Assessment of Trauma Exposure and Post-Traumatic Stress in Long-Term Care Veterans: Preliminary Data on Psychometrics and Post-Traumatic Stress Disorder Prevalence

Military Medicine, Oct 2005 by Cook, Joan M, Elhai, Jon D, Cassidy, Erin L, Ruzek, Josef I, Et al

This article reports preliminary data on trauma and post-traumatic stress disorder (PTSD) prevalence, as well as test psychometrics, among 35 cognitively intact veterans residing in long-term care settings. Participants received a traumatic event screening, the Mini-Mental Status Examination, Combat Exposure Scale (CES), PTSD Checklist (PCL), and Mississippi Combat PTSD Scale (M-PTSD). Results demonstrated adequate reliability for the CES, PCL, and M-PTSD for use in these settings, with several significant intercorrelations. A high prevalence of trauma exposure was found, in particular combat. Based on the PCL and M-PTSD, although most veterans did not meet full PTSD diagnostic criteria, a moderate proportion met partial criteria. The need for assessment and treatment of trauma exposure and PTSD in Veterans Affairs long-term care settings is emphasized.

Introduction

Extensive information exists on the prevalence of post-traumatic stress disorder (PTSD) in community-residing combat veterans.1,2 However, despite PTSD's often chronic course, sometimes lasting a lifetime,3 there is little information regarding PTSD assessment in veterans residing in extended care residence.4 This preliminary study examined the reported trauma exposure and PTSD in a predominantly older sample of veterans residing in long-term care, with data on the psychometrics of trauma exposure and PTSD instruments and PTSD prevalence in this sample.

In general, research has shown that combat-related PTSD is a significant and long-lasting problem for some veterans, with up to 15% of male Vietnam veterans meeting current and 31% meeting lifetime PTSD diagnostic criteria.2 Moreover, an additional 11% of male Vietnam veterans suffer from partial (subsyndromal) PTSD, which has received recent attention.5,6 Individuals with partial PTSD can have clinically significant symptoms that affect their psychological functioning, physical health and social relations, and thus they may be in need of intervention.

Special considerations may need to be made when assessing older (i.e., ≥60 years) individuals who have survived trauma exposure,7 particularly with regard to special needs in long-term care settings.8 A few case studies of older adults with exposure to combat or other non-military-related traumas suggest that Stressors like illness, loss of significant others, and retirement, as well as institutionalization itself, may interact negatively with unresolved trauma to maintain or reawaken psychological distress in later life.9"11 Recent research demonstrates that older veterans with PTSD in general may evidence decreased psychiatric problems as compared to their younger counterparts, but use significantly more Veterans Affairs (VA) primary care medical services.12 Additionally, it has been suggested that organic age-related changes in the brain (e.g., dementia processes) may exacerbate underlying PTSD symptomatology.13,14 Assessing PTSD in older veteran long-term care residents and establishing preliminary estimates of PTSD prevalence is therefore needed.

This topic's significance is highlighted by the fact that the demographic contour of the U.S. population is shifting, with a substantial increase in the proportion of individuals living into older adulthood.15,16 The veteran population is especially affected by this trend, with male veterans being older on average than the overall adult male population.17 Male veterans 65 years and over are expected to increase from 26% of the male veteran population in 1990 to more than 40% by the year 2010.17 As this population shift continues, it can be anticipated that more services for older adult veterans, including those with PTSD residing in long-term care settings, will be required.

This study's purpose was twofold: (1) to provide information on the reliability and validity of several trauma and PTSD instruments among a predominantly older sample of veterans in long-term care and (2) to provide preliminary estimates on how prevalent trauma exposure and PTSD are in this population. Despite being untested previously, it was expected that the assessment measures would evidence adequate reliability in this sample. Furthermore, we expected that most of this primarily older veteran sample would fail to meet full PTSD diagnostic criteria (perhaps previously meeting full criteria), but would still evidence clinically significant symptoms, from research exploring partial PTSD in older community-residing veterans.18

This investigation is important, providing a crucial first step in measuring PTSD in long-term care residents. Although PTSD is likely not as rampant as depression in these settings,19 it is thought to be a problem that requires recognition, assessment and intervention, especially in those facilities with high concentrations of trauma survivors.

Method

Participants

The initial sample consisted of 51 male residents from two settings at a Department of Veterans Affairs in the Western United States: A nursing home (NH; n = 38) and an extended care psychiatric unit (ECPU; R = 13). This sample was relatively small, given the difficulty researchers have obtaining access to these settings and the longer periods of time patients reside there (keeping new patient flow to a minimum). Furthermore, two veterans refused to be interviewed. Additionally, participants with Mini-Mental State Examination (MMSE)20 scores below 24 (suggesting cognitive impairment which could interfere with study performance; n = 22) were considered for exclusion. However, only 14 (of these 22) participants were actually excluded for having obvious cognitive impairment, since the remaining 8 obtained low scores17"23 primarily due to paralysis and/or difficulty in using their hands. The remaining sample included 25 NH and 10 ECPU participants.