Barton Palmer is a Staff Psychologist; Samantha Friend, Steve Huege, and James Lohr are Psychiatrists; Mallory Mulvaney is a Research Associate; all at the Center of Excellence for Stress and Mental Health, Veterans Affairs San Diego Healthcare System in California. Barton Palmer is a Professor-in- Residence, Steve Huege is a Clinical Professor, and James B. Lohr is Professor Emeritus; all at the Department of Psychiatry, University of California, San Diego in La Jolla. James Lohr is Professor Emeritus at the Department of Neurosciences, University of California, San Diego in La Jolla. Albaraa Badawood and Abdulaziz Almaghraby are Visiting Scholars; both at the Health Sciences International, University of California, San Diego in La Jolla. Correspondence: Barton Palmer (bpalmer@ucsd.edu)
Author disclosures The authors report no actual or potential conflicts of interest regarding this article.
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Current VA treatment guidelines recommend trauma-focused therapies, with the strongest evidence base for prolonged exposure (PE), cognitive processing therapy (CPT), and eye movement desensitization and reprocessing (EMDR) therapies.51Unfortunately, there is a dearth of published empirical data to evaluate the risks and effectiveness of these therapies not just in the context of Korean War veterans, but among any older adult with PTSD population.33,44,52,53 Recently, Thorp and colleagues published the first randomized controlled trial comparing PE to a relaxation training (RT) therapy among older veterans (83% were from the Vietnam era).54 RT is frequently used as a control condition for RCTs involving trauma-focused therapies. They found PE as well as RT to be well-tolerated by participants. They also found some evidence for superior efficacy in PE relative to RT, although the persistence of that improvement was less for self-rated vs clinician-rated symptoms. As the investigators noted, only 35% of those receiving PE exhibited clinically significant change, and 77% still met diagnostic criteria for PTSD, suggesting a persistence of symptom distress and need for further intervention research to advance treatment for PTSD in older adults.
There have been several excellent prior reviews discussing treatment of PTSD in older adults generally.10,43,44,52 These reviews have invariably expressed concern about the lack of sufficient empirical studies, but based on evidence from studies and case reports, there seems to be tentative support that trauma-focused therapies are acceptable and efficacious for use with older adults with PTSD. In their recent scoping review, Pless Kaiser and colleagues made several recommendations for trauma-focused therapy with older adults, including slow/careful pacing and use of compensatory aids for cognitive and sensory deficits.44 When cognitive impairment has exacerbated PTSD symptoms, they suggest therapists consider using an adapted form of CPT completed without a trauma narrative. For PE they recommend extending content across sessions and involving spouse or caregivers to assist with in vivo exposure and homework completion.44
Recent studies suggest that PTSD may be a risk factor for the later development of neurodegenerative disorders, and it is often during assessments for dementia that a revelation of PTSD occurs.10,43,47,55 Cognitive impairment may also be of relevance in deciding on the type of psychotherapy to be implemented, as it may have more adverse effects on the effectiveness of CPT than of exposure-based treatments (PE or EMDR). It may be useful to perform a cognitive assessment prior to initiation of a cognitive-based therapy, although extensive cognitive testing may not be practical or may be contraindicated because of fatigue. A brief screening tool such as the Montreal Cognitive Assessment or the Mini-Mental State Examinationmay be helpful.56, 57
Prolonged exposure has been reported by many clinicians to be effective in older adults with PTSD; however, due consideration should be given to the needs of individuals, as many have functioned for decades by suppressing memories. Cognitive impairment may be important, as cognitive resources may have been utilized to cope with earlier traumas, and there may be a recrudescence or exacerbation of PTSD symptoms as these resources are compromised. There may therefore be a reemergence of symptoms that are more amenable to an exposure-based treatment. Veterans with PTSD and dementia can present particularly difficult treatment dilemmas because with progression of the dementia, standard PTSD treatments, including exposure-based treatments, may cease to be viable. Instead, the focus of intervention may need to be on specific environmental triggers and behavioral approaches that may also be designed to aid caregivers.
Apart from the treatment needs for specific PTSD symptoms, the decades-long effects of poor sleep, irritability, hypervigilance, and dissociation also have social consequences for patients, including marital discord and divorce, and social and family isolation that should be addressed in therapy when appropriate. In addition, many Korean War veterans, like all veterans, sought postmilitary employment in professions that are associated with higher rates of exposure to psychological trauma, such as police or fire departments, and this may have an exacerbating effect on PTSD.58
