Research Highlights
THE AUSTRALIAN EXPERIENCE: POST-TRAUMATIC STRESS DISORDER IN THE ELDERLY

BY RICHARD BONWICK

During World War II (WWII) (1939-1945) over one million Australians served in various theatres of war. Many of them suffered privations and life threatening trauma of considerable magnitude. Those veterans of WWII who are still alive (some 300,000) are now in their eighth and ninth decades of life. Many remain psychologically scarred by their wartime experiences. A high percentage, perhaps 20-25%, still suffers symptoms of post-traumatic stress disorder (PTSD).

Until recently there has been limited awareness of PTSD in elderly war veterans. In Australia the experience of treating PTSD in veterans of the Vietnam War has created a growing awareness of combat-related PTSD in all age groups. Recognition of the magnitude of the morbidities associated with PTSD in all war veterans resulted in the establishment in 1994 of the Australian National Centre for War-related PTSD. With the support of the NC-PTSD a series of PTSD treatment programs for Australian war veterans of all ages have been developed across Australia. The first program for WWII veterans was established at the Older Veterans’ Psychiatry Program in Melbourne in 1996; further programs have been established in other cities (Adelaide 1999, Perth 2001).

PTSD is an important anxiety disorder in elderly veterans. It is more common than expected by most clinicians, frequently misdiagnosed, and a cause of considerable morbidity. Despite its importance there is a dearth of research concerning PTSD in this group of veterans. Available case studies and reports indicate that PTSD is a lifelong disorder, still present 60 years after its onset. There is also evidence that PTSD, which has been latent or in partial remission, may be exacerbated by psychological and social stressors typically associated with old age. PTSD co-morbidities including depression, alcohol abuse and panic attacks are often more problematic in old age.

The Syndrome of PTSD

Following work with American Vietnam veterans, the syndrome PTSD was included in the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) in 1980. The criteria were slightly modified in subsequent editions.

PTSD is initiated by exposure to extraordinarily stressful life events, of which war is a prime example. The initiating event typically involves risk of injury or death (to self or others). Three major symptom clusters characterize the syndrome: re-experiencing phenomena, numbing and avoidance symptoms, and hyperarousal. Intrusive and unpleasant re-experiencing of the traumatic event is manifested as memories, dreams, hallucinations or flashback experiences. Distress or arousal in response to symbolic reminders of the trauma occurs. The patient makes efforts to avoid activities, people, events, thoughts and feelings associated with the trauma. The inability to recall significant aspects of the trauma is common. The patient describes feelings of detachment, a sense of a foreshortened future, and a restriction of the range of emotional feelings. There is decreased interest in significant activities. Increased arousal produces sleep disturbance, irritability, angry outbursts, poor concentration, hypervigilant behavior, and an exaggerated startle response.

The syndrome is frequently complicated by alcohol abuse or dependence, and less frequently by other substance misuse disorders. There is a high rate of co-morbid depression. The combined effects of these psychopathologies on occupational function and interpersonal relationships can be devastating. Thus the syndrome not only affects the sufferer, but also a spouse, family, friends and workmates.

The Course of PTSD in WWII Veterans

Stress reactions to war have been described throughout military history. They have variously been termed "soldiers heart" or "war neurosis" or "shell shock". These reactions probably equate with the PTSD syndrome. Erich Maria Remarque poignantly dedicated his novel about World War I, All Quiet on the Western Front, to "a generation of men who, even though they may have escaped its shells, were destroyed by the war." The long-term psychological outcome of WWI soldiers was not studied, but even in recent years interviews with Australian WWI veterans suggests that many continue to experience PTSD symptoms until their death.

During and immediately following WWII interest in this field was renewed. Many returned Australian WWII servicemen were diagnosed with "combat fatigue," "traumatic war neurosis,, "psychoneurosis,"and "gross stress syndrome." Initially it was thought these disorders would be self-limiting. Surprisingly, despite the availability of WWII veterans for observation, there have not been any good longitudinal studies on the natural course of PTSD in this group. It is now generally accepted that PTSD is chronic with a number of different patterns, including a fluctuating course with relapses and remissions, a subacute presentation that gradually becomes chronic, and possibly a delayed-onset type.

Re-exacerbation of PTSD in Late Life

With the aging of WWII veterans, the phenomenon of exacerbation of PTSD in late life has been clinically noted. As with depressive disorders, stressors of late life leave the sufferer of chronic PTSD vulnerable to a worsening of their symptoms. The re-emergence of the experiencing and arousal symptomatology, especially intrusive recollections, nightmares, insomnia and hyper vigilance in response to a stressor is a common feature. Medical illness is probably the most important, especially where pain, disfigurement and loss of physical capacity are present. Reduced ability to pursue physical activity may remove a previously successful coping mechanism, which has kept the symptoms of PTSD in check. Retirement from work, and a diminution of family responsibilities also removes a source of distraction from unwanted memories. Many veterans report loneliness as a major stress. Loneliness is usually associated with other stressors, such as the death of a spouse—a loss may resemble the deaths of comrades during the war. The role of cognitive impairment, especially where PTSD had been complicated by alcohol abuse, may be significant. Numerous other events, which resemble or simulate the initial trauma, have been reported as causing exacerbations of longstanding PTSD.

Prevalence of PTSD in Elderly Veterans

The presence of PTSD has been identified in large numbers of WWII veterans in many countries but the precise prevalence is currently unknown. The best available studies on US combat veterans from Vietnam suggest a rate of PTSD in the vicinity of 15%. No large studies of elderly war veterans have been performed, but there is little reason to think the rate is any different. In some groups who suffered extreme trauma, such as those interred as prisoners of war, the rate is likely to be higher. Even on conservative estimates there are likely to be at least 30,000 living Australian WWII veterans with symptomatic PTSD.

Clinical Presentation in Elderly Veterans

A common theme concerning the presentation of WWII veterans suffering PTSD is that veterans either do not present, or present with vague psychiatric or somatic complaints. Patients often have dealt effectively with anxiety by denial or avoidance, and presentation in the elderly group is clouded by this phenomenon. An aversion to discussing war experiences, often for fear of "opening up a can of worms" is a common factor. Even when elderly veterans present with psychiatric symptoms, diagnosis can be problematic. PTSD is often not considered by the assessing clinician. For a number of reasons clinicians generally lack rigor in pursuing a full military history, and its potential sequelae, in elderly veterans. Events in the distant past may not be seen as relevant to the current presentation. Direct questioning about the typical symptoms of PTSD is essential before this diagnosis can be excluded in any veteran, no matter how old. This line of questioning must be pursued sensitively, because unearthing distressing recollections can itself be a traumatic experience. Adequate follow-up to allow opportunities to review the effects of the assessment interview with the patient should be provided.

The presence of co-morbidities such as other anxiety disorders, affective disorders, alcohol abuse and psychosocial complications such as chronic marital difficulties, can further complicate the picture and make diagnosis more difficult.

Data from the Australian NC-PTSD suggests that overall symptomatology for WWII veterans is less severe than for Vietnam veterans, and that older veterans presenting for treatment have less severe avoidance and numbing symptoms.

Treatment

Studies on the treatment of PTSD have focussed on younger groups, especially American Vietnam veterans. From these, the general principles of treatment are to combine pharmacotherapy, psychotherapy, peer group participation and family therapy. Common treatment elements include establishing a therapeutic alliance; providing education; managing anxiety; and facilitating the experiencing and integration of the initial trauma.

Here in Melbourne our approach for elderly veterans with PTSD is an initial multidisciplinary assessment, which includes a standard psychogeriatric interview and examination, domiciliary visit, structured PTSD interview (such as the Clinician-administered PTSD scale (CAPS)), functional occupational therapy assessment, and interview with the veteran’s partner. Any associated co-morbidities, such as depression or alcohol dependence, are addressed. The veteran is then offered a place in a specific group treatment program for PTSD. This is run in a 12 session, weekly attendance, full-day program for a closed group of 8 veterans and their partners. Veterans and partners attend a psychoeducation group on PTSD, its common co-morbidities and associated topics. Veterans are given symptom management training (e.g. anger management and relaxation techniques) and participate in a facilitated therapy group with a trauma focus. This allows veterans to explore their traumata and their sequelae in a safe, supported environment. There is also a partners group, which is predominantly supportive and educational.

There is increasing evidence that pharmacotherapy, especially SSRI anti-depressants, is beneficial to all clusters of PTSD symptomatology. A medication trial cannot be considered adequate unless given at standard therapeutic doses for a period of three to six months. Generally elderly veterans have not been included in drug trials, but a recent study at our hospital on the efficacy of venlafaxine on PTSD included a number of elderly veterans who benefited from this.

To this time about 100 WWII veterans (average age 78) have attended the group program described above. Outcome data are collected and entered into the Australian NC-PTSD database. They show improvements in measures of PTSD symptomatology, levels of anxiety and depression, alcohol problems, marital satisfaction, physical health, social function and satisfaction with life. Anecdotally the veterans report satisfaction with the program, symptom diminution and an improved quality of life. Word of mouth within the veteran community provides the greatest source of referrals for the program.
 

Dr Richard J. Bonwick MBBS, MMed, FRANZCP, is a Consultant Psychiatrist at the Older Veterans’ Psychiatry Program of the Austin and Repatriation Medical Centre in Melbourne, Australia. He can be contacted at Richard.Bonwick@armc.org.au.

Richard Bonwick

Reprinted from IPA Bulletin, Volume 19, Number 1