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PTSD: National Center for PTSD

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PTSD Assessment and Treatment in Older Adults

   

Older Adults and PTSD

Anica Pless Kaiser, PhD, Eve Davison, PhD, Jennifer Moye, PhD, Avron Spiro, PhD, and Sadie Larsen, PhD

In the U.S. and worldwide, people are living longer and healthier lives, leading to a growing proportion of the population being older adults (sometimes considered to be age 65 and older, other times 50 or 55 and older). Older adults with PTSD may have unique presentations and issues related to their PTSD symptoms. Although PTSD in some older adults will be chronic, other older adults may experience an emergence or exacerbation of PTSD symptoms as they age, and some may experience a late-life trauma that leads to a new onset of PTSD. This article will describe the presentation of PTSD in older adults as well as implications for assessment and treatment.

It is important to note that much of the research on PTSD in older adults has been conducted with military Veterans, and as such, the information and suggestions below may be most applicable to older, often male, Veteran samples.

PTSD and Aging

Prevalence

The prevalence of both current and lifetime PTSD is found in most studies to be somewhat lower in older adults than in younger adults (1). For instance, the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) found that lifetime prevalence of PTSD in the general US population was 7% for adults below 65, but 3% for adults ages 65 or older (2). Likewise, among Veterans, the prevalence of PTSD generally decreases in older age groups (3).

Although full PTSD may be somewhat less common in older adults, there is some suggestion that subthreshold PTSD may continue at similar rates into older age. Therefore, those who are older may be equally as likely to have subthreshold as full PTSD (4) or perhaps more likely (5). People with subthreshold PTSD carry higher risk for poor functioning and comorbidity than those with no/minimal PTSD (though lower than those with full PTSD; 5).

Definitions of subthreshold PTSD vary widely across studies, making it challenging to compare prevalence rates. A large study in Veterans used an empirically-derived definition of subthreshold PTSD including a specification of symptoms for at least 1 month as well as symptom-related distress or functional impairment. Subthreshold PTSD was as common in older Veterans (aged 65 and above) as full PTSD, whereas in younger cohorts, full PTSD was more prevalent (noting both full and subthreshold PTSD were less prevalent in older than younger Veterans; 6).

Why might PTSD prevalence be lower among older versus younger adults? Some possibilities include:

  • Resilience: Older adults may have developed better methods of coping. Decreasing PTSD severity may be partially explained by theories of aging, in which older adults adopt more of a focus on the present in order to maximize meaning and nurture positive emotions in the shorter time remaining in their lives (7). In part, this may entail de-emphasizing the role of past traumas in their identities (8).
  • Risk factors: PTSD is related to a range of negative health outcomes (see below). Although findings are mixed, in general, PTSD is associated with increased mortality (9). As such, there may be fewer people living with PTSD at older ages.
  • Period effect: Because PTSD was not an official diagnosis until 1980, with the release of DSM-III , it is possible that generations of current older adults were less likely to be diagnosed with PTSD in the past, or to seek a diagnosis later in life (10).
  • Cohort effects: Older adults may share unique cultural norms that affect their awareness of or willingness to report mental health difficulties. For example, older adults may be:
    • More likely to express mental health difficulties as somatic concerns
    • Reluctant to acknowledge mental health difficulties due to stigma or stoicism
  • Lower mental health care utilization: Older adults may have lower rates of mental health care utilization (11). Although this is unlikely to fully explain differences in PTSD prevalence as measured by standardized interviews, it is supported by research suggesting older adults are less likely to be referred to mental health treatment by providers (12).

Is the experience of PTSD different in older adults?

Over the years, some have suggested that in addition to lower prevalence, the presentation of PTSD may be different in older adults (13), even necessitating a different set of criteria for diagnosing PTSD in older adults (14). That said, there have been very few studies, mostly small, with no consistent findings of differences in symptom presentation across studies.

Research does suggest there are some ways in which PTSD and aging interact to make for a different experience of PTSD for some in older age:

  • Comorbidity and accelerated aging: For older adults who have had PTSD much of their lives, the effects of other mental and physical health comorbidities can accumulate meaningfully in older age. A review of the literature indicated that for those with PTSD, there is an increased risk of early or accelerated aging, of increased morbidity of aging-related conditions (e.g., cardiovascular disease, diabetes, and dementia), and of early mortality (15). Further, chronic pain is a common comorbidity of PTSD, and the relationship between pain and PTSD may strengthen with older age (16).
  • Delayed onset and LATR: Some older adults will have new-onset symptoms or an exacerbation of symptoms in older life. For those with delayed-onset PTSD, there are likely to have been at least some symptoms present that are then exacerbated at a later point (17,18). In older adulthood, developmental changes and aging-related challenges such as retirement, loss of loved ones, increasing loneliness, poor physical health, or disability may trigger feelings of loss, helplessness, or burden may lead to some re-emergence of symptoms. Loneliness and poor social connection itself may be related to PTSD bidirectionally (19,20). And for some, having additional time to think (e.g., post-retirement or post-illness) can foster increased thoughts about past traumatic events. There has been some suggestion that it may be normative for older Veterans to reengage with earlier unresolved wartime experiences, a process called later-adulthood trauma reengagement (LATR; 21), which can lead to either distress or growth depending on the ability to make meaning.
  • Age, cohort, period, and intersectional factors: Our understanding of older adults and PTSD will shift over time as new cohorts grow older. Older generations are more likely to downplay symptoms, but this may be a generational effect that will change as current young people grow older. Another example would be war experience—older adults who were deployed in World War II versus Vietnam versus the Persian Gulf will all have very different experiences based on their wartime, homecoming, and general cultural experiences (20). Moreover, experiences of isolation and discrimination will be different for women, people of color, and LGBTQ+ Veterans who served in earlier versus later conflicts.

Evidence and Considerations for Assessment and Treatment in Older Adults

Assessment

In terms of assessment, a few studies have found that standard assessment measures perform similarly in older adults as in younger adults. For instance, the PTSD Checklist for DSM-5 (PCL-5) shows excellent psychometric properties in older adults (22). Both the Primary Care PTSD Screen (PC-PTSD-5) and the PCL-5 appear to differentiate those with and without PTSD equally well in older versus younger adults, with similar cutoffs (23). Thus, evidence to date points to using symptom measures similarly with older and younger adults. One consideration is to assess for subthreshold as well as full PTSD in older adults, as subthreshold PTSD may be at least as common and still linked to functioning and health deficits.

Psychotherapy

In terms of psychotherapy, two systematic reviews indicate that there have been relatively few studies of PTSD psychotherapy that included or studied older adults (24,25). The more recent review focused on individual trauma-focused psychotherapy in older adults and found that trauma-focused psychotherapy was well-tolerated, showed positive effects on symptoms, and had relatively low dropout (ranging from 0% to 19%; 25). More recently a report of Eye Movement Desensitization and Reprocessing (EMDR) in a non-controlled sample of older adults with significant comorbidities also showed a positive effect (26). Finally, two non-randomized studies have compared psychotherapy outcomes in older versus younger adults, in one case finding no differences between matched samples of older and younger adults (EMDR; 27) and in the other case finding that both benefited, but younger adults had greater changes in PTSD despite attending fewer sessions on average (Cognitive Processing Therapy [CPT]; 28).

In summary, there is nothing in the existing treatment literature to contraindicate using a first-line psychotherapy with an older adult with PTSD. The available evidence indicates that older adults do benefit from trauma-focused psychotherapy, with some indicating that perhaps they benefit slightly less, while others find no difference between older and younger adults with PTSD. Likewise, although older adults may be less likely to seek or receive therapy (29), once they do attend, they are less likely to drop out (30). Despite the studies above including participants with a variety of physical and psychological comorbidities, none systematically modified therapies, and none identified contraindications. There are, however, some important limitations of the existing, small evidence base for psychotherapy among older adults, including few adults in the treatment literature older than 75, no randomized trials comparing younger to older adults, fewer civilian than Veteran samples, and few studies specifically including older adults with medical illness or cognitive changes.

Pharmacotherapy

Although specific psychotherapies are recommended as first-line PTSD treatment, specific medications are also effective for PTSD and should be considered for older adults as well. Unfortunately, medication studies are also likely to exclude older adults or have not examined whether safety or effectiveness are affected by aging. (See table below for considerations in prescribing with older adults.)

Considerations for tailoring assessment and treatment to older adults

In general, an evidence-based approach to assessment and treatment of older adults can look similar to assessment and treatment of all adults, not modifying unless it seems necessary. Of note, randomized controlled trials including older adults have generally not made any universal modifications, though case studies with older adults often note specific modifications made to tailor the treatment to a given individual (31). Below are some considerations that may affect assessment or treatment with specific older adults, although providers should be careful not to assume that modifications are needed without assessing (32).

Age-Related Findings Clinical Implications
Current cohorts of older adults may be more stoic, more likely to focus on somatic complaints, or less likely to identify symptoms as trauma related. Providers may be more likely to recognize comorbidities than to identify PTSD. One study found that older adults in VA were less likely to receive therapy after a new PTSD diagnosis (29).
  • As in VA, universal screening for trauma and PTSD (e.g. using the PC-PTSD-5) may be more helpful than expecting a patient to raise the issue of trauma or PTSD on their own.
  • It may also be helpful to avoid psychological jargon and be mindful of potential stigma around mental health (e.g., describing being “on guard” vs “afraid”; 33), or describing Prolonged Exposure without using the word “prolonged.”
  • It is best to assume that older adults may be as likely to benefit from therapy as younger adults.
Older adults may be less likely to have full PTSD but may still have subthreshold PTSD that is impairing.
  • Consider whether a PTSD treatment may still be helpful even if a full diagnosis of PTSD is not met.
Older adults may be more likely to have decreased mobility, transportation challenges, and sensory (hearing, seeing), changes.
  • As needed, use written materials with larger, bold font.
  • When indicated, make sure to speak directly to the patient in a clear voice, louder and slower only as necessary.
  • Consider consults to audiology or to blind and visual impairment rehabilitation services, which can help with assistive technologies (e.g., screen readers). Have devices (magnifying glass, pocket talkers—or personal sound amplifiers) on hand in office.
  • Consider including caregivers or family members as appropriate for purposes of transportation, reinforcing messages from the treatments, or facilitating treatment (but be careful to always address the patient first).
  • Consider telehealth to help with transportation barriers.
Pain is often comorbid with PTSD, and this relationship can be exacerbated with age (16).
PTSD can also affect care at end of life.
Not all older adults will have neurocognitive impairment, but PTSD does increase risk for neurocognitive disorder (NCD), and vice versa.
  • In general, mild and moderate NCD are not contraindications for PTSD treatment. If there is a concern about NCD (e.g., inattentive to appearance, a poor historian, or forgetful during interview), a cognitive screening is warranted (standardized options include the MOCA [34] and the less validated but free SLUMS [35]). If NCD is suspected, a referral for a comprehensive neuropsychological exam can be helpful. If delirium is suspected, or there is a question about medication interactions, a medical evaluation can be considered. See Assessment and Treatment for PTSD with Co-occurring NCD
Clinicians may have concerns about exposure therapy leading to increased physiological arousal among older adults, especially those with cardiovascular conditions.
  • There is no evidence that this concern should contraindicate evidence-based psychotherapy (EBPs) for PTSD. The 2 systematic reviews noted above included various forms of exposure and trauma-focused therapies for PTSD, none with exclusions for any comorbidities. None of the included studies reported long-term adverse events in this population. One study of imaginal exposure in patients with PTSD due to a life-threatening cardiovascular event found no adverse effects or “cause for worry” after monitoring changes in heart rate and blood pressure during treatment (36). On the other hand, untreated PTSD contributes to worse physical health outcomes, and daily symptoms already cause cardiac strain—whereas treatment may improve cardiometabolic disease severity or lower risk (37).
  • If there are particular concerns, clinicians can consult and collaborate with medical providers. In cases of higher risk, medical providers can clear patients for treatment and monitor cardiac status during treatment.
  • Shared decision-making can be used to think through potential risks and benefits of various options, including first-line PTSD EBPs and non-trauma-focused treatments.
There has been relatively little research on medications in older adults with PTSD. However, in general, older adults may be more susceptible to side effects due to slower metabolism. And for those taking other medications there is an increased risk of drug-drug interactions.
  • Consider the side effect profiles of various medications.
  • Be cautious about polypharmacy and drug-drug interactions.
  • “Start low and go slow,” adjusting one medication at a time. Older adults often respond to lower doses of medications than younger adults.
  • Benzodiazepines are not recommended in general for PTSD and they are particularly to be avoided with older adults given that they can cause cognitive impairment, sedation, respiratory problems, and fall risk.
Social support is generally an important buffer against PTSD symptoms, and role changes or losses of key loved ones later in life may constrain social support.
  • It can be helpful to assess for changes in roles (e.g. retirement, changes in living situations) along with social connectedness (loneliness, bereavement). If relevant, helping problem solve to address isolation may help to buffer PTSD symptoms.

Summary

Older adults may be somewhat less likely to have PTSD than younger adults. However, full or subthreshold PTSD can contribute to accelerated aging in older adults. Emerging evidence indicates that assessment and psychotherapy can generally proceed similarly with older and younger adults, though we have provided some considerations (e.g., pharmacotherapy, co-occurring conditions) to optimize care for older adults with PTSD.

Resources

References

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