Monday, January 18, 2010

Post Traumatic Stress in Late Life


Over the past year, I have had several 80+ patients, combat veterans of WWII, who have had very significant symptoms of post-traumatic stress. These symptoms included nightmares and flashbacks related to their military service almost over 60 years ago. In several cases, the patient told me of these longstanding symptoms after I had cared for them for several years. In another case, I learned of these symptoms from a spouse.

I am not so sure why it did not occur me to ask about post-traumatic stress. Without thinking about it much, I guess I just presumed that if they had no previously documented history of post-traumatic stress symptoms it would not present itself decades later. As I have thought about this, I have concluded that my view here was incorrect, and that I needed to be more alert to the possibility of post-traumatic stress in my older Veteran patients.

A very important study in the December issue of the Journal of the American Geriatrics Society , led by Dr. Lance Rintamaki, demonstrates the importance of thinking about post traumatic stress in older persons. They surveyed 157 WWII Veterans who had been prisoners of war. Over 60 years after the war, many of these Veterans had significant symptoms of post-traumatic stress, including flashbacks, insomnia, and nightmares. A signficant number (17%) met the diagnostic criteria for post traumatic stress disorder. However, the most notable finding, is that these symptoms of post-traumatic stress often got worse after retirement. Over half of the Veterans reported that they think more about their POW experience since they retired, and over 40% stated that their recollections have become more distressing since they retired.

One can not know for sure if these results have implications for our older patients who have had not had military traumas in early life. By examining this issue in POWs, this study focused on a quite severe trauma. (Many of the subjects were tortured or witnessed executions). Still, I think it is likely that this study does have more generalizable relevance. Many of our older patients have had suffered severe physical or psychological trauma earlier life. I can't think of any reason why the mechanisms that cause late life resurgence of military stress would be any different for civilian stress.

What might these mechanisms be? In an outstanding, must read editorial, Dr. Jules Rosen suggests that less structured time in retirement, coupled with some of the stressful events of aging, such as loss of spouse or friends and declining physicial health, could precipitate the reemergence of post-traumatic stress decades after the actual event. I think it may also be the case that declining cognitive function could inhibit the ability of the older brain to suppress traumatic memories.

Dr. Rosen's editorial gives some excellent advice about the recognition and management of post-traumatic stress in late life. As with my patients, many will be reluctant to report symptoms of post-traumatic stress. You must ask. Many patients with flashbacks and nightmares may just request sleeping pills. It is important to be alert to the possibility of post-traumatic as one of the causes of sleep disturbance in the elderly. Also, some with post-traumatic stress may self-medicate, and the new development of substance and alcohol disorders in the elderly should alert one to the possibility of post-traumatic stress.

Dr. Rosen notes that in many cases, a sympathetic physician who assures their patient that late life symptoms of post-traumatic stress are common and not a sign of weakness may be the only therapy a patient needs. Patients whose symptoms impair daily functioning or lead to alcohol or substance disorders should generally be referred to a specialist.

Dr. Rintamaki and colleagues note that, "clinicians working with individuals who experienced significant trauma in the past must be mindful of these phenomena and their tendency to increase in later in life. Despite the signficance of prior trauma, clinicians tend to focus on physical health while overlooking psychosocial problems and their effect on patients' lives, particularly when working with elderly patients."

This paper will make me more alert to the possibility that severe early life trauma may be causing significant distress in my older patients.

3 comments:

Janice said...

Your post reminded me of a patient over ten years ago. We had a fire alarm drill and as per protocol all the rooms' doors were shut. When it was over and I opened the door, the patient was not in his bed. I looked in the bathroom and he was there cowering in a corner saying "Fire in the hold". It turned out he was a vetern of WWII who had been on a ship that caught fire. It was frightening for him and I worry about that now with each fire drill, but I didn't realize until a couple of years ago it was most likely PTSD and should have been addressed more completely. Could it be as well that as we get older and tend to remember things of long ago a little more easily than the present that the traumatic things are remembered easily and affect us as well?

Dan Matlock said...

I remember a WWII vet who I asked about nightmares as part of a required Denver VA quality measure for PTSD. He proceeded into a long story about a nightmare he had had every night since WWII where he relived the experience of reaching into the chamber of a turret gunner to give a guy his final Morphine as the B-17 fled to the base after being hit.

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