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Psychological Trauma among Older Adults

Introduction

Psychological trauma is a type of injury to the mind, which develops after an extremely distressing or life threating event. The repercussions of trauma take a unique form within the geriatric community, as there are differences in prevalence, symptom presentation, assessments, risk and protective factors.

Prevalence of Trauma

Research indicates that 90% of older adults have experienced a traumatic event in their lifetime. However, the number of older adults that present with overt symptoms of PTSD is much lower compared to children and adults. (Creamer & Parslow, 2008; Kuwert, Pietrzak, & Glaesmer, 2013; Ogle, Rubin, & Siegler, 2013). In fact in a sample of older adults about 65.5% of older adult men and 50.9% of older adult women experienced lifetime trauma exposure (Creamer & Parslow, 2008). However, the 12-month prevalence of Post Traumatic Stress Disorder (PTSD) was only 2% of older adult men and 3.2% of older adult women fulfilled diagnostic criteria for PTSD (Creamer & Parslow, 2008). Therefore, paradoxically while the percentage of lifetime trauma exposure increased with age for both men and women, the 12-month prevalence rate for PTSD symptoms decreased (Creamer & Parslow, 2008).

Several explanations have been put forth to explain the discrepancy between increased prevalence of trauma, but decreased prevalence of symptom presentation within the geriatric population (Creamer & Parslow, 2008). Firstly, it is believed that there is a cohort effect, in that many older adults experience a decline in cognitions, memory and overall executive functioning. This decline may affect the accuracy of their reporting style and the importance/significance of the event (Creamer & Parslow, 2008). Secondly, low prevalence of PTSD symptoms among older adults may be due to the natural process of healing, recovery, and effective coping (Creamer & Parslow, 2008). In other words there is positive relationship with increasing age and increased effective coping strategies.

Perception of Psychological Trauma

In western cultures psychological trauma is defined as an incident in which an individual is open to “exposure to actual or threatened death, serious injury, or sexual violence…” (American Psychiatric Association, 2013, p. 271). This definition is generalized to children, adolescence, adults, and older adults (American Psychiatric Association, 2013). Trauma can be experienced in several different ways including directly undergoing the traumatic incident such as a car accident, natural disaster, rape, abuse, or military combat (American Psychiatric Association, 2013). Other ways in which individuals may experience trauma include viewing traumatic events as they occurs to others, learning that a close family member or friend experienced a traumatic event that may or did result in death, or being continuously subjected to unfavorable details of traumatic events (American Psychiatric Association, 2013). Experiencing such events may result in severe symptoms that evoke distress and affect the individual’s ability to function within their lives. It is important to be aware that each cultural group perceives and understands trauma differently, the definition provided above is primarily the perception of trauma in countries that use the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)or the International Statistical Classification of Diseases and Related Health Problems (ICD-10).

Symptom Presentation

The DSM-5 defines Post Traumatic Stress Disorder based on the following criteria: intrusion symptoms, avoidance of stimuli or triggers related to the trauma, negative mood alterations, and finally the disturbance must result in extreme distress and must impair functioning (American Psychiatric Association, 2013). Research highlights that in addition to the DSM-5 diagnosis of Post Traumatic Stress Disorder, the majority of older adults will experience other symptoms (Dulin & Passmore, 2010; "The Late-Life Psychological Effects of Childhood Abuse," 2003; Petkus, Gum, King-Kallimanis, & Wetherell, 2009). Firstly older adults who have been exposed to trauma may have symptoms of chronic depression and anxiety (Dulin & Passmore, 2010; "The Late-Life Psychological Effects of Childhood Abuse," 2003; Petkus et al., 2009). Highlighting that majority of individuals do not have one disorder or diagnosis but that many diagnosis overlap and intersect with one another. Other patterns among older adults who have faced trauma include the tendency to avoid heightened emotional arousal and have difficulty regulating these affective states when they occur. ("The Late-Life Psychological Effects of Childhood Abuse," 2003).

Another common symptom presentation amongst older adults who have experienced trauma is the process of somatization (Petkus et al., 2009). Somatization is the progression whereby an individual may be experiencing extreme stress and anxiety, expressed in the form of physical pain (American Psychiatric Association, 2013). Many older adults report bodily pains, stomachaches, or other health concerns, that may be better explained by somatization (Petkus et al., 2009). Another way in which older adults may express the effects of trauma exposure are through decline in cognitions ("The Late-Life Psychological Effects of Childhood Abuse," 2003). Cognitive decline amongst older adults may be misdiagnosed as dementia. Leslie Kiloh published his 1961 paper in which he used several vignette cases of older adults who were suffering from cognitive decline that looked like dementia, but in fact were suffering from severe depression (Snowdon, 2011). From these cases he coined the term of pseudodementia, which is the condition where depression mimics the symptoms of dementia (Snowdon, 2011). Therefore, it is important to understand the differences and similarities between the two conditions, in order to disentangle diagnoses.

Psychological Assessments

There is a plethora of psychological assessments evaluating the number of traumatic events individuals have experienced and the symptoms presentations that precede the event. However, these psychological assessments are not necessarily normed for the geriatric population (Cook, Elhai, & Areán, 2005). Older adults who have experienced either isolated trauma or lifetime trauma are also dealing with other symptoms compared to the general adult population (Cook et al., 2005). Older adults normally experience higher rates of declines in cognitions, executive functioning, memory, and a possibly misinterpret psychological symptoms as somatic pains (Cook et al., 2005). A common PTSD assessment, the Post Traumatic Stress Disorder Checklist (PCL), has been evaluated as an appropriate measure for older adults. The PCL is a 17-item assessment that utilizes a 5-point Likert scale, 1 meaning not at all to 5 meaning extremely (Cook et al., 2005). The researchers discovered adequate reliability with a score of internal consistency at .85 (Cook et al., 2005). This assessment has proven to be advantageous concerning generalizing the results to the older adult population because the sample reported to be representative of the population (Cook et al., 2005). Currently the only other report of reliable trauma assessment for older adults in addition to the PCL is the Self Rating Inventory for Post Traumatic Stress Disorder (SRIP) (van Zelst & Beekman, 2012). The SRIP is a survey consisting of 47 items assessing level of numbing, intrusion symptoms, avoidance behaviors and sleep difficulties (van Zelst & Beekman, 2012). Other widely used instruments assessing trauma that are not normed with the older adults are the Brief Trauma Questionnaire (BTQ), Evaluation of Lifetime Stressors (ELS), Life Events Checklist DSM-5 (LEC), Stressful Life Events Screening Questionnaire (SLESQ), and the Traumatic Life Events Questionnaire (TLEQ) to name a few. These questionnaires focus upon if the individual has or has not experienced an event that is labeled as a traumatic. In addition the items also follow a general outline of the DSM-5 definition of PTSD.

Risk Factors

Older adults who are exposed to trauma and who tend to have a poor social support, limited financial support, deprived health status, and evidence of intergenerational trauma may be at a high risk for experiencing psychological symptoms of distress (Acierno, Ruggiero, Kilpatrick, Resnick, & Galea, 2006; Joshi, Kumar, & Avasthi, 2003; Krause, 2004; Waretini-Karena, 2014). Amongst the research the relationship among trauma exposure, emotional support, and life satisfaction in three cohorts of the geriatric population has also been examined (Krause, 2004). It was found that greater exposure to lifetime trauma was associated with a decreased life satisfaction. Additionally, older adults who received more emotional support throughout their lives tended have higher life satisfaction (Krause, 2004). The trend among the data showed that emotional support reduced the association between lifetime trauma and decreased life satisfaction by 87%, thus, highlighting the importance of having social support, particularly for those who have experienced trauma (Krause, 2004).

Another major risk factor noted by the researchers for older adults was those who were financially unstable and were considered as living in low socioeconomic status (Acierno et al., 2006). A multitude of older adults have a fixed income and are not prepared for situations that require more funds (Acierno et al., 2006). These financial constraints may act as a barrier to receiving the proper resources and psychological services individuals require when exposed to trauma. In addition to financial insatiability perceived or actual poor health status is considered as a risk factor for older adults in regards to increased in symptomology (Joshi et al., 2003). Approximately 88.9% of older adults disclosed that they had an illness (Joshi et al., 2003). Of the sample 87.5% had severe disabilities and about 66% of the older adults reported physical and psychological distress. Other researchers have noted that increased exposure to traumatic events also increased the rate and risk of cardiovascular disease and other poor health outcomes (Kuwert et al., 2013). These barriers to health care and perceived or actual poor health status may also increase the individuals sense of hopelessness, anxiety, and depression (Acierno et al., 2006).

Intergenerational trauma is the notion that those who have ancestors whom have experienced trauma they may then be at a higher risk for experiencing psychological symptoms (Waretini-Karena, 2014). For example groups of individuals who have extensive historical trauma have been shown to experience a reoccurring cycle of poverty, trauma, mood disorders, other psychopathologies, increased violence, and increased substance use (Waretini-Karena, 2014). Thus, older adults who are part of groups who have a history of trauma are more at risk to experience more trauma and other ailments (Waretini-Karena, 2014). Recent research suggests that there is a genetic component to intergenerational trauma and it has the ability to alter some fundamental brain structures (Yehuda et al., 2014). Therefore there may be an increased risk of psychological symptoms for those within this group.

Protective factors

When exposed to trauma the results may be detrimental and include increased psychopathology. However, there are protective factors in which an individual may utilize to cope more effectively. For the geriatric population some protective factors include social support, religion, prayer, and their age (Acierno et al., 2006; Beattie, Pachana, & Franklin, 2010; Chatters et al., 2008; Krause, 2009; Moberg, 2005).

Social support and emotional support from family and/or the community is an important protective factor for members of the geriatric community (Beattie et al., 2010; Krause, 2004). Lack of emotional support has been associated with decreased life satisfaction when one has experienced a trauma (Krause, 2004). Thus emotional and social support act as protective factors and enhanced coping skills following exposure to a traumatic event.

Other protective factors include religiosity; service attendance, prayer, and spirituality, which have all been noted within the research to play a buffering function for those who are exposed to trauma (Chatters et al., 2008; Krause, 2009; Moberg, 2005). Service attendance was significantly related to less symptomology for those who had experienced trauma or other psychopathologies (Chatters et al., 2008). The researchers highlight that service attendance is another form of social support from the community and is viewed as a safe and effective coping skill (Chatters et al., 2008). Prayer is another stress-buffering phenomeon among older adults in that it provides a sense of hope, positive feelings, and positve thoughts (Krause, 2009). The Krause (2009) study established the important function prayer plays for older adults who experieced childhood trauam compared to those who did not use prayer as a source of coping. Overall, in addition to religiousity the research highlights that spirituality was associated with increased life satisfaction, well-being, and physical health (Moberg, 2005).

Lastly, age was noted as a protective factor against traumatic symptomology when being exposed to trauma (Acierno et al., 2006). Older adults then to report less symptomology when exposed to trauma, thus, highlighting that their age may play a protective factor. Older adults may have more effective ways of coping and are thus more prepared for the effects (Creamer & Parslow, 2008).

Conclusion

In general little psychological research and attention has been given to the older adult community, however they are a growing population. It is estimated by 2030 that the older adult population will consist of about 71 million, which is a 19.6% increase (Control & Prevention, 2003). Thus, increasing the literature and understanding some of the basic information such as prevalence, symptom presentation, and risk/protective factors will assist in regards to better care for this population. This entry is specific to psychological symptoms of trauma, however it helps provide the basic foundation for other psychological disorders and symptoms older adults may be experiencing.

References

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