PTSD: National Center for PTSD

Posttraumatic Stress Symptoms among Older Adults: A Review

Anica Pless Kaiser, PhD, Jennifer Schuster Wachen, PhD, Carrie Potter, BA, Jennifer Moye, PhD, & Eve Davison, PhD, with the Stress, Health, and Aging Research Program (SHARP)

Demographic patterns across the globe are changing, and older people constitute a growing proportion of the population. Although many older adults enjoy well-being and satisfaction in later years, some experience psychiatric and mental health difficulties. A topic of particular significance to professionals working with older adults, both Veteran and non-Veteran, is the understanding, assessment, and treatment of posttraumatic stress, as posttraumatic stress symptoms can emerge or re-emerge late in life.

Age-related factors can interact with psychiatric symptoms and carry implications for research and clinical care. For clinicians, see PTSD Assessment and Treatment in Older Adults for recommendations.

Posttraumatic Stress Disorder (PTSD) and Aging

There are a number of reasons why symptoms of PTSD can increase with age. Both chronological age (cohort effects of birth-year groupings) and developmental processes of aging impact the experience of PTSD. For instance:

• Role changes and functional losses may make coping with memories of earlier trauma more challenging for the older adult. Such stressors include retirement, increased health problems, decreased sensory abilities, reduced income, loss of loved ones, decreased social support, cognitive impairment, and other stressors and causes of functional decline (1).
• To manage posttraumatic stress symptoms in early and mid-life, individuals may engage in avoidance-based coping strategies (such as drinking alcohol or over-committing oneself to work) that are less available or effective as they get older.
• At the same time, adaptation and resilience developed over a lifetime can provide a rich reservoir of coping resources upon which to draw.

Continuing Education

PTSD and Aging

This course reviews the incidence and prevalence of PTSD in older adults and describes the role of aging and cognitive impairment among older patients.

Prevalence of Trauma Exposure in Older Adults

In the general population, approximately 70% to 90% of adults aged 65 and up have been exposed to at least one potentially traumatic event during their lifetime (2). Gender differences exist in regard to trauma exposure. Based on a community sample of older adults, about 70% of older men reported lifetime exposure to trauma; older women reported a lower rate, around 41% (3). This research attributed the gender differential to combat exposure (3).

Prevalence of PTSD in older adults

Although the literature on PTSD in older adults is growing, there is still a dearth of studies examining trauma among geriatric populations. It is, therefore, possible that current estimates may under-represent the prevalence of PTSD in older adults (4).

• The prevalence of current PTSD in adults over 60 ranges from 1.5% to 4%, as reported in several community studies (5).
• The lifetime prevalence of PTSD in the general adult population is about 8% (6), with point estimates ranging from 2% to 17% among US military samples (7).
• Although many older adults do not meet full criteria for a PTSD diagnosis, they may still exhibit some symptoms. The percentage of older adults with sub-clinical levels of PTSD symptoms ranges from 7% to 15% (8-10).

Trauma and PTSD among older Veterans

Much of the research on PTSD in older adults has been conducted with older Veterans. For many older Veterans, especially combat Veterans, memories of wartime experiences can be upsetting long after completion of military service. Compared to the general population, older Veterans have higher rates of both lifetime trauma exposure and PTSD symptomatology due to combat and warzone-related exposures.

• Among older male Veterans, the prevalence of lifetime exposure to traumatic events is approximately 85% (11).
• In a study of older male combat Veterans and ex-POWs of WWII and Korea (median age = 71), the lifetime prevalence of PTSD was 53% and the prevalence of current PTSD was 29% (12).

Estimates differ depending on the population being assessed; among psychiatric treatment-seeking older Veterans, PTSD estimates are found to range from 37% to 80% (13). Richardson et al. (2010) provided a thorough discussion of reasons for discrepant prevalence estimates, some of which include measurement strategies, sampling, inclusion/exclusion of DSM-IV impairment criterion, differences in time of exposure, assessment intervals, recall bias, and differences in combat experiences (7).

Trauma and PTSD among older women in the community

Although there is a growing body of research examining the effects of traumatic events more frequently experienced by women, such as rape and domestic violence, older women have often been underrepresented in previous studies. More recent research has assessed the longer-term, lifecourse consequences of such interpersonal traumas, as well as the prevalence and nature of PTSD in older women. For example:

• Among a community sample of older women (average age = 70), 72% had experienced at least one type of interpersonal trauma during their lives (e.g., childhood physical or sexual abuse; rape) and higher rates of interpersonal trauma were related to increased psychopathology (14).
• In comparison, approximately 44% to 55% of women of all ages report having experienced lifetime interpersonal trauma (15, 16).
• One type of interpersonal trauma especially relevant for older women is intimate partner violence. Middle-aged and older women (ages 45-70) are more likely than younger women to have experienced intimate partner violence for a longer time span and to have remained in a violent relationship (17).

Findings should be considered within the context of cohort effects and gender role patterns. It is important to recognize that the role of women in multiple domains has - and continues to - change over time. For example, there are increasing numbers of women participating in the general labor force and the military than in the past. These changes may affect both the prevalence of interpersonal trauma and psychological sequelae in current and future cohorts of older women.

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Differences in PTSD Between Older and Younger Adults

The available research suggests that experiences of traumatic events and subsequent reactions may differ between younger and older adults (and Veterans). There is also evidence to suggest that age at trauma exposure may play a role in subsequent symptomatology.

Prevalence and symptoms

PTSD is less prevalent in older Veterans than in younger Veterans. Older Veterans report more somatic complaints such as appetite, sleep, or memory problems and fewer PTSD symptoms (especially arousal and numbing symptoms); they also report less depression, hostility, and guilt than younger Veterans (18, 19). Older adults who experienced trauma later in life report more avoidance, sleep problems, and hyperarousal than younger adults (20). Some of the differences in symptom presentation may be partially explained by selective mortality. For example, research in Veteran samples shows that some Veterans with more severe symptoms died before reaching older age (21).

Age and cohort factors

Cohort factors also explain some differences. Older adults may be less likely to identify problems from a psychological framework. For example, older Veterans may attribute problems to more proximal issues and to the aging process, and not relate symptoms to events that occurred long ago (22). It is also possible that trauma history and posttraumatic stress symptoms are often overlooked in older adults because PTSD is a relatively new disorder within the diagnostic system, so older adults who were exposed to traumatic events earlier in life and had symptoms in the aftermath of exposure were not identified (23).

PTSD and co-occurring conditions

In general, PTSD often co-occurs with physical or other psychiatric conditions. Of particular concern are: substance use disorders, major depression, post-concussive symptoms (mild TBI), and chronic pain (24). Furthermore, aging is associated with increased risk of physical and mental health complications. Thus, among older adults, there are several major areas in which comorbidity with PTSD is commonly observed:

• Medical problems: In a large sample of older adults, greater lifetime trauma exposure was related to poorer self-rated health, more chronic health problems, and more functional difficulties (25). Other studies reported that PTSD was associated with the occurrence of multiple medical problems such as arterial disorders, gastrointestinal complaints, dermatological problems, and musculoskeletal disorders among older ex-POWs and combat Veterans (26, 27).
• Psychiatric problems: Among older adults and older Veterans, PTSD is associated with lower psychosocial functioning and higher rates of other mental health problems, such as mood disorders, other anxiety disorders, and substance use problems (28-30).
• Cognitive problems: Older adults and Veterans with dementia may exhibit more PTSD symptoms. Conversely, PTSD may be a risk factor for dementia (31, 32). Data from a large VA cohort study indicate that individuals diagnosed with PTSD were almost twice as likely to develop dementia, when compared to those not diagnosed with PTSD (33).

Late-Onset Stress Symptomatology (LOSS)

Researchers at VA Boston are looking into a possible late-life process that may be a consequence of combat exposure earlier in life. This phenomenon has been termed Late-Onset Stress Symptomatology (LOSS) and refers to the development of increased thoughts and reminiscences about, and emotional responses to, one's wartime experiences. This process occurs in the context of losses associated with aging, such as retirement, loss of loved ones, and increased health problems, and can develop in Veterans who have otherwise functioned well throughout their adult lives (34, 35).

In contrast to PTSD, LOSS is less associated with clinically significant distress and is more related to normative life stressors (such as concerns about retirement) and to older Veterans’ search for meaning and growth in late life. LOSS may be more related to subthreshold or partial PTSD than to clinically significant PTSD (36). Although LOSS has only been studied with combat Veterans, these concepts may also apply to the general population of aging survivors of early life trauma.

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Other Resources on Aging and PTSD

Educational Booklet

Understanding PTSD and Aging

Download and share this booklet with your clients. The challenges faced later in life as a result of PTSD are discussed including effective treatment. English | en Español (PDF)

Author Note: SHARP is co-directed by Avron Spiro, PhD and Eve Davison, PhD, and is coordinated by Anica Pless Kaiser, PhD. SHARP is supported by the Behavioral Science Division of the VA National Center for PTSD and the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System.

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References

1. Cook, J. M. (2001). Post-traumatic stress disorder in older adults. PTSD Research Quarterly, 12, 1-7.
2. Norris, F. H. (1992). Epidemiology of trauma: Frequency and impact of different potentially traumatic events on different demographic groups. Journal of Consulting and Clinical Psychology, 60, 409-418.
3. Creamer, M. C., & Parslow, R. A. (2008). Trauma exposure and posttraumatic stress disorder in the elderly: A community prevalence study. American Journal of Geriatric Psychiatry, 16, 853-856.
4. Cook, J. M., & Niederehe, G. (2007). Trauma in older adults. In M. J. Friedman, T. M. Keane & P. A. Resick (Eds.), Handbook of PTSD: Science and practice (pp. 252-276). New York, NY: Guilford Press.
5. Acierno, R., Lawyer, S. R., Rheingold, A., Kilpatrick, D. G., Resnick, H. S., & Saunders, B. E. (2007). Current psychopathology in previously assaulted older adults. Journal of Interpersonal Violence, 22, 250-258.
6. Kessler, R. C., Berglund, P. A., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.
7. Richardson, L., Frueh, C., & Acierno, R. (2010). Prevalence estimates of combat-related post-traumatic stress disorder: Critical review. Australian and New Zealand Journal of Psychiatry, 44, 4-19.
8. Glaesmer, H., Gunzelmann, T., Braehler, E., Forstmeier, S., & Maercker, A. (2010). Traumatic experiences and post-traumatic stress disorder among elderly Germans: Results of a representative population-based survey. International Psychogeriatrics, 22(4), 661-670.
9. Schnurr, P. P., Spiro, A., Vielhauer, M. J., Findler, M. N., & Hamblen, J. L. (2002). Trauma in the lives of older men: Findings from the Normative Aging Study. Journal of Clinical Geropsychology, 8, 175-187.
10. van Zelst, W. H., de Beurs, E., Beekman, A. T. F., Deeg, D. J. H., & van Dyck, R. (2003). Prevalence and risk factors of posttraumatic stress disorder in older adults. Psychotherapy and Psychosomatics, 72, 333-342.
11. Hankin, C. S., Spiro, A., Miller, D. R., & Kazis, L. (1999). Mental disorders and mental health treatment among U.S. Department of Veterans Affairs outpatients: The Veterans Health Study. American Journal of Psychiatry, 156, 1924-1930.
12. Engdahl, B., Dikel, T. N., Eberly, R., & Blank, A., Jr. (1997). Posttraumatic stress disorder in a community group of former prisoners of war: A normative response to severe trauma. American Journal of Psychiatry, 154, 1576-1581.
13. Blake, D., Keane, T. M., Wine, P. R., Mora, C., Taylor, K. L., & Lyons, J. A. (1990). Prevalence of PTSD symptoms in combat Veterans seeking medical treatment. Journal of Traumatic Stress, 3, 15-27.
14. Higgins, A. B., & Follette, V. M. (2002). Frequency and impact of interpersonal trauma in older women. Journal of Clinical Geropsychology, 8, 215-226.
15. Iverson, K. M., Dick, A., McLaughlin, K. A., Smith, B. N., Bell, M. E., Cook, N., Gerber, M. R., & Mitchell, K. S. (in press). Exposure to interpersonal violence and its associations with psychiatric morbidity in a U.S. national sample: A gender comparison. Psychology of Violence. doi: 10.1037/a0030956
16. Tjaden, P. & Thoennes, N. (1998, November). Prevalence, incidence, and consequences of violence against women: Findings from the National Violence Against Women Survey. Research in Brief, Washington, D.C.: US Department of Justice, National Institute of Justice Centers for Disease Control and Prevention.
17. Wilke, D. J., & Vinton, L. (2005). The nature and impact of domestic violence across age cohorts. Affilia, 20, 316-328.
18. Davidson, J. R., Kudler, H. S., Saunders, W. B., & Smith, R. D. (1990). Symptom and comorbidity patterns in World War II and Vietnam Veterans with posttraumatic stress disorder. Comprehensive Psychiatry, 31(2), 162-70.
19. Frueh, B. C., Buckley, T. C., Cusack, K. J., Kimble, M. O., Grubaugh, A. L., Turner, S. M., & Keane, T. M. (2004). Cognitive-behavioral treatment for PTSD among people with severe mental illness: A proposed treatment model. Journal of Psychiatric Practice, 10(1), 26-38.
20. Goenjian, A. K., Najarian, L. M., Pynoos, R. S., Steinberg, A. M., Manoukian, G., Tavosian, A., et al. (1994). Posttraumatic stress disorder in elderly and younger adults after the 1988 earthquake in Armenia. American Journal of Psychiatry, 151, 895-901.
21. Hyer, L., Walker, C., Swanson, G., & Sperr, S. (1992). Validation of PTSD measures for older combat Veterans. Journal of Clinical Psychology, 48, 579-588.
22. Owens, G. P., Baker, D. G., Kasckow, J., Ciesla, J. A., & Mohamed, S. (2005). Review of assessment and treatment of PTSD among elderly American armed forces Veterans. International Journal of Geriatric Psychiatry, 20, 1118-1130.
23. Thorp, S. R., Sones, H. M., & Cook, J. M. (2011). Posttraumatic stress disorder among older adults. In K. H. Sorocco & S. Lauderdale (Eds.), Cognitive Behavior Therapy with Older Adults: Innovations Across Care Settings. Springer Publishing Company.
24. U.S. Department of Veterans Affairs/Department of Defense. (2010). VA/DoD clinical practice guideline for management of post-traumatic stress. Retrieved from https://www.healthquality.va.gov/ptsd/ptsd-sum_2010a.pdf (PDF)
25. Krause, N., Shaw, B. A., & Cairney, J. (2004). A descriptive epidemiology of lifetime trauma and the physical health status of older adults. Psychology and Aging, 19(4), 637-648.
26. Kang, H., Bullman, T., & Taylor, J. (2006). Risk of selected cardiovascular diseases and posttraumatic stress disorder among former World War II prisoners of war. American Journal of Epidemiology, 16, 381-386.
27. Schnurr, P. P., Spiro, A., III, & Paris, A. H. (2000). Physician-diagnosed medical disorders in relation to PTSD symptoms in older male military Veterans. Health Psychology, 19(1), 91-97.
28. Averill, P. M., & Beck, J. G. (2000). Posttraumatic stress disorder in older adults: A conceptual review. Journal of Anxiety Disorders, 14(2), 133-156.
29. Durai, U. N. B., Chopra, M. P., Coakley, E., Llorente, M. D., Kirchner, J. E., Cook, J. M., & Levkoff, S. E. (2011). Exposure to trauma and posttraumatic stress disorder symptoms in older Veterans attending primary care: Comorbid conditions and self-rated health status. Journal of the American Geriatric Society, 59, 1087-1092.
30. Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2012). Psychiatric comorbidity of full and partial posttraumatic stress disorder among older adults in the United States: Results from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. American Journal of Geriatric Psychiatry, 20, 380-390.
31. Borson, S. (2010). Posttraumatic stress disorder and dementia: A lifelong cost of war? Journal of the American Geriatrics Society, 58(9), 1797-1798.
32. Qureshi S., Kimbrell, T., Pyne, J., Magruder, K. Hudson, T. Petersen, N., et al. (2010). Greater prevalence and incidence of dementia in older Veterans with posttraumatic stress disorder. Journal of the American Geriatrics Society, 58(9), 1627-1633.
33. Yaffe, K., Vittinghoff, E., Lindquist, K., Barnes, D., Covinsky, K., Neylan, T. et al. (2010). Post traumatic stress disorder and risk of dementia among US Veterans. Archives of General Psychiatry, 67, 608-613.
34. Davison, E. H., Pless, A. P., Gugliucci, M. R., King, L. A., King, D. W., Salgado, D. M., Spiro, A., III, & Bachrach, P. (2006). Late-life emergence of early-life trauma: The phenomenon of late-onset stress symptomatology among aging combat Veterans. Research on Aging, 28, 84-114.
35. King, L. A., King, D. W., Vickers, K., Davison, E. H., Spiro, A., III. (2007). Assessing late-onset stress symptomatology among aging male combat Veterans. Aging & Mental Health, 11, 175-191.
36. Potter, C. M., Pless Kaiser, A., King, L. A., King, D. W., Davison, E. H., Seligowski, A. V., Brady, C., & Spiro, A., III. (2012). Distinguishing late-onset stress symptomatology from posttraumatic stress disorder in older combat Veterans. Aging and Mental Health. doi: 10.1080/13607863.2012.717259

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