PTSD in Late Life: An Update on Clinical Issues

SPECIAL REPORT: GERIATRIC PSYCHIATRY

Trauma may not be readily observable in older adults. Patients may not acknowledge or may minimize the importance of their experiences, and health care providers may not recognize or provide timely and appropriate mental health treatment (Table 1). Data from a study examining the influence of chronic posttraumatic stress disorder (PTSD) on biological aging processes in older adult men and women with PTSD in New York City found that 43% were currently receiving some kind of medication or psychotherapy.¹

Of those, less than 25% were receiving an adequate dose and duration of a first-line pharmacotherapy option, and not one individual was currently participating in an evidence-based psychotherapy for PTSD, which is disappointing given the larger treatment effect sizes observed with such psychotherapy compared with pharmacotherapy.² (For more information on the prevalence of PTSD and similar issues, please see the previous review article, “PTSD in Late Life,” which appeared in 2018.³)

These low rates are consistent with national findings from the US Department of Veterans Affairs Health Care System. Although most older veterans with newly diagnosed PTSD received at least 1 follow-up mental health visit, increased age was associated with decreased odds of receiving combined psychotherapy and pharmacotherapy, decreased number of psychotherapy visits, and increased waiting times.⁴

Treating PTSD in Older Adults

There are many reasons for mental health providers to be enthusiastic about promoting healing from trauma and PTSD in their older adult patients and a number of options exist (Table 2). Even though most randomized controlled trials of psychotherapy do not include sufficient numbers of older adults to make definitive age comparisons, existing data suggest that psychotherapy is feasible and efficacious for older individuals.⁵ However, it may require adjustments for this age group, including increasing the number of sessions, or modifications such as adding additional content or components.⁶

For example, although there are case studies^5-7 or investigations⁸ that show acceptability and preliminary efficacy for an evidence-based psychotherapy for PTSD—prolonged exposure (PE)⁹—results of the first randomized controlled trial of PE that specifically focused on older adults indicated that effects may not be as strong as those reported in studies for younger adults.¹⁰ Although both veterans who received PE and those who received the comparison condition (relaxation therapy) experienced significant declines in PTSD symptoms after intervention, many symptom gains were lost by the time of the 6-month follow-up. In addition, depression symptoms did not significantly change over time, nor were they moderated by treatment condition. It is possible that while exposure can reduce PTSD symptoms in older adults during active engagement, it does not work as well during the maintenance phase. This may be due to several factors, including the difficulty in recalling older memories and potentially weakened trauma processing. Some older adults may need additional frequency and intensity of PE sessions to gain full therapeutic effect. In addition, digital health delivered via internet or mobile devices may be used to increase the reach of PE and other evidence-based psychotherapies, as well as to help older adults engage more actively in treatment or enhance care after formal intervention has ended.¹¹

These findings are consistent with those from a study of another evidence-based psychotherapy, cognitive processing therapy (CPT).¹² A multivariate model predicting post-CPT symptom severity indicated lower PTSD symptoms for veterans of wars in Iraq and Afghanistan than for Vietnam veterans.¹³ Thus, treatment for older veterans with moderate-to-severe PTSD may also need to address such issues as aging and retirement and incorporate motivational techniques. A current psychotherapy trial in Israel testing the use of life review¹⁴ compared with a supportive control condition for PTSD, depression, and/or prolonged grief in Holocaust survivors appears promising.¹⁵ Life review takes a narrative approach and includes the developmental life-span orientation as well as exposure therapy.

The gold-standard pharmaceutical treatments for PTSD² in the general adult population are selective serotonin reuptake inhibitors (SSRIs), particularly sertraline, paroxetine, and fluoxetine, and a selective serotonin and norepinephrine reuptake inhibitor (SNRI), venlafaxine; all of these are commonly used for depression.

However, few pharmacotherapy studies focus on or include patients who are 65 years and older. Simply generalizing findings from randomized controlled trials of younger adults with PTSD to the clinical treatment of older adults may be problematic. It is possible that age-related changes in the brain (eg, declining locus coeruleus functioning with consequent alterations in noradrenergic tone¹⁶) may specifically affect treatment responses to SSRIs and SNRIs in older adults. Moreover, intervention studies exclusively enrolling younger adults typically do not contain outcome measures relevant to older adults, such as assessments of cognitive and physical functioning. It may be the case that, similar to the aforementioned psychotherapy trials for PTSD, pharmacotherapy in older adults will require aging-informed adjustment in order to achieve optimal responses. For example, good clinical medication management for PTSD in older adults must also consider potential frailty, complex comorbidities, multimorbidity, and polypharmacy.

Differences in clinical phenomenology, brain mechanisms, and treatment responsivity based on age have been well documented in the case of major depressive disorder in older adults, which is quite relevant to individuals with PTSD given its frequent cooccurrence.¹⁷ The average response to antidepressant medication tends to be higher in younger than older adults.¹⁸ Reasons for attenuated responses and more chronic clinical courses include age-related biological processes, such as cerebrovascular infarcts; development of frailty; inflammation and neurochemical changes like diminished dopamine signaling; and oxidative stress and mitochondrial aging.¹⁹ One forward-thinking strategy is to identify and deploy precision treatments rather than apply an empirical treatment (eg, antidepressant medication) that may not address the specific disease process occurring in a given patient.¹⁹ In addition, optimal management of late-life depression should begin earlier in adulthood, incorporating preventive strategies as well as a focus on such lifestyle strategies as exercise.¹⁹

Thus, while pharmacotherapy research into PTSD in older adults is lagging far behind the psychotherapy literature, lessons learned from treatment of depression in older adults may be informative. In addition, innovative pharmacotherapy augmentation or second-tier interventions for increasing the mental health treatment response in older patients with PTSD include the use of d-cycloserine and 3,4-methylenedioxymethamphetamine⁵ as well as an α-2 adrenergic receptor antagonist, yohimbine.²⁰

Traumas in Later Life

One important caveat to the issues presented earlier in this article is that most of the empirical literature focuses on older adults with trauma occurring earlier in life (eg, combat, sexual assault). Attention must also be paid to older adults who are currently experiencing trauma. At least 11% of community-residing older adults in the United States have experienced some form of mistreatment—emotional, physical, sexual, financial, and neglectful events—in the past year.²¹ Older adults who are experiencing current polyvictimization are also in need of identification, assessment, and intervention. Methods to promote help-seeking and healing in survivors of elder abuse are available and should be integrated across a range of health care and law enforcement systems.²²

Concluding Thoughts

Trauma-related psychiatric disorders such as PTSD and grief often go undetected and untreated in older adults. There are evidence-based psychotherapies and pharmacotherapies that could provide great benefit in symptom reduction and increased life functioning, although augmentation or modification may be necessary for older adults. In order to assist older survivors in receiving timely and appropriate mental health treatment, targeted outreach, psychoeducation, and assessment in health care settings is warranted.

Dr Cook is a professor of psychiatry, Yale School of Medicine, New Haven, CT. Dr Rutherford is the John and Myrna Daniels Professor of Psychiatry in Honor of Dr Herbert Pardes, Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, and co-director, Research Area on Brain Aging and Mental Health, New York State Psychiatric Institute, New York, NY. Dr Acierno is the executive director, Trauma and Resilience Center, vice chair for Veterans Affairs, and professor in the Louis Faillace Department of Psychiatry at McGovern Medical School, University of Texas Health Science Center at Houston.

The authors report no conflicts of interest concerning the subject matter of this article.

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