Trauma-related psychiatric disorders such as PTSD and grief often go undetected and untreated in older adults. Here's how to help.
Andrey Popov/AdobeStock
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
Caring for Older Adults With Mental Health Disorders During the Pandemic
Rajesh R. Tampi, MD, MS, DFAPA, DFAAGP
COVID-19, Cognition, and Dementias: What Role Has the Pandemic Played?
Eric E. Brown, MD, MSc; Tarek K. Rajji, MD; and Benoit H. Mulsant, MD, MS
Recognizing and Addressing Psychiatric Implications of Sleep Disorders
Christine Juang, PhD; Colleen Mills-Finnerty, PhD; Erin Cassidy-Eagle, PhD, DBSM; Makoto Kawai, MD; Christine Gould, PhD
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)
Table 1. Treatment Options for PTSD in Older Adults
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
Table 2. PTSD Assessment Considerations
For example, although there are case studies5-7 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.
References
1. Rutherford BR, Zilcha-Mano S, Chrisanthopolous M, et al. Symptom profiles and treatment status of older adults with chronic post-traumatic stress disorder. Int J Geriatr Psychiatry. 2021;36(8):1216-1222.
2. Guideline Development Panel for the Treatment of PTSD in Adults, American Psychological Association. Summary of the clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults. Am Psychol. 2019;74(5):596-607.
3. McCarthy E, Cook JM. PTSD in late life. Psychiatric Times. 2018;35(8):13-14.
4. Smith NB, Cook JM, Pietrzak R, et al. Mental health treatment for older veterans newly diagnosed with PTSD: a national investigation. Am J Geriatr Psychiatry. 2016;24(3):201-212.
5. Dinnen S, Simiola V, Cook JM. Post-traumatic stress disorder in older adults: a systematic review of the psychotherapy treatment literature. Aging Ment Health. 2015;19(2):144-150.
6. Yasinski C, Maples-Keller J, Trautner H, et al. A review of PTSD augmentation strategies for older adults and case of rTMS-augmented prolonged exposure. Am J Geriatr Psychiatry. 2020;28(12):1317-1327.
7. Cook JM, McCarthy E, Thorp SR. Older adults with PTSD: brief state of research and evidence-based psychotherapy case illustration. Am J Geriatr Psychiatry. 2017;25(5):522-530.
8. Yoder MS, Lozano B, Center KB, et al. Effectiveness of prolonged exposure for PTSD in older veterans. Int J Psychiatry Med. 2013;45(2):111-124.
9. Foa E, Hembree E, Rothbaum B, Rauch S. Prolonged Exposure Therapy For PTSD: Emotional Processing of Traumatic Experiences, 2nd edition. Oxford University Press; 2019.
10. Thorp SR, Glassman LH, Wells SY, et al. A randomized controlled trial of prolonged exposure therapy versus relaxation training for older veterans with military-related PTSD. J Anxiety Disord. 2019;64:45-54.
11. Price M, Yuen EK, Goetter EM, et al. mHealth: a mechanism to deliver more accessible, more effective mental health care. Clin Psychol Psychother. 2014;21(5):427-436.
12. Resick PA, Monson CM, Chard KM. Cognitive Processing Therapy for PTSD: A Comprehensive Manual. Guilford Press; 2016.
13. Chard KM, Schumm JA, Owens GP, Cottingham SM. A comparison of OEF and OIF veterans and Vietnam veterans receiving cognitive processing therapy. J Trauma Stress. 2010;23(1):25-32.
14. Haight BK, Haight BS. The Handbook of Structured Life Review. Health Professions Press; 2007.
15. Forstmeier S, van der Hal E, Auerbach M, et al. Life review therapy for Holocaust survivors (LRT-HS): study protocol for a randomised controlled trial. BMC Psychiatry. 2020;20(1):186.
16. Shibata E, Sasaki M, Tohyama K, et al. Age-related changes in locus ceruleus on neuromelanin magnetic resonance imaging at 3 Tesla. Magn Reson Med Sci. 2006;5(4):197-200.
17. Neria Y. Functional neuroimaging in PTSD: from discovery of underlying mechanisms to addressing diagnostic heterogeneity. Am J Psychiatry. 2021;178(2):128-135.
18. Mulsant BH, Blumberger DM, Ismail Z, et al. A systematic approach to pharmacotherapy for geriatric major depression. Clin Geriatr Med. 2014;30(3):517-534.
19. Rutherford BR, Taylor WD, Brown PJ, et al. Biological aging and the future of geriatric psychiatry. J Gerontol A Biol Sci Med Sci. 2017;72(3):343-352.
20. Tuerk PW, Wangelin BC, Powers MB, et al. Augmenting treatment efficiency in exposure therapy for PTSD: a randomized double-blind placebo-controlled trial of yohimbine HCl. Cogn Behav Ther. 2018;47(5):351-371.
21. Williams JL, Racette EH, Hernandez-Tejada MA, Acierno R. Prevalence of elder polyvictimization in the United States: data from the National Elder Mistreatment Study. J Interpers Violence. 2020;35(21-22):4517-4532.
22. Burnes D, Acierno R, Hernandez-Tejada M. Help-seeking among victims of elder abuse: findings from the National Elder Mistreatment Study. J Gerontol B Psychol Sci Soc Sci. 2019;74(5):891-896.
