Problem: Can you summarize this article for me?
Despite the increase in research on the impact of trauma in younger populations, considerably little is known about the extent and consequences of traumatic exposure in older adults. Most studies examining the impact of traumatic exposure either does not recruit sufficient numbers of older adults to examine age effects, or fail to include them at all.
Case studies and the limited research currently available suggest that there are both developmental and cohort differences between younger and older individuals, which may affect the manifestation, course, assessment, and treatment of trauma-related distress in late life.
Many developmental changes that occur in older adulthood constitute stressors. These include diminished sensory capacities, decreased mobility, physical frailty, income shrinkage and financial limitations, loss of friends and social status, isolation, changes in housing, multiple medications, complex medical problems, ill health, retirement widowhood, cognitive impairment or loss, and impaired self-care. Unresolved distal or recent trauma may interact negatively with these age related changes to affect physical and mental health functioning in later life.
In addition, cohort differences that may affect the presentation, assessment, and treatment of trauma-related distress in older adults include misinterpretation of psychological difficulties as somatic complaints and reluctance to admit to psychological difficulties due to the associated stigma for this generation. Also, for the current cohort of older adults, trauma that occurred before their middle adulthood preceded the introduction of PTSD into the diagnostic nomenclature in 1980.
Thus, knowledge of the effects of traumatic experiences was less developed, and specific terminology, understanding, and support were less available for this generation.
The demographic shape of the United States population is rapidly shifting. The most prominent alteration is an unparalleled change in the number of older adults. The number of persons living into older adulthood has drastically increased while the proportion of young people has decreased (U.S. Department of Health and Human Services, 1995). Thus there may be older adults living with the effects of traumatic stress than ever before. This also means that present-day younger trauma survivors may also live to old age and thus be faced with similar developmental challenges in coping with their trauma. For example, issues related to aging are increasingly relevant for the largest service group of the U.S. veteran population, those who served in Vietnam.
The current quarterly provides some highlights of the literature on trauma, its related symptoms, course, assessment, and treatment in older adults.
Empirical inquiry in this area has increased over the past two decades. Examination of that literature reveals a progression in understanding of aging issues for trauma survivors, but there remain many gaps open for investigation. Several new areas of inquiry are noted and future directions are suggested in this issue.
Unfortunately, there are no epidemiological studies, utilizing a representative sample, that examine the incidence or prevalence of traumatic exposure and PTSD in older adults. The estimates of traumatic exposure and PTSD vary depending on the traumas and symptoms assessed and samples surveyed. In a community sample, Norris (1992) found that past-year exposure to 10 potentially traumatic events was higher than and caused more PTSD among younger than middle-aged or older adults. In a large longitudinal cohort study of community-residing male veterans from World War II (WWII) and the Korean War, traumatic exposure to combat was high, with those exposed to moderate or heavy combat in WWII having 13.3 times greater risk of PTSD decades later (Spiro et al., 1994). Although most participants in a large sample of community-dwelling older survivors of WWII bombardments, persecution, resistance, and combat did not meet diagnostic criteria for PTSD, many were suffering negative long-term after-effects (Bramsen & van der Ploeg, 1999). These studies highlight the need for the examination of sub-threshold PTSD as well as other trauma-related symptoms, such as depression, in older adults.
Most research on older adult trauma survivors has been conducted on individuals exposed to combat/internment, natural or human-made disasters, or the Holocaust. In a review of this literature, Falk and colleagues (1994) found that older adults meet diagnostic criteria for PTSD as many as 45 years after trauma. As in younger adults, PTSD in older persons is strongly associated with degree of traumamatic exposure (Fontana & Rosenheck, 1994).
Empirical studies on the course of PTSD across the lifespan are sorely needed. To date, the longitudinal trajectory of trauma-related symptoms into older adulthood has only been examined in American WWII and Korean Conflict ex-prisoners of war (Port et al., in press). Though some of this work has shown symptom stability over decades (Engdahl et al., 1993), more recent investigation suggests that symptoms were highest after exposure, decline for years, and increase in later-life (Port et al., in press). Potential increase in trauma-related symptoms among older survivors of remote severe trauma deserves more attention.
Though patterns of expression vary due to dose and duration of trauma, clinical presentation of trauma-related distress in older adults, in general, appears less intense than the manifestation of distress in younger populations (Fontana & Rosenheck, 1994; Norris, 1992). For example, some trauma-related symptoms, such as dissociation, may be less persistent over time (Yehuda et al., 1996). Older adults may also experience different symptoms or difference in coexisting disorders in response to trauma (Goenjian et al., 1994). Again, because of these differences, it is crucial to include dimensional measures of symptomatology in studies of older adult trauma survivors.
Whether life events in old age are related to symptom exacerbation/occurrence has been discussed or examined using retrospective methods. This issue is directly linked to the debate between the stress evaporation model and the residual stress model in older adults. While some have suggested that traumatic exposure may have an inoculating effect that leads to greater resilience, this may be dependent, in part, on the type and severity of stressor to which the individual was initially exposed. Older adult survivors of less severe trauma, such as natural disasters, may display both direct and cross-tolerance (Knight et al., 2000; Norris & Murrell, 1988), suggesting that exposure reduces the impact of the same and different stressors.
However, some evidence from both Holocaust and combat veterans supports the vulnerability perspective (Danieli, 1997). Older adult survivors of severe trauma may have a heightened vulnerability to subsequent stressors (Yehuda, Kahana, Schmeidler et al., 1995). These stressors may be environmental, such as war (Solomon & Prager, 1992) and discrimination (Eaton et al., 1982), or internal, such as disease (Peretz et al., 1994).
Protective mediating variables, such as locus of control, instrumental coping, and appraisals of desirable and undesirable effects of traumatic experience, have received some attention in the older-adult literature (Aldwin et al., 1994; Harel et al., 1988). For example, perceiving potential benefits might mitigate the effect of traumatic exposure (Aldwin et al., 1994). Adaptive resources and capacities of resilience in older age warrant further investigation given the intervention implications of these findings.
Although no psychiatric assessment measure has been specifically designed for use with older trauma survivors, the reliability and validity of several widely used PTSD measures has been established (Summers et al., 1996). Interviewer-rated scales as well as self-report measures have been shown to be consistent and able to discriminate between older veterans with and without PTSD. However, lower cutoffs as well as the use of several tests together are recommended for diagnostic efficiency (Summers et al., 1996).
Neurobiological factors have received limited empirical attention in older trauma survivors. Biological abnormalities, such as low cortisol levels, in younger PTSD patients have been shown to persist into older adulthood (Yehuda, Kahana, Binder-Brynes et al., 1995). Recent advances in the literature on the neurochemistry and neurocircuitry alterations of trauma suggest that prolonged stress or exposure to glucocorticoids has an adverse effect on cortical dysfunction, which may contribute to memory impairment (Sapolsky, 2000). Because aging individuals with cognitive impairment are typically excluded from studies, little is known about the relationship between a history of extreme trauma/PTSD and cognitive impairment. Preliminary evidence suggests, however, that individuals exposed to prolonged and extreme trauma, such as being a prisoner of war or in a Nazi concentration camp, demonstrate neurological concomitants, decades after traumatic exposure (Sutker et al., 1995). Preliminary investigation also suggests that persons who experienced severe trauma may demonstrate behavioral disturbances, such as physical and verbal aggression, while in longterm-care settings or in the beginning stages of dementia (Cook et al., 2001).
Topics around trauma and older adults that remain open for examination are plentiful. There is little empirical investigation on the prevalence and effects of several types of trauma, such as criminal victimization or elder abuse, neglect, or exploitation (McCabe & Gregory, 1998; Pillemer & Finkelhor, 1988). Although there is some evidence to suggest that abused older adults suffer more depression than their non-abused counterparts, other psychological consequences of abuse, most notably PTSD, remain unstudied (Comijs et al., 1999). Although some studies have been conducted on the effect of trauma on psychological and physical health functioning in older adulthood (Elder et al., 1994; Schnurr et al., 1998; Schnurr et al., 2000), broader effects such as changes in terms of relationship (marriage, children, friends), and social functioning (involvement with community, groups) have rarely been examined. Importantly, several groups of older adults have received modest examination in the traumatic stress literature, specifically older women as well as minorities (Bechtle & Follette, in press; Wolkenstein & Sterman, 1998).
Another area where information is sorely lacking is in the treatment of trauma-related distress in older adults. Although some therapy interventions are similar to those used in PTSD with younger adults (i.e., education about symptoms, enhancement of social support, and provision of coping tools to more effectively manage symptoms), special considerations that are unique to older adults are rarely addressed. Knowledge of the unique problems of older adults as well as needed adaptation of current psychological interventions is required (APA Working Group on the Older Adult, 1998). Although there are a few reports of therapy with older survivors in the literature, none has been empirically validated. There is one manualized psycho-educational treatment program for older combat veterans, which was developed at the Cleveland VA (Clower et al., 1996). This program involves therapy education, PTSD education, life review, stress management, building of social support, anger management, grief and loss, and forgiveness.
Cognitive-behavioral treatment for younger adults has often focused on exposure therapy, the goal being to reduce PTSD symptoms through repeated exposure to images associated with the traumatic event. Because exposure therapy may produce profound physiological effects on heart rate and respiration, and because the health of older adults is often compromised, the use of exposure has been questioned (Hyer & Woods, 1998). One well-known therapeutic treatment known as life review has recently received support in older adult trauma survivors in a single case design (Maercker, in press). Life review is a directed therapy of reminiscence, in which a therapist helps the patient to organize and evaluate memories of the consecutive stages of life. Integration of the traumatic event into discussion of the stages of life may show potential as a therapeutic tool.
In summary, the impact and effects of trauma can be long lasting, and indeed PTSD does occur in older adults.
The symptom course is variable, with some being continuously troubled, others having waxing and waning of symptoms across the lifespan, and some remaining symptom-free (Zeiss & Dickman, 1989). Trauma-related distress may be less intense in some circumstances, but does resemble PTSD in younger adults. Assessment needs to be comprehensive and, when special circumstances, like cognitive impairment, are present, requires special adaptation, such as observation and collateral reports. Empirically based treatments for older adults with trauma-related distress are critically needed. Need Assignment Help?