (2015). Trauma and posttraumatic stress disorder in older adults: A systematic review of the psychotherapy treatment literature. Aging and Mental Health, 19, 144-150.
Feldman, D. B. (2017). Stepwise psychosocial palliative care: A new approach to the treatment of posttraumatic stress disorder at the end of life. Journal of Social Work in End of Life and Palliative Care, 13(2-3), 113-133.
Feldman, D. B. (2017). Stepwise psychosocial palliative care: A new approach to the treatment of posttraumatic stress disorder at the end of life. Journal of Social Work in End of Life and Palliative Care, 13(2-3), 113-133.
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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Glick, D. M., Cook, J. M., Moye, J., & Pless Kaiser, A. (2018). Assessment and treatment considerations for posttraumatic stress disorder at end of life. American Journal of Hospice and Palliative Medicine, 35, 1133-1139.
Glick, D. M., Cook, J. M., Moye, J., & Pless Kaiser, A. (2018). Assessment and treatment considerations for posttraumatic stress disorder at end of life. American Journal of Hospice and Palliative Medicine, 35, 1133-1139.
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.
Lely, J. C. G., Knipscheer, J. W., Moerbeek, M., ter Heide, F. J. J., van den Bout, J., & Kleber, R. J. (2019). Randomised controlled trial comparing narrative exposure therapy with present-centred therapy for older patients with post-traumatic stress disorder. British Journal of Psychiatry, 214(6), 369–377.
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McCarthy, E., Cook, J. M., & Thorp, S. R. (2020). PTSD at late life: Context and treatment. In J. Gayle Beck and D. M. Sloan (Eds.), Oxford Handbook of Traumatic Stress Disorders (2nd ed.). New York, NY: Oxford University Press.
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Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive processing therapy for PTSD: A comprehensive manual. New York, NY: Guilford Press.
Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive processing therapy for PTSD: A comprehensive manual. New York, NY: Guilford Press.
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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.
Thorp, S. R., Stein, M. B., Jeste, D. V., Patterson, T. L., & Wetherell, J. L. (2012). Prolonged exposure therapy for older veterans with posttraumatic stress disorder: A pilot study. The American Journal of Geriatric Psychiatry, 20(3), 276-280.
Thorp, S. R., Stein, M. B., Jeste, D. V., Patterson, T. L., & Wetherell, J. L. (2012). Prolonged exposure therapy for older veterans with posttraumatic stress disorder: A pilot study. The American Journal of Geriatric Psychiatry, 20(3), 276-280.
Thorp, S., Glassman, L. H., Wells, S., Walters, K., Gebhardt, H….Wetherell, J. (2019). A randomized controlled trial of prolonged exposure therapy versus relaxation training for older veterans with military-related PTSD. Journal of Anxiety Disorders, 64, 45-54.
Thorp, S., Glassman, L. H., Wells, S., Walters, K., Gebhardt, H….Wetherell, J. (2019). A randomized controlled trial of prolonged exposure therapy versus relaxation training for older veterans with military-related PTSD. Journal of Anxiety Disorders, 64, 45-54.