Almost 90% of older adults have experienced at least one traumatic event in their lifetime, yet posttraumatic stress disorder (PTSD) continues to be overlooked in older patients. Clinicians should routinely assess for symptoms of PTSD, as a missed diagnosis can lead to poor health outcomes including increased suicide risk. In this episode, we will shed some light on assessing and treating PTSD in the older patient. 

Published On: 7/24/2023

Duration: 12 minutes, 27 seconds

Transcript: 

Dr. Aziz: Almost 90% of older adults have experienced at least one traumatic event in their lifetime, yet posttraumatic stress disorder (PTSD) continues to be overlooked in older patients. Clinicians should routinely assess for symptoms of PTSD, as a missed diagnosis can lead to poor health outcomes including increased suicide risk. In this episode, we will shed some light on assessing and treating PTSD in the older patient. 

Welcome to The Carlat Psychiatry Podcast.

This is another episode from the geriatric psychiatry team. 

I’m Rehan Aziz, an associate professor of psychiatry and neurology at  Hackensack-Meridian School of Medicine. I am also the associate program director for geriatric psychiatry at Jersey Shore University Medical Center

Prabhjot Gill: And I’m Prabhjot Gill. I am the podcast coordinator at Carlat publishing and I am entering graduate school very soon to pursue my doctorate in psychology. 

Dr. Aziz: We have some exciting news for you! You can now receive CME credit for listening to this episode and all new episodes going forward on this feed. Follow the Podcast CME Subscription link in the show notes to get access to the CME post-test for this episode and future episodes.

Prabhjot Gill: Dr. Aziz, can you begin by talking about what the prevalence of PTSD looks like for older adults? 

Dr. Aziz: Absolutely. While most patients with trauma histories do not develop PTSD, the prevalence of PTSD in late life is between 1% and 3.5%, making it a relatively common disorder.

Prabhjot Gill: And how does PTSD present in older adults?

Dr. Aziz: In older adults, PTSD can be chronic, and symptoms may first appear in childhood or adulthood, or they may present decades after the initial trauma. For example, many Vietnam and Korean War veterans continue to experience PTSD even 40 to 50 years after they experienced combat trauma, while some veterans develop PTSD for the first time in late-life. Symptoms may flare in late life due to triggers, such as retirement, especially in people who coped through immersing themselves in work.

Prabhjot Gill: What are some of the common risk factors?

Dr. Aziz: Advancing age has a mixed effect on vulnerability to trauma. On the one hand, there’s greater susceptibility to PTSD because of physical and cognitive deterioration, decreased social support, and reduced financial resources to replace material losses. On the other hand, older adults have several protective factors. Older adults may demonstrate resilience when faced with traumatic events, as they’ve had a lifetime of learning to cope with prior traumas.

Prabhjot Gill: You mentioned that there is a greater risk due to physical and cognitive deterioration. Does this mean older adults are also at a higher risk for medically induced PTSD?

Dr. Aziz: Definitely. Older adults are at higher risk for medically induced PTSD because of their overall declining health and increased number of medical illnesses. It can be caused by delirium or greater exposure to medical traumas, like longer ICU stays or longer duration of cancer treatment. Other contributing causes are pain, isolation, and loss of function. I recommend screening for medically-induced PTSD in your older patients who’ve suffered from any of the following: cancer, multiple sclerosis, falls, heart attacks, cardiac surgery, ICU admissions, or long-term care stays. 

Prabhjot Gill: Are there any comorbidities that often co-occur with PTSD in older adults?

Dr. Aziz: There are two main comorbidities: psychiatric and medical. So, when you're working with patients who have PTSD, it's really important to ask about any other mental health issues they might be experiencing. In fact, about 83% of the time, patients with PTSD have at least one other psychiatric illness. In older adults, PTSD often co-occurs with mood and anxiety disorders, like major depressive disorder (which affects 50% to 70% of patients) or generalized anxiety disorder (which affects 15% to 45% of patients).

Prabhjot Gill: Wow, that's interesting. So what about medical comorbidities? What medical problems do older patients with PTSD experience?

Dr. Aziz: So, when someone experiences PTSD, their body can go into overdrive and become hyper aroused, which can lead to elevated resting heart rate and blood pressure. PTSD has actually been linked to a 24% to 46% increased risk of hypertension. This is a major concern in older adults, and something to keep an eye on  due to the potential for strokes and cardiovascular disease. Now, even if someone gets treated for their PTSD, it doesn't completely eliminate their risk of developing hypertension, but it can reduce it.

Prabhjot Gill: How often do clinicians see older adults bring up concerns for PTSD on their own during primary care checkups? 

Dr. Aziz: Not too often. It is important to proactively ask your older patients about trauma, as they may not spontaneously bring it up, especially if the trauma occurred a long time ago. Many older adults might also somaticize their symptoms and present with nonspecific complaints of fatigue, GI distress, or pain, particularly in primary care settings. Last, keep in mind that cognitive impairment can influence a patient’s ability to interpret or express symptoms.

Prabhjot Gill: Are there any specific assessments you recommend using when screening for PTSD in older adults?

Dr. Aziz: Yes, the gold standard is the Clinician-Administered PTSD Scale (CAPS) but it’s primarily used in research. For clinical use, I recommend either the PTSD Checklist for DSM-5 (PCL-5) or the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5). The PCL-5 is filled out by the patient and can be completed in the waiting room. It’s 20 questions long and only takes 5 to 10 minutes. 

Prabhjot Gill: Ok, so we have discussed the epidemiology, comorbidities, risk factors, and screening tools, but what about treatment? How do medications and psychotherapy compare in effectiveness when treating PTSD in older adults?

Dr. Aziz: When it comes to treating PTSD in older adults, therapy is often more effective than medications, and trauma-focused psychotherapy is considered the best option. Cognitive behavioral therapy (CBT) is another effective form of treatment. Despite potential barriers like medical, psychosocial, and cognitive issues, older adults can still benefit from therapy. However, if a patient has a comorbid substance use disorder (SUD), it's important to address that before starting trauma-focused therapy. 

The VA/DOD Guidelines recommend manualized trauma-focused psychotherapies that have a primary component of exposure and cognitive restructuring The most strongly recommended therapies typically consist of 8 to 16 sessions and include prolonged exposure, cognitive processing therapy, eye movement desensitization and reprocessing, brief eclectic psychotherapy, narrative exposure therapy, and written narrative exposure.

Prabhjot Gill: If therapy is the most effective treatment, when should medications be used?

Dr. Aziz: Medications can be complementary with therapy, and patients may require stabilization on medications before they can tolerate trauma-focused therapy. Medications are also preferred in patients who choose not to engage in or are unable to access trauma-focused psychotherapy. 

Prabhjot Gill: What types of medications are recommended for late life PTSD?

Dr. Aziz: When it comes to medications for treating late-life PTSD, there's not a lot of data available. The VA/DOD 2017 PTSD Practice Guidelines suggest using certain antidepressants like sertraline, paroxetine, fluoxetine, or venlafaxine as a first-line treatment. However, among these medications, paroxetine and fluoxetine are less frequently used in older adults because of their side effect profiles. They have a higher risk of drug interactions and fluoxetine's long half-life and paroxetine's anticholinergic effects make them less favorable choices. 

For PTSD-related nightmares, prazosin and clonidine can be used, but they may not be suitable for older adults because of concerns about low blood pressure and falls. Antipsychotics, benzodiazepines, MAOIs, topiramate, and tricyclic antidepressants are not recommended for treating PTSD in older adults due to their poor side effect profiles.

Prabhjot Gill: There you have it. Remember, PTSD is not uncommon in older adults and is best treated with a combination of trauma-focused psychotherapy and antidepressant medications. Make sure to proactively ask your older patients about trauma as they are more susceptible to  psychiatric and medical comorbidities.

Dr. Aziz: The newsletter clinical update is available for subscribers to read in The Carlat Geriatric Psychiatry Report. Hopefully, people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.

Prabhjot Gill: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry. 

Dr. Aziz: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information that you can trust. 

Prabhjot Gill: And don’t forget, you can now earn CME credits for listening to our podcasts. Just click the link in the description to access the CME post-test for this episode.

As always, thanks for listening and have a great day!

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.