Geriatric psychiatrists can take a leadership role in providing optimal mental health services for older survivors of trauma. One way to accomplish this goal is through ongoing and routine education and training of interdisciplinary team members—such as primary care physicians, social workers, and frontline nursing staff—related to a possible association between past trauma, PTSD, cognitive impairment, and behavioral problems among older adults. Health care professionals who work with older trauma survivors usually lack the training or confidence to deal with the effects of trauma. Many are not prepared to recognize PTSD. Most have received no or little information about the effects of trauma in general, and the personal trauma history of the patients for whom they provide care. PTSD, when present, may be mistaken for more familiar problems encountered among older adults, such as depression, psychosis, and other anxiety disorders.
Improving recognition of PTSD among cognitively impaired older adults will involve training a range of health care professionals in taking trauma histories and assessing PTSD symptoms. If the older trauma survivor is able to provide relatively reliable answers, use of the primary care PTSD screen may be helpful (
+12). The probe for this screen is the question, "In your life, have you ever had any experiences that were so frightening, horrible, or upsetting that, in the past month, you (a) had nightmares about it or thought about it when you did not want to? (b) tried hard not to think about it or went out of your way to avoid situations that reminded you of it? (c) were constantly on guard, watchful, or easily startled? and (d) felt numb or detached from others, activities, or your surroundings?" (
+12).
People who respond "yes" to two or more of these questions should receive further assessment. If the geriatric health professional is unable to fully recognize the nuances of trauma-related distress, he or she should refer the patient for a diagnostic evaluation and appropriate recommendations for treatment interventions. If the patient is unable to provide reliable answers about traumatic exposure or psychiatric distress, psychiatrists can enlist family members in obtaining corroborating information from collateral sources, such as searching medical or military service records.
Psychiatry can also take a leadership role in training interdisciplinary staff and formal and informal caregivers in the clinical management of PTSD and related behavioral problems. A chief strategy may be the identification and subsequent removal, avoidance, or minimization of traumatic cues. For example, military attire and the presence of related symbols can be triggers for combat veterans, and these cues can be removed from a patient's environment (
+8).
Efficacious treatments for younger adults have often focused on repeated exposure to images or memories associated with the traumatic events (
+13). Because the physical health of older adults is often compromised and direct trauma processing can produce strong physiological effects—such as changes in heart rate and respiration—that may exacerbate existing health conditions, the benefit of using exposure in the treatment of older adults with PTSD has been questioned (
+14). For example, providing detailed accounts of traumatic life experiences through such methods as reminiscence or review therapies may be contraindicated for Holocaust survivors (
+15).
In addition, the patient's level of cognitive impairment is a key factor in the choice of management approaches. With minimal cognitive impairment, interventions may be similar to those used in PTSD treatments: psychoeducation about PTSD, help with more effective coping with symptoms, and improvements in social support. However, declining cognitive abilities may not support the use of self-management strategies that require retention of new information about PTSD and implementation of recommendations for effective coping. Nonpharmacologic interventions, such as providing social support or engaging in positive activities, may be effective in reducing problem behaviors (
+16). The geriatric psychiatrist can be an essential consultant to the primary care physician in the selection of appropriate type, dosage, frequency, and duration of medications available for symptom relief in conjunction with nonpharmacologic interventions as needed.
Geriatric psychiatrists are crucial in facilitating education by encouraging less blaming of the patient for cognitive or behavioral problems that might be explained by a history of trauma or PTSD. PTSD-related education for health professionals who work with cognitively impaired older adults may lead not only to an earlier identification of patients at risk but also to an increase in empathy for patients and the chance to provide professionals with an armamentarium of strategies for effective management. For example, helping health professionals recognize that a patient with both PTSD and cognitive impairment is aggressive partly because of traumatic experiences may make the staff less likely to take the behavior personally, potentially preventing unproductive responses. Psychiatrists can help educate staff in long-term-care settings and family members by providing inservices in which they review types of trauma and expected behaviors. Videotapes are available to facilitate these discussions (
+17,
+18).
PTSD-related education will be welcomed by health care providers who work in long-term-care settings if the administrators understand that related behavioral problems such as agitation often frustrate staff and lead to staff burnout. These behaviors require excessive staff time, are potentially dangerous, and direct attention away from other patients. The behaviors can also lead to premature placement in a long-term-care facility by family members.