PTSD: National Center for PTSD

PTSD Assessment and Treatment in Older Adults

Anica Pless Kaiser, PhD, Jennifer Schuster Wachen, PhD, Carrie Potter, BA, Jennifer Moye, PhD, & Eve Davison, PhD, with the Stress, Health, and Aging Research Program (SHARP)

Barbara Hermann, PhD

Age-related factors can interact with posttraumatic stress symptoms and associated problems and carry implications for research and clinical care. It is important for health care professionals to be well-informed regarding appropriate interventions based upon patient age as well as the broader context of aging processes.

Assessment Considerations

• Most older adults do not have cognitive impairment. However, for an older patient who is inattentive to appearance, a poor historian, or forgetful during the interview, cognitive screening using a standardized instrument is warranted. If the clinician suspects dementia, the patient should be referred for a comprehensive diagnostic evaluation. In addition, if delirium is suspected, or there is a question about medication interactions, the individual should be referred for medical evaluation.
• Assessment of trauma and related symptoms should be routine. Older patients may not spontaneously report traumatic experiences or they may minimize their importance, especially if the event(s) occurred a long time ago.
• Older patients may talk about problems or respond to questions differently than younger people. For example, older individuals (Veterans and non-Veterans) may be more likely to report physical concerns or pain, sleep difficulties, gastrointestinal issues, cognitive difficulties, or use a general term like "stress." They are less likely to describe emotional difficulties, like depression or anxiety, and may describe "issues" or "concerns" rather than report "problems" (1). Older adults may present to primary care clinics with these complaints rather than seek mental health services. Providers, particularly primary care doctors, should follow up reports of physical issues with questions about changes in mood and activities. Additionally, it is important to consider potentially adaptive strategies that older adults may have developed over a lifetime and encourage use of these coping resources.
• Many trauma and PTSD assessment measures have been used validly with older adults (2). This includes the Clinician-Administered PTSD Scale (CAPS; 3), the gold standard in structured diagnostic interviews, and the self-report PTSD Checklist (PCL; 4). Normative studies for older adults are not yet available for the DSM-5 versions of the CAPS (CAPS-5) or the PCL (PCL-5).
• Suicide assessment is particularly important in older patients. Older (and younger) Veterans are at greater risk for completed suicide than are middle-aged Veterans (5).

Continuing Education Course

Prescribing for Older Veterans with PTSD

This course reviews the prevalence and incidence of PTSD in older adults and describes the role of aging and cognitive impairment in PTSD among older patients. Based upon data primarily from Veteran samples, recommendations and cautions for psychopharmacology in older adults with PTSD are presented.

Treatment Considerations

• To date, no evidence exists that older patients cannot benefit from Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE), or that modifications to the treatment protocols are universally necessary due to older age. Providers should consider specific needs of each individual and apply the treatment in the most beneficial manner. There are no randomized controlled trials currently published on the efficacy of PTSD treatment in older adults. However, a pilot study (6) demonstrated that conducting PE with older Veterans is both feasible and efficacious.
• The presence of cardiovascular problems should not prevent older patients from receiving trauma-focused psychotherapy. The 2017 VA/DoD Clinical Practice Guideline for PTSD (7) reports one randomized clinical trial that evaluated the issue of the safety of delivering imaginal exposure to patients who have PTSD resulting from a cardiovascular event and found no evidence of adverse outcomes from the treatment (8). In addition, there is some evidence that exposure therapy is not only safe, but that treating PTSD may reduce PTSD-associated hypertension risk (9). Several trials of exposure treatments for other anxiety disorders (for example, panic disorder) have indicated they are efficacious and well-tolerated among older adults (10). If, after discussion with the patient, it is decided that trauma-focused treatment is feasible, mental health providers should monitor patients at greater risk from high arousal.
• The presence of cognitive decline may impact memory, learning, attention, or concentration. The provider may want to repeat material, present information in various ways, and focus on one topic at a time. In addition, cognitive decline can alter the way in which trauma-related stimuli impact an individual with PTSD. For example, certain sounds, sites, and even staff activities can serve as trauma-related triggers (11).
• Beyond modifying treatment administration and seeking consultation, treatment providers working with older patients with cognitive or physical impairments may want to engage caregivers, informal and formal. Caregivers can often play a critical role within a treatment plan for an older adult with physical or cognitive issues by providing additional support, helping reinforce information presented in therapy, and assisting with transportation to treatment.
• The majority of medication studies for PTSD have not included older adults, so results may not generalize to this segment of the population. One study suggests older individuals may have a less robust response to medications for PTSD than younger patients (12). Per the 2017 VA/DoD Clinical Practice Guideline for PTSD, trauma-focused psychotherapy is more efficacious than medication for the treatment of PTSD. As with younger patients, trauma-focused psychotherapy should always be offered when possible. If, because of patient preference or because of a primary focus of somatic, rather than cognitive/emotional symptoms, an older patient prefers medication to psychotherapy, the CPG strongly recommends the SSRIs sertraline, paroxetine, or fluoxetine, or the SNRI venlafaxine (7).
• Older adults are often more sensitive to medication side effects, and are often managing more co-occurring medical problems and multiple medications than are younger people. As a result, it may be important to start with a low dose when introducing a new medication and make adjustments as needed. Furthermore, given the greater likelihood that an older individual is receiving medications for a medical condition, practitioners should always be concerned about drug-drug interactions - especially when prescribing SNRIs. Prescribers should assess for any confusion about medication use or poor adherence among older patients who take multiple medications. In addition, the 2017 VA/DoD Clinical Practice Guideline for PTSD strongly recommends against the use of benzodiazapines as a treatment for any patient with PTSD due to their association with known adverse side effects (7).

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Other Resources on Aging and PTSD

For a more extensive review of the research literature, see Posttraumatic Stress Symptoms in Older Adults: A Review and Co-occurring PTSD and Neurocognitive Disorder (NCD).

Educational Booklet

Understanding PTSD and Aging

Download and share this booklet with your clients. The challenges faced later in life as a result of PTSD are discussed including effective treatment. English | en Español (PDF)

AUTHOR NOTE: SHARP is co-directed by Avron Spiro, PhD, and Eve Davison, PhD, and is coordinated by Anica Pless Kaiser, PhD. SHARP is supported by the Behavioral Science Division of the VA National Center for PTSD and the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System.

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References

1. Aldwin, C. M., Sutton, K. J., Chiara, G. & Spiro III, A. (1996). Age differences in stress, coping, and appraisal: Findings from the Normative Aging Study. Journals of Gerontology: Psychological Sciences, 51B, 179-188.
2. 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. Springer Publishing Company.
3. Blake, D., Weathers, F., Nagy, L., Kaloupek, D., Gusman, F., Charney, D., et al. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8, 75-90.
4. Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993, October). The PTSD Checklist: Reliability, validity, and diagnostic utility. Paper presented at the annual meeting of the International Society for Traumatic Stress Studies, San Antonio, TX.
5. Zivin, K., Kim, H. M., McCarthy, J. F., Austin, K. L., Hoggatt, K. J., Walters, H. M., Valenstein, M. (2007). Suicide mortality among individuals receiving treatment for depression in the VA health system: associations with patient and treatment setting characteristics. American Journal of Public Health, 97(12), 2193-2198.
6. Thorp, S. R., Stein, M. B., Jeste, D. V., & Wetherell, J. L. (2012). Prolonged Exposure therapy for older Veterans with posttraumatic stress disorder: A pilot study. American Journal of Geriatric Psychiatry, 20, 276-280.
7. Department of Veterans Affairs and Department of Defense. (2017). VA/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Washington DC: Author. Retrieved from: https://www.healthquality.va.gov/guidelines/MH/ptsd/
8. Shemesh, E., Annunziato, R. A., Rubinstein, D., Sultan, S., Malhotra, J., Santra, M. Weatherley, B. D., Feaganes, J. R., Cotter, G., & Yehuda, R. (2009). Screening for depression and suicidality in patients with cardiovascular illnesses. American Journal of Cardiology,104,1194-1197. doi:10.1016/j.amjcard.2009.06.033
9. Burg, M. M., Brandt, C., Buta, E., Schwartz, J., Bathulapalli, H., Dziura, J., Edmondson, D. E., & Haskell, S. (2017). Risk for incident hypertension associated with posttraumatic stress disorder in military Veterans and the effect of posttraumatic stress disorder treatment. Psychosomatic Medicine, 79, 181-188. doi:10.1097/PSY.0000000000000376
10. Swales, P. J., Solfvin, J. F., & Sheikh, J. I. (1996). Cognitive-behavioral therapy in older panic disorder patients. American Journal of Geriatric Psychiatry, 4, 46-60.
11. Cook, J. M., Areán, P. A., Schnurr, P. P., & Sheikh, J. I. (2001). Symptom differences between older depressed primary care patients with and without history of trauma. International Journal of Psychiatry in Medicine, 31, 401-414. doi:10.2190/61me-f2m0-3ph5-g59e
12. Wetherell, J. L., Petkus, A. J., Thorp, S. R., Stein, M. B., Chavira, D. A., Campbell-Sills, L., & Roy-Byrne, P. (2013). Age differences in treatment response to a collaborative care intervention for anxiety disorders. The British Journal of Psychiatry: The Journal of Mental Science, 203, 65-72. doi:10.1192/bjp.bp.112.118547

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