Posttraumatic Stress in Older Adults: When Medical Diagnoses or Treatments Cause Traumatic Stress

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Key points

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    Most older patients adapt after catastrophic medical diagnoses and treatments, but a significant number may develop posttraumatic stress disorder (PTSD) symptoms.

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    PTSD symptoms create added burden for the individual, family, and health care system for the patient’s recovery.

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    Medical-related PTSD may be underdiagnosed by providers who may be unaware that these health problems can lead to PTSD symptoms.

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    Treatment research is lacking, but pharmacologic and nonpharmacologic approaches to treatment may

Process of Eliminating Alternative Diagnoses/Problems

Although anxiety and depression may frequently co-occur with catastrophic medical illness, PTSD can be differentiated from these, especially by the presence of experiences described by the patient as traumatic (criterion A) and intrusive thoughts, memories, and dreams of these events (criterion B). Avoidance is a cardinal component of PTSD but may not be present if the patient is unable to avoid aversive reminders (such as having to return for ongoing health care at the site of the initial

Source of Data

Patient interview and reports of family and professional caregivers provide the key data on PTSD. Patients are most aware of internal signs and often do not tell others about intrusive symptoms. Caregivers are often more aware of external signs such as anger and agitation.

Examination

A clinical interview focusing on symptoms of PTSD is the foundation of the examination. The most important issue is to ask about the occurrence and impact of catastrophic medical events because PTSSs from these are often

Interventions: current evidence base and what to do when evidence is lacking

Treatment of older adults with PTSD, particularly when medically induced, is weakly supported by age-specific and trigger-specific evidence. Although progress has been made on assessment and treatment protocols in the adult population, similar advances have lagged behind for older adults.20 Therefore, clinical decision making must draw from the literature on younger adults and war or sexual trauma, supplemented with clinical experience.

Many older veterans whom we have seen in our practice at

Psychopharmacologic treatment

Pharmacologic interventions should target the individual core symptoms of PTSD with attention paid to the medical comorbidities and the risks and benefits of medications. As patients feel threatened, as in the case of the Vietnam veteran during and after his cardiac event, overwhelming fear tends to trigger a typical fight-or-flight response with symptoms of nightmares, insomnia, depressed and anxious mood, and hyperarousal, which is thought to arise from the brain’s amygdala.

Sleep

Patients often report that insomnia is the most distressing PTSD symptom. Lack of sleep can exacerbate other symptoms of PTSD. For these reasons it is useful to treat insomnia first.22 Sleep disturbances in PTSD are thought to be related to hyperarousal and increased adrenergic activity, which may lead to related symptoms such as nightmares, difficulty initiating sleep, and frequent awakenings. Two medications that decrease nightmares and improve sleep quality are prazosin, and trazodone.23

In

Lifespan Context

In work with older veterans who are experiencing PTSD, often as a resurgence of symptoms late in life, the decision of whether and how to approach the trauma narrative is tempered by the combat trauma having occurred 40 to 60 years ago, being interwoven with that individual’s lifespan development, and occurring in the context of multiple vulnerabilities such as chronic illness and, potentially, lower cognitive resources. Our research on older veteran cancer survivors suggests a different

Early intervention

PTSD arising out of medical trauma occurs in or near a health care context, providing the opportunity for early intervention by health care providers. Although early trauma debriefing is not advised,29 more recent approaches have combined early intervention in the inpatient setting, supplemented with pharmacotherapy and psychotherapy in the weeks after discharge, a so-called stepped collaborative care approach, to reduce PTSD symptoms.30 Although not tested in older adults, these and other

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    Disclosure: This material is the result of work supported with resources and the use of facilities at the Boston VA Medical Center. Dr J. Moye received funding for research from the Department of Veterans Affairs Rehabilitation Research and Development Service #5I01RX000104-02.

    Conflict of Interest: The authors have no conflict of interest relating to this study or this article.

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