St. Cloud State UniversitytheRepository at St. Cloud State

Culminating Projects in Gerontology Program in Gerontology

12-2018

Post-Traumatic Stress Disorder and Dementia inAging Veterans: An Overview for Health CareProfessionalsBethany Marybethanymary@usa.com

Follow this and additional works at: https://repository.stcloudstate.edu/gero_etds

This Starred Paper is brought to you for free and open access by the Program in Gerontology at theRepository at St. Cloud State. It has been acceptedfor inclusion in Culminating Projects in Gerontology by an authorized administrator of theRepository at St. Cloud State. For more information, pleasecontact rswexelbaum@stcloudstate.edu.

Recommended CitationMary, Bethany, "Post-Traumatic Stress Disorder and Dementia in Aging Veterans: An Overview for Health Care Professionals" (2018).Culminating Projects in Gerontology. 7.https://repository.stcloudstate.edu/gero_etds/7

Post-TraumaticStressDisorderandDementiainAgingVeterans:

AnOverviewforHealthCareProfessionals

by

BethanyMary

AStarredPaper

SubmittedtotheGraduateFacultyof

St.CloudStateUniversity

inPartialFulfillmentoftheRequirements

fortheDegreeof

MasterofSciencein

Gerontology

December,2018

StarredPaperCommittee:PhyllisGreenberg,Chairperson

RonaKarasikBethKnott

2TableofContents

Chapter Page

1.Introduction…………………………………………………………………………………………………….4

ReasonsforResearch………………………………………………………………………………..4

PrevalenceofPTSD…………………………………………………………………………………..5

PrevalenceofDementias…………………………………………………………………………..6

TheCurrentProject………………………………………………………………………………….7

2.LiteratureReview……………………………………………………………………………………………8

TheoreticalFrameworks…………………………………………………………………………..8

CopingStrategies……………………………………………………………………………………..9

SymptomatologyofPTSD………………………………………………………………………..11

PersistenceandReemergenceofTrauma………………………………………………...12

SymptomatologyofDementias………………………………………………………………..13

BiologicalSimilaritiesofPTSDandDementias…………………………………………14

PossibleCausalRelationshipsofPTSDandDementias……………………………..16

CurrentVAServicesforPTSDandDementias…………………………………………..17

ValueofTherapeuticApproaches…………………………………………………………....19

CaseStudies…………………………………………………………………………………………...21

3.PotentialFutureResearch……………………………………………………………………………...24

TargetAudience………………………………………………………………………………….….24

ScreeningandInitialTreatment………………………………………………………….…..24

SpecializedPopulations………………………………………………………………………….25

3Chapter Page

Long-TermCareImplications………………………………………………………………..26

IncreasingSupportandTherapyAdherence…………………………………………..27

BiologyandTraumaticBrainInjury……………………………………………………….29

ReferenceSheet:AQuickLookatPTSDandDementia………………………………………31

References………………………………………………………………………………………………………33

4Chapter1:Introduction

ReasonsforResearch

Post-traumaticstressdisorder(PTSD)hasbeendefinedbytheNationalInstituteof

MentalHealthasamentalhealthconditionthatmaydevelopwhenadistressingevent

occursandinducessymptomssuchasintrusivethoughts,hypervigilance,panicattacks,or

flashbacks(Bartzak,2016).WhilethesignsofPTSDmostoftenoccurwithinweeksor

monthsfollowingthetrauma,PTSDcanmanifestafterseveralyears(AustralianNursing

andMidwiferyFederation,2015).PTSDwasnotformallyrecognizeduntilthe1980safter

theVietnamWar;however,itcertainlyexistedbeforethis,andwaslabeledshellshockin

WorldWarIandcombatfatigueinWorldWarII(AustralianNursingandMidwifery

Federation,2015;Averill&Beck,2000;Barnes&Harvey,2000).

Asthepopulationages,anotherhealthconcernthatisemergingforveteransisthe

increased,althoughnotcertain,riskofdementia.ThefiftheditionoftheDiagnosticand

StatisticalManualofMentalDisorders(DSM-5)definesdementiaaspartofacontinuumof

neurocognitivedisorders;amildneurocognitivedisorder(NCD)consistsofcognitive

declinethatdoesnotinterferewithone’sabilitytofunctionindependently,whereasa

majorNCD,onetypeofwhichisdementia,isamoreseveredecline(AmericanPsychiatric

Association,2013).Thisleadstodifficultywithmemory,thinking,orientation,judgement,

language,learning,andothercognitiveskills(Reisberg,2006).Theremayalsobesocial,

emotional,andfunctionalchallengesthataccompanyadementiadiagnosis,largelydueto

theprominentsymptomofmemoryimpairment(Alzheimer’sAssociation,2007;Reisberg,

2006).Symptomsofdementiascanvaryfrompersontopersonandfromthedifferent

formsofdementia,butmentaldeclineisgenerallyenoughtointerferewithactivitiesof

5dailyliving.Astheveteranpopulationcontinuestogrowandage,PTSDanddementias

willbothbecomemoreprevalentandeffectiveserviceswillbecomemorenecessary.

PrevalenceofPTSD

InearlystudiesoftheIraqandAfghanistanwarsin2003,11-19%ofdeployed

soldiersalreadydisplayedsymptomsofPTSD,whichisnearlytwicetherateofcivilians

(Beidel,Stout,Neer,Frueh,&Lejuez,2017;Finley,2011;Menefeeetal.,2016;Safir,

Wallach&Rizzo,2015).By2009,theOperationEnduringFreedom(OEF)andOperation

IraqiFreedom(OIF)veteranswithaprovisionalPTSDdiagnosistotaledmorethan22%,

withone-thirdofOEF/OIFveteranswithtraumaticbraininjuryalsohavingPTSD

(Chapman&Diaz-Arrastia,2014;Finley,2011;Qureshietal.,2010).Lifetimeprevalenceof

PTSDinveteransisestimatedashighas31%,andisoftenmorefrequentandseverein

infantrysoldierswithhighcombatexposure(Bakalar,Blevins,Carlin,&Ghahramanlou-

Holloway,2016;Weineretal.,2014).

Asmedicaladvancesenablesoldierstosurvivethroughmoretraumaticwar

experiences,nearlyfourtimesthenumberofsoldierswoundedinactioncomehomewith

PTSD(Finley,2011).Thearmydiagnosedmorethantwicethenumberofveteranswith

PTSDin2010thanitdidin2005;thesenumberscanbeexpectedtocontinueincreasing

(Safiretal.,2015).Itisimportanttothinkabouttheimplicationsforclinicaltreatmentsand

residentialcarefacilitiesasthishighproportionofveteransageswithsuchtraumatic

histories.

Someolderveteransarealreadyfacingtheseissues.Between9-15%ofVietnam

veteransstillsufferfromPTSD15yearsafterdiagnosis,andifveteransfromtheKorean

WarandWorldWarIIarealsoconsidered,thisstatisticreaches24%(Qureshietal.,2010).

6InastudyofolderveteransofPearlHarbor,itwasnotedthat45yearslater,65%still

experiencedintrusivememories,42%reportedsurvivorguilt,and33%reported

symptomsofavoidance,hyperarousal,andemotionalnumbness(Averill&Beck,2000;

Wilson,Harel&Kahana,1989).PTSDdoesnotonlydevelopfromthecombatofwar,but

alsocanalsooccurwithsexualassault.Between13-30%offemaleveteransreportthat

theywererapedduringtheirservice,withnumbersaveragingaround25%forsexual

assaultand60%forsexualharassment(Finley,2011;Safiretal.,2015).

Whileanextensivebodyofresearchhasestablishedthatveteransfacemanykinds

oftraumaticexperiencesduringtheirmilitaryservice,muchmoreneedstobeundertaken

toanalyzetheprevalenceofdementiadevelopinginpeoplewithPTSD,andhowthislarge

proportionofveteranswithPTSDalsohandlesadementiadiagnosis.

PrevalenceofDementias

Estimatesofdementiainthepopulationofpeopleage65andoldertypicallyfall

within10-12%ofthepopulation,althoughriskofdevelopingaformofdementiarises

considerablywithage(Alzheimer’sAssociation,2016).Inadditiontodementia,amild

cognitiveimpairment(MCI),whichcausesaminordeclineinthinkingandmemory

functionandcanevolveintodementia,isthoughttoaffect15-20%ofadultsovertheageof

65(Alzheimer’sAssociation,2012).

Anadditionalconcernisadiagnosisofcognitiveimpairmentnodementia(CIND).

SomeonewithCINDis5-23timesaslikelytoprogresstoadementiaassomeonewithout

CIND,andonerecentstudyrevealedthatapproximately18%ofveteranshadCIND

(Holsingeretal.,2015).Otherstudiessuggestthatoveronequarterofveteransoverthe

ageof75mayhaveaformofdementia(Chodoshetal.,2007).Dementiadiagnosiscanbe

7difficult,however,andthepatientcanmakeitevenharder.Almosthalfofveteranswho

screenpositivelyforadementiarefusefurtherevaluation,and27%feelthatthetimeand

effortittakestoschedulemedicalappointmentsistoogreat(Chodoshetal.,2007).

Screeningsanddiagnosesmaybeofparticularimportanceforveteranswhopossess

specificriskfactorsforcertaindementias.Thereissomeevidencediscussedlaterinthis

paperaboutPTSDpotentiallyincreasingdementiarisk.Thereisalsoevidencethat

approximately20%ofveteransfromtheIraqandAfghanistanwarshaveexperienceda

traumaticbraininjury(TBI),whichcanleadtoadementia(Bartzak,2016;Tanielian&

Jaycox,2008).Veteransarealsoatincreasedriskforsubstanceabuse,andithasbeen

foundthat40%ofthosewithsubstanceusedisordersinsurveyedVAnursinghomeshave

adementiaaswell(Lemke&Schaefer,2010).Wernicke-Korsakoffsyndrome,analcohol-

induceddementia,isworthwatchingforinveterans(Finley,2011).

TheCurrentProject

Theaforementionedstatisticsanddemographicsregardingveteranswithmental

healthissuesinspiredthisproject.Thegoalistoexplorehowagingveteranscopewith

PTSDinlaterlife,especiallywhentheyhavethepotentialtoexperiencethisinconjunction

withadementia.Thisprojectdiscussessymptomsandchangesinneuroanatomythatare

similarinbothdisorders,andapossiblecausalrelationship.Thecollectionofresearch

presentedshouldraiseawarenessofthedisordersandtherapyoptions,andthequestionof

howtobestprovidecareforolderveteranswiththisuniquesetofmemory-centered

comorbidities.

8Chapter2:LiteratureReview

TheoreticalFrameworks

Thefieldsofgerontologyandsociologyhavetwotheoreticalframeworksthatare

particularlyusefulinunderstandingtheimpactofPTSDonthelivesofolderveterans.The

first,cumulativedisadvantagetheory,suggeststhatearliertraumamaycontributetolater

problems,accumulatingtoestablishamindsetof“priorvulnerability”andtohaveastrong

negativeimpactonmentalhealthfunctioning(Agaibi&Wilson,2005;Sachs-Ericsson,

Joiner,Cougle,Stanley&Sheffler,2016;Schmied,Larson,Highfill-Mcroy&Thomsen,2016).

Thisphenomenonisalsocalledthestressgenerationmodel;traumaoftenfollowssomeone

throughouttheirlifecoursebecausepsychiatricproblemscancontributetoactively

creatingmorestressfullifeexperiences(Schmiedetal.,2016).

OnelongitudinalstudyofGulfWarveteransfoundthatthosewithPTSD

experiencedhigherratesofassaultandinjury,andastudyofVietnamveteransfoundthat

thosewithPTSDweremorelikelytodieofexternalcausessuchasaccidentsorhomicides

(Schmiedetal.,2016).ThePost-DeploymentStress(PDS)studyfoundthat16%ofveterans

hadbeenrobbedorhadtheirhousebrokenintosincereturningfromdeployment,16%

hadwitnessedanassaultordeath,and12%hadbeenassaultedthemselves(Finley,2011).

Traumamaynotendwhenaveteranreturnsfromwar;itcouldsimplychangeforms.

Asecondtheory,Tornstam’stheoryofgerotranscendence,advocatesa

developmentalshiftinolderage.Thisisamovetowardinternalvaluesinthreecategories:

thevalueofunitywiththeuniverse,lesspreoccupationwithmaterialobjectsand

egotisticalinterests,andtheincreasedimportanceofmeditationtimeinsteadofsocial

obligations(Buchanan,Ebel,Garcia,VandeNest&Omlie,2016;Jewell,2014;Read,Braam,

9Lyyra&Deeg,2014).Anumberofgerotranscendentattitudes,suchaswithdrawalandnot

seeingtemporalboundariesbetweenpastandpresent,canbeinterpretedaspathological

andareoftenseeninpeoplewithbothPTSDanddementias(Buchananetal.,2016).Itmay

beunpleasanttoreviewhowone’slifehasdevelopedifonehastraumaticmemoriesofthe

past,anditmaybeconfusingtotrytopieceeventstogetherwithlittlesenseofaproper

timeline.ItisimportantforpeoplewithPTSDanddementiastobeabletoundergoa

peacefullifereviewprocess,andtounderstandhowtocopewithsymptomsandimpactsof

theirconditions.

CopingStrategies

Insomeinstances,asapossiblecountertocumulativedisadvantagetheoryand

supportforgerotranscendencetheory,PTSDmaynotreduceanindividual’sabilitytocope

withtrauma.Theconceptofpost-traumaticgrowthisbuiltaroundtheideathatadifficult

experiencecanaltersomeone’smentalorpsychologicaloutlookinapositivemanner,such

asleadingsomeonetoappreciatetheirownstrengthsmore(Finley,2011).Itispossible

thatsurvivingtraumacanincreasesomeone’sconfidenceandrecoverycapital,definedas

theintrapersonalandinterpersonalsupportiveresourcesthatfacilitatenaturalrecovery

(Searby,Maude&McGrath,2015).Evenifthiseffectisnotevident,thereissometimesat

leasta“steelingeffect”inincreasedresilience(Agaibi&Wilson,2005).

However,thispositivityandgrowthmaybemoredifficultforsomeolderadults.

Dementiacanreduceanindividual’sabilitytoutilizepreviouslysuccessfulcopingskills,

especiallycombinedwithstressfulsocialchangessuchasretirementandperceived

rolelessness(Grossman,Levin,Katzen&Lechner,2004;Sachs-Ericssonetal.,2016).An

olderveteranwhodefinedtheirself-imagebasedontheirmilitarylifemaynolongerbe

10abletoseethemselvesinthiswayastheirbrains,bodies,andenvironmentschange.As

oneages,thereisanincreasedriskofexperiencingdepressinganddisorientingincidences

ofphysicalandmentaldeterioration,newmedicaldiagnoses,familydeaths,andother

stressorsthatcanadduptotakeatollonone’sresilience(Dewey,2004;Paulson&

Krippner,2007).Itmaybemoredifficultforanolderveterantosummonthereservesof

strengthnecessarytocopewithPTSD,especiallyiftheyalsohaveadementiaandcannot

rememberhowtheymayhavepreviouslysuccessfullycoped(Finley,2011).Theymay

continuetofacethesamestrugglesseveraltimesasifeachtimeisthefirst.

Toaddtothishardship,manyveteransarenotscreenedortreatedforPTSDwhen

theyreturnfromdeployment.Onestudyfoundthatlessthan10%ofOEF/OIFveterans

withPTSDcompletedtherecommendednumberoftreatmentsessionsinthefirstyearof

theirdiagnosis(Finley,2011).ItisimperativethatveteranswithPTSDdealwithany

emotionalissuesthatnegativelyaffecttheirqualityoflife,especiallywhenagingmayadd

morestressandinabilitytomentallyprocessdisturbingfeelingsandmemories.Developing

copingstrategiesshouldhelptoalleviatevarioussymptoms.

SymptomatologyofPTSD

PTSDwasnotformallyincludedintheDSMuntil1980(Averill&Beck,2000;Barnes

&Harvey,2000).IntheDSM-5,therearefoursymptomcategoriesoutlinedforPTSD:re-

experiencing,avoidance,arousal,andnegativecognitionsandmood(AmericanPsychiatric

Association,2013).Re-experiencingentailsflashbacksandmemoriesofthetrauma,

whetherunpromptedortriggered.Avoidanceisthepracticeoftryingtoavoidthesere-

experiencingthoughts,feelings,andsituations.Arousalreferstoaggressiveorreckless

behaviorandhypervigilancethatmaydisruptsleep.Negativecognitionsandmoodcanbe

11viewedasaflipsidetoarousal,asthisreferstoestrangementanddisinterest(American

PsychiatricAssociation,2013).

Onesymptomthatisparticularlytroublesomeforveteransisthearousalsymptom

ofsleepdifficulty.ResearchbypsychiatristvanderKolkbeginninginthe1970sreveals

thatthenightmarecontentofsomeveteranswithPTSDhasstayedthesamefor15years,

andinanotherstudy,nearlyhalfofveteransreportedproblemsgettingtosleeporstaying

asleep(Finley,2011;Naparstek,2005).Withregardtoveteransattendingtreatment

facilities,halfwerediagnosedwithaformofsleepapneaandonequarterwerediagnosed

withinsomnia,with40%gettinglessthanfivehoursofsleepeachnight(Yaffe,Hoang,

Byers,Barnes&Friedl,2014).Atonementalhealthclinic,studiesreportedresultsashigh

as80%ofWorldWarIIveteransdealingwithinsomniaand75%dealingwithdisturbing

nightmares(Averill&Beck,2000).

Whilethesesleepsymptomsappearrelativelyuniversal,othersymptomscanbe

morespecifictoaveteran’scombatsituation.Soldierswhoaremoreinvolvedincombat

tendtohavemoreviolentoutburstsymptoms,whereassoldierswhoareonlyvictimsof

violencehavemorememoryproblems(Naparstek,2005).Thosewhohavebeenprisoners

ofwarcanbemoreparanoidwithlessoutwardagitation;blankfacialexpressionscalled

the“thousandyardstare”perhapshadsurvivalvalueinprisonerofwarcamps(Dewey,

2004;Vermaetal.,2001).Someotherbehavioralsymptomsincludeadulledsensitivityto

loss,easystartling,andrelationshipdifficulty(Barnes&Harvey,2000).Veteranswith

PTSDrecruitedtotakealearningtestdemonstratedadiminishedabilitytoencodeand

consolidatenewinformation,andhadadelayedabilitytorecallknowninformation,which

oftencausesfrustration(Yehuda,Golier,Tischler,Stavitsky&Harvey,2005).

12 PTSDsymptomsrarelydisappearcompletely.Almostallveteransexperiencean

anniversaryreprise,meaningthataroundthesametimeofyearaspasttraumaticevents

occurred,moresymptomsreappear(Dewey,2004).Currenteventscanalsoinfluencethe

recurrenceofsymptoms.AtthestartoftheIraqandAfghanistanwars,thenumberof

patientsinPTSDclinicsinVAhospitalsquadrupled;manyofthesepatientswereVietnam

veteranswhosePTSDreactivatedwiththedeploymentofnewsoldiers(Glasser,2011).

Thisremembranceoftraumadoesnothavetobeawhollynegativeexperience,however;it

canbeachancetoreconcileandmoveon.

PersistenceandReemergenceofTrauma

Inlaterlife,someveteransreengagewiththeirtraumaticmemoriesofwarinan

attempttofindmeaningandbuildcoherence(Davisonetal.,2016).Othersmaybe

engagingforthefirsttime.Thisdelayed-onsetPTSD(DPTSD)maybeduetoareductionin

physicalandmentalresilienceovertime,bringingsuppressedmemoriestotheforefront

(Averill&Beck,2000).Lifecoursechangesthatlessentheeffectivenessofcopingskills,

suchasretirementandbereavement,mayalsoleadtoDPTSDinolderveterans,because

theymaynothavetherecoverycapitaltocopewiththesechanges(Averill&Beck,2000;

Davisonetal.,2006;Sachs-Ericssonetal.,2016;Safiretal.,2015).

Onelongitudinalstudyconductedfrom1982-2002foundthatittookthisperiodof

20yearsfor13%ofveteranstodevelopDPTSD(Safiretal.,2015).Thisfindingmaybe

influencedbythisparticularperiodinhistory,asDPTSDcanbetriggeredbysimilarevents;

theIraqandAfghanistanwarsraisepainfulmemoriesforveteransofpreviouswars.An

averageof85%ofveteransreportedmorepreoccupationwithwarmemoriesinlaterlife,

13andhalfreportedhavingflashbackswhentheyhadnothadanybefore(Davisonetal.,

2006).

Twophenomena,late-onsetstresssymptomatology(LOSS)andlate-adulthood

traumareengagement(LATR),describereasonswhyolderveteransmayconsciously

choosetoprocesstraumaticmemoriesdecadesaftertheirwarexperience.LOSSandLATR

arelessstronglyassociatedwithmentalhealthsymptomsthanPTSD,andmorestrongly

associatedwithconcernsaboutlifecoursechanges.Avoidancesymptomsareoneofthe

fourcriticalcategoriesforaPTSDdiagnosis,whereasLOSSandLATRrequireintentional

reminiscenceinlaterlife,whenanindividualpossiblyhasmoretimeforreflection

(Davisonetal.,2016).

SymptomatologyofDementias

AlthoughtheDSM-5definesdementiaasamajorNCD,aformofseverecognitive

declineinoneormoreareas,thespecificsymptomscanvarybasedonthetypeofdementia

(AmericanPsychiatricAssociation,2013).Inearlystagesofmostdementias,people

experiencedifficultywithmemoryandcognitivefunctioning,aswellassomemood

changessuchasanxietyordepression.Memoryproblemsarediagnosedwithtestssuchas

theMiniMentalStateExamination(MMSE),CambridgeCognitiveExamination(CAMCOG),

andpsychologicalbatteryteststargetinglanguage,abstractthinking,calculation,and

attention(VanderLinde,Stephan,Matthews,Brayne&Savva,2012).Cognitiveand

functionaldeclinehasalsobeenassociatedwithwandering.

Behavioralsymptomsincludesleepdisturbances,outbursts,restlessness,delusions,

andhidingorlookingforthings(Alzheimer’sAssociation,2007).Thediagnosticcriteriafor

psychosisofAlzheimer’sdiseaseconsistsofthreetypes:agitationwithorwithout

14aggression,negativesymptomsofapathyandavolition,anddepressionorhypersomnia

(VanderMusseleetal.,2014).Notalldementiadiagnosesrequirepsychosis;however,itis

importanttonotethese“psychosisclusters,”astheydooccurinupto85%ofcasesandare

identicaltoPTSDsymptomslikehallucinationsandparanoia(VanderMusseleetal.,2014).

TheGeriatricMentalStateAutomatedGeriatricExaminationforComputerAssisted

Taxonomy(GMS-AGECAT)providesabehaviorsymptomlistincludingdepression,apathy,

anxiety,paranoia,irritability,agitation,andelation–insum,anyintenseorrapidly

fluctuatingfeelings(VanderLindeetal.,2012).TheNeuropsychiatricInventory(NPI),

NeurobehavioralRatingScale,BehaviorRatingScaleforDementia,andBehavioral

PathologyinAlzheimer’sDiseaseScaleprovidescorestoindicatetheseverityofbehavior

symptoms(VanderLinde,Dening,Matthews&Brayne,2013).Teststhatanalyzebehavior

areimportantbecausetheyarerelativelyeasytoperformandrepeat,whereasmost

dementiascannotbediagnosedormonitoredbasedontheappearanceofdifferentbrain

regions.Nevertheless,therearecertainkeychangesthatcanbeobservedbiologically.

BiologicalSimilaritiesofPTSDandDementias

Variouschangesinneuroanatomicalstructurerelatedtomemorycapacityand

emotionalresponsesaresimilarinbothPTSDandmanyofthediseasesthatcause

dementias.Theseincludealteredsensitivityofthehypothalamic-pituitaryaxis(HPA)

system,reducedhippocampalvolume,andcorticalabnormalities.Thesecommonalities

suggestalinkbetweenPTSDanddementias.

TheglucocorticoidcascadehypothesisexplainschangesintheHPAsystem.Stress

activatestheHPAsystemforprolongedperiodsoftime,leadingtooversecretionof

glucocorticoidsthatdamagethehippocampus.Exposuretostressors,asincasesofPTSD,

15heightensthesensitivityofthissystemtostressandthereforecausesmorehippocampal

decline,specificallyinthesubiculumanddentategyrussubfields(Greenberg,Tanev,Marin

&Pitman,2014;Sachs-Ericssonetal.,2016).Thishyperresponsivenesshasalsobeentied

toagitationandpsychosisindementias(Vermaetal.,2001;Yaffeetal.,2010).Stressalso

playsaroleinelevatingtheproductionofpro-inflammatorycytokines,whichinduces

neuroinflammation(Greenbergetal.,2014).Agreaterdegreeofinflammationhasbeen

correlatedwithearlieronsetofAlzheimer’sdisease,andimpairstheabilitytostorenew

memories(Greenbergetal.,2014).

Studieshavereportedeitherleft,right,orbilateralhippocampalvolumereduction

rangingfrom5-26%,onascalewhereareductionof40%isthoughttoreflectcomplete

neuronloss(Qureshi,2010;Safiretal.,2015).Thisresultsinshort-termmemoryworking

onlyathalfcapacityinthemostseverecases,whilelong-termmemoriesremainintact.For

aveteranwithPTSD,thisrelianceonlong-termmemoriesthatcontaintheirtraumacould

beverydistressing(Grossmanetal.,2004).Foraveteranwhoalreadyhadsome

hippocampalvolumereductionfromPTSD,apossiblefurtherreductionfromadementiais

evenmoreworrisome.

ThosewithPTSDhavealsobeenshowntohavereducedanteriorcingulatecortex

(ACC)graymattervolumesandhypoactivemedialprefrontalcortexes(MPFC),cortical

changeswhicharealsopresentindementias(Safiretal.,2015;Zhou,Chu&Luo,2011).

Corticalsystemsaresupposedtoregulatetheemotionalresponsesoftheamygdala,but

thislessenedcorticalactivitymeansthattheamygdalaishyperresponsive.Thiscould

causemanyoftheemotionalsymptomsinPTSDanddementias(Costanzo,Jovanovic,

Norrholm,Ndiongue,Reinhardt,&Roy,2016).

16PossibleCausalRelationshipofPTSDandDementias

PTSDanddementia-producingdiseasescanbeconceptualizedasmemorydisorders

withchangesinnotonlymemorybutalsoattention,learning,andexecutivefunctioning.

Qureshi(2010)conductedan11-yearstudyusingadministrativedatafromtheVeterans

IntegratedServiceNetwork(VISN)togatherfourgroupsofveterans:thosewithnoPTSD

andnoPurpleHeart;thosewithPTSDandnoPurpleHeart;thosewithnoPTSDanda

PurpleHeart;andthosewithPTSDandaPurpleHeart.VeteranswithPTSDwerefoundto

betwiceaslikelytodevelopadementiacomparedtothosewithoutPTSD,andhavinga

PurpleHearthadlittleinfluence.ThissuggeststhatPTSDisagreaterriskfactorfor

dementiasthantraumathatisspecificallycombat-related,sincePurpleHeartsareawarded

forcombatexperiences.Yaffe(2010)conductedasimilarstudyandreachedthesame

conclusion,thatveteranswithPTSDaretwiceaslikelytodevelopadementia,andMeziab

(2014)andWeiner(2014)bolsteredthesefindingsmorerecently.Onestudyevenfounda

fourfoldincreasedrisk(Wangetal.,2016).Thisfurthersuggeststhattheresultswouldbe

similarifthePTSDwereinducedbyanon-warexperiencesuchassexualassault,asitisthe

disorderanditssymptomsetthatappearstoleadtogreaterincidenceofdementias.More

definitivestudiesstillneedtobeconductedintheseareas.

Furtherresearchcouldalsobeusefulforthepopulationofprisonersofwar.One

studyconcludedthatnearlyone-thirdofprisonersofwaralsohadPTSD,andtheincidence

ofadementiawas31.6%inprisonersofwarversus19.5%innon-prisonersofwar(Meziab

etal.,2014).Therehasbeenfoundtobemorethana50%increaseintheriskofadementia

inveteranswithprisonerofwarstatusalone,andmorethana75%increasedriskin

veteranswithPTSDalone(Meziabetal.,2014).

17 SleepstudieshaveyieldedsomeinterestinginformationaboutPTSDand

dementiasimilaritiesaswell.Sleep-disorderedbreathing,alteredcircadianrhythm,and

decreasedslow-wavesleep,whichcommonlyoccurwithPTSD,arealsoassociatedwith

increasedriskofadementia(Mohlenhoff,Chao,Buckley,Weiner&Neylan,2014;Yaffeet

al.,2014).Onestudyfoundthatworseinsomniawastiedtosmallerhippocampalvolume

(Mohlenhoffetal.,2014).Traumareenactmentssuggestarelationshipwithrapideye

movementbehaviordisorder(RBD)andassociationwithLewybodydementia(LBD)

becauseofvisualhallucinations(Dallam,Mellman,Bhatnagar,Nguyen&Kurukumbi,

2011).Othertypesofdementiacanhavetheirownspecificriskfactorsaswell.For

example,peoplewithPTSDtendtohavehigherincidencesofhypertensionanddiabetes,

whichcoulddevelopapredisposedpathophysiologicalpathwaytovasculardementia

(Greenbergetal.,2014).

Thesesimilaritiesinsymptomatologyandneuroanatomy,andthepossiblecausal

link,makePTSDanddementiasimportantconditionstostudyintandem.Theprevalenceof

theseconditionsandthegrowingpopulationofafflictedveteransmeansthatservicesmust

bestreamlined,effective,andreadilyavailable.Gapsinservicesmustbeidentifiedand

filledsothateachveteran’scarecanbewell-roundedandcomplete.

CurrentVAServicesforPTSDandDementias

DementiaisoneofthemostcostlychronicconditionsthattheVAtreats,andolder

people’sconcernsaboutmemorylossreceivelimitedphysicianattention(Chodoshetal.,

2007).TheVeteransHealthAdministrationrecommendsthatveteransshouldbe

periodicallyscreenedfordepressionandPTSD,butthepushforcognitiveimpairmenttests

islessintense(Préville,2015).SomeVAfacilitieshavedevelopedspecializeddementiacare

18programs,bothinpatientandoutpatient,toestablishabaselinebalanceforbehavioral

issuestoenableveteranstobettermanagetheirillnessesontheirown.

TheOfficeofGeriatricsandExtendedCare(OGEC)directsmanycareprograms,one

ofwhichistheAdvancesinHome-BasedPrimaryCareforEndofLifeinAdvancing

Dementia(AHEAD)trainingprogram(Cooley&Asthana,2010).However,theseinitiatives

mostlyfocusonveteranswholiveintheirhomes,andtheyalsoonlyfocusondementias

ratherthanhowthiscognitivedegenerationworkswithothercomorbiditieslikePTSD.One

projectismeanttohighlightthedifferencesbetweendementia,delirium,anddepression,

whichisbeneficial,butstilldoesnotincludePTSD.

AnotherVAtrainingprogramisStaffTraininginAssistedLivingResidences(STAR),

whichfocusesonidentifyingandchangingtheenvironmentalandpersonalcausesof

certainbehavior,increasingindividuallypleasurableactivities,andhavingrealistic

expectationsandcommunicationstrategiestolistentoandprovidewhatresidentveterans

need(Karel,Teri,McConnell,Visnic&Karlin,2016).Thesetypesofinterventionswould

clearlybenefitresidents,andshouldalsohelpstaffunderstandwhyresidentsare

exhibitingcertainbehaviors.

TheJointVAandDepartmentofDefenseEvidence-BasedPracticeWorkgroup

recommendsfourtherapiesforprimarilytreatingveteranswithPTSD:prolongedexposure

therapy(PE),cognitiveprocessingtherapy(CPT),stressinoculationtraining(SIT),andeye-

movementdesensitizationandreprocessingtherapy(EMDR)(Steenkamp&Litz,2013).

Between2006-2008,theVAmandatedthatPEandCPTmadeavailabletoallveteranswith

PTSD(Lu,Plagge,Marsiglio,&Dobscha,2016;Menefeeetal.,2016;Steenkamp&Litz,

2013).By2009,allVAmedicalcentersofferedatleastoneofthetwotherapies,with72%

19offeringboth;thispercentagegrewto98%offeringbothby2012(Luetal.,2016;

Steenkamp&Litz,2013).Nowthatthesetherapiesarewidelyavailable,morestudiesneed

tobeconductedtodemonstratetheireffectiveness.

ValueofTherapeuticApproaches

TreatmentandmanagementofPTSDshouldtargetanindividual’sneeds,whichis

oftenaccomplishedbyfocusingoneachindividual’suniquetrauma.Prolongedexposure

therapyrequiresthatparticipantsre-imagineandconfrontthedetailsoftheirtraumatic

memories.ThisisapopulartreatmentstyleforPTSDbecauseofitspotentialtoreduceor

eliminatefearresponses;however,othersymptomcategoriesremainunaddressed,and

20-50%ofexposuretherapyparticipantsstillmeetthediagnosticcriteriaforPTSDafter

completingtreatment(Dutton,Bermudez,Matás,Majid&Myers,2013;Steenkamp&Litz,

2013).ForonestudyonCPT,ofwhichPEisonlyonetype,upto60%oftherapy

participantsstillmetPTSDcriteriaaftercompletion,and70%metPTSDcriteriaataone-

monthfollow-up(Steenkamp&Litz,2013).Itisimportantthatthesefollow-upsbedoneto

ensurethatsymptomreliefisnotonlytemporary.Astheresearchcurrentlyshows,thetwo

therapiesthattheVAismandatedtoofferaregenerallynotenoughtotreatPTSDby

themselvesinthelongterm.

OthertherapiesmaybeneededtocomplementCPTandaddressothersymptoms.

Forexample,mindfulness-basedstressreductiontherapy(MBSR)teachesattention

focusingskillsandemotionalconsciousness,withtheintentofhelpingtheparticipant

handlemoment-to-momentsensationsinthepresentratherthandiggingintothepast

detailsofthetraumastory(Duttonetal.,2013).ThecentralMBSRcomponentsofbody

scanningandmeditationchallengepeoplewithPTSDtositstillandconcentrateforlong

20periodsoftime,butthisdisciplineassistsinmanagingagitation(Duttonetal.,2013).

Participantsinonestudydescribeddecreaseddistressandanger,decreasedavoidanceof

thoughtsandfeelings,andincreasedawareness,empowerment,focus,andbelonging

(Duttonetal.,2013).

MBSRcouldproveespeciallyusefulforveteranswhoalsohaveadementia,dueto

itsemphasisonsymptomreliefandbehavioralimprovementsinthepresentmoment,with

norelianceonspecificpastmemories.IthasbeenshownthatCPTandPEhavebeen

beneficialforveteranswithPTSD,butmanytrialshaveexcludedveteranswithother

psychiatriccomorbiditiessuchasdementias(Menefeeetal.,2016).Processingtraumatic

memoriesmaybetoomuchforsomeonewithadementia,andcouldonlyexacerbate

feelingsofdistressandanxiety.

Repetitivetranscranialmagneticstimulation(rTMS)hasalsobeenstudiedin

veteranswithPTSDwhenothertreatmentmethodsarenotenough.Thistherapyusesan

electriccoiltodepolarizeneuronsintheleftdorsolateralprefrontalcortex(DLPFC),ata

lowfrequencythatdoesnotcauseseizuresorotherbraindamagingeffects(Bartzak,

2016).VeteransusingrTMShaveimprovedtheirscoresontheBeckDepressionInventory,

BeckAnxietyInventory,andImpactofEventsScale–Revised(IES-R),andhave

demonstrateddecreasedhypervigilanceandfearresponses(Bartzak,2016).

Traumamanagementtherapy(TMT)wasdevelopedinthe1990sasaformof

intenseexposuretherapythatalsoincludesgroupsessionsforsocialandemotionalneeds

(Beideletal.,2017).TMTaimstoteachveteranscopingskills,angermanagement,

maintainingsocialinvolvement,andaspectsofthesleepcycle,withthegoalofimproving

symptomcontrolandinterpersonalrelationships(Beideletal.,2017).TrialsofTMTin

21Vietnamveteransin1996and2011reporteddecreasedPTSDsymptomsincluding

anxietyandincreasedparticipants’frequencyanddurationofsocialinteractions(Beidelet

al.,2017).Thesegeneralizedresultsfromlargetrialsarehighlightedinindividualcase

studiestomoreclearlyshowhowimpactfulthesetherapiesare.

CaseStudies

One2013casestudy,researchedbyDuax,Waldron-Perrine,Rauch,andAdams,

followsaVietnamwarveteranwithPTSDreferredtoasMr.C.Hissymptomswere

connectedtowitnessing“theunloadingandpreparationofdeceasedsoldiers’bodies”

(Duax,Waldron-Perrine,Rauch&Adams,2013).Duringhisprolongedexposuretherapy

(PE)treatment,Mr.Creportedbeing“lessscared”ofhismemoriesandhavingbetter

groundinginrealitywhenheflashedbackorre-imaginedthetraumaticincident(Duaxet

al.,2013).Hisneuropsychologicalassessmentbatteryafteroneyearoftreatmentshowed

onlyoneofeightemotionaldistressscaleselevated,comparedtosevenofeightemotional

distressscalesbeforetreatment(Duaxetal.,2013).Hislanguageandknowledgetest

scoresimproved,perhapsduetodecreasedanxiety;hismemoryfunctionappeared

unchanged,remainingpoor;andhisvisuospatial,attention,andexecutivefunctions

declined,perhapsattributedtocerebrovascularissues(Duaxetal.,2013).Overall,PE

seemedtoimproveMr.C’sPTSDsymptoms.

Therehavebeenafewcasestudiesanalyzinghowtofortifysocializationand

relationshipsamongveteranswhohaveexperiencedsexualassault.Nearly22%ofwomen

studiedreportedMSTwhenscreenedbytheVA(Cloitre,Jackson&Schmidt,2016).Skills

TrainingforAffectiveandInterpersonalRegulation(STAIR)isatypeofCPTfocusingon

22buildingskillstomanageemotionsandmaintainhealthyrelationships,andthis

approachisoneofthefrontlinechoicesfortreatingPTSD(Cloitreetal.,2016).

ThefirstofthreeSTAIRcasestudiesdealswithKathy,aNavyveteranwho

experiencedchildabuseandthenmilitarysexualassault.Shereportedthecrimeandwas

eventuallydischargedduetoa“personalitydisorder.”HergoalsundertheSTAIRtherapy

programweretolearnhowtoidentify,express,andmanageheremotions,sothatshe

couldengagemoreinsocialactivities.Kathywasabletoincreasehersocialization,view

herselfmorepositively,andseethatothersviewherpositivelytoo.Shewasabletoreduce

herPTSDscorefrom77to46inherfirsttenweeksoftherapy(Cloitreetal.,2016).

AsecondSTAIRcasestudywasconductedwithBarbara,withafocusonnarrative

therapy.Barbarawasbotheredbydeterioratingfamilyrelationships,andwantedto

increaseherawarenessofheremotionsandcommunicationskills.Afterreviewingher

traumaticpastwithatherapistovertenweeks,BarbarareducedherPTSDscorefrom77to

38,disclosedhersexualassaulttoherhusbandandtheVA,andjoinedanadvocacygroup

(Cloitreetal.,2016).

ThefinalSTAIRcasewasdonewithamaleArmyveteran,Stephen,whoexperienced

asexualassaultthirtyyearspriortostartingtherapy.Hisgoalwasangermanagement,and

thekeytohisrecoverywasacknowledgingthelinkbetweenhisabuseandhisanger.He

hadjoinedthemilitarytoescapeabuseathome,onlytoexperiencemoretrauma,andhe

feltbetrayed.Throughrole-playingandschemareplacement–changinghisbeliefsfrom“if

Iopenup,I’llbebetrayed”to“ifIaskforhelp,Icangetbetter”–StephendroppedhisPTSD

scorefrom75to43aftersixteenweeks(Cloitreetal.,2016).

23 Itisevidentthatdifferentkindsoftherapiesworkfordifferentkindsofpeople

whohavePTSD,dependingontheirparticulartraumaticcircumstances.Thenextsectionof

thispapershouldprovidesomeinsightsintohowtherapiescanfurtherbedevelopedand

offeredtoveteransfortheirspecificneeds.

24Chapter3:PotentialFutureResearch

TargetAudience

Thefollowinginformationisintendedforthosewhowishtoknowwhatmightbe

donetoimprovevariousareasofPTSDanddementiaresearch,andhowtobettercarefor

thosewhohavethesedisorders.Theseresearchareasincludediagnostic,therapeutic,

economic,andbehavioralconsiderationsforthispopulationofolderadults.Theseresearch

avenuesshouldbeespeciallybeneficialforanyhealthcareproviderssuchaslong-term

careworkers,whocanexpecttodealwithanincreaseinthepopulationofresidentswith

PTSDanddementia.WhetherornotoneisaffiliatedwiththeVAshouldnotaffectthehigh

valueofthinkingabouthowtoimprovecurrentprocesses.

ScreeningandInitialTreatment

WhiletheSTAR-VAprogramispredominantlyatrainingprogramforexistingstaff,

therearetwoothermodelsthatoutlinedifferentcareprovidersandplansthatwouldbe

beneficialforolderadultswithPTSDanddementias.TheImprovingMood–Promoting

AccesstoCollaborativeTreatment(IMPACT)modelhasfivecomponents:“(1)adepression

caremanager,(2)adesignatedpsychiatrist,(3)collaborativecarebetweenthepatient’s

primarycarephysician,caremanager,andpsychiatrist,(4)outcomemeasurementof

depressivesymptoms,and(5)asteppedcaremodelforimplementingatreatmentplan”

(Rybarczyketal.,2013).ThePreventionofSuicideinPrimaryCareElderly–Collaborative

Trial(PROSPECT)modelhasonehealthspecialistworkingwiththeprimarycarephysician

tomonitorandmanagesuicidalideation(Rybarczyketal.,2013).TheGeriatricSuicide

IdeationScale(GSIS)couldalsobeimplementedifnecessary,asithasbeeneffectively

25appliedtobroadgroupsofolderadultsincommunitysettingsandcouldprovide

valuableinsightsinresidentialcarefacilitiesaswell(Heisel,2016).

TheClinicianAdministeredPTSDScale(CAPS)andtheRepeatableBatteryfor

AssessmentofNeuropsychologicalStatus(RBANS)canbeusefulinevaluatinghow

symptomsfluctuateovertime(Sanietal.,2012).Thiscanaidhealthcareprovidersin

determiningwhichmedicationsmaybehelpingorhinderingsomeone’srecoveryprocess;

forexample,memantineisacommonmedicationforAlzheimer’sdisease,themost

commondementia,butmoreresearchneedstobedoneonhowitaffectsPTSDand

whetheritwouldbeaneffectivetreatmentforaveterandealingwithbothconditions(Sani

etal.,2012).

SpecializedPopulations

ThedifferencesinPTSDtreatmentamongdifferentgendersshouldbestudiedmore

inthefuture.Historically,femaleveteranshavenumberedlessthan5%ofthetotalveteran

population,soVAinpatientpsychiatricunitsproportionallyreservefewerbedsforwomen

(Menefeeetal.,2016).Researchmustbedoneonhowtoincreasesafespacesand

treatmentprogramsforwomentotakeintoaccounttheiruniqueexperiences.Twogender-

specificinpatienttreatmentprogramshavebeenstudied,butshouldbestudiedmore

extensively:ReturningOEF/OIF/ONDEnvironmentofRecovery(ROVER)forthemen,and

theWomen’sInpatientSpecialtyEnvironmentofRecovery(WISER)forthewomen

(Menefeeetal.,2016).TheseROVER/WISERinitiativeswerefocusedonbuildingcoping

andinterpersonalskillsunderHerman’smodelofrecovery,whichtargetsthreestagesof

safety,remembranceandmourning,andreconnectiontoself(Menefeeetal.,2016).It

26shouldbeinvestigatedhowmenandwomencompareintheirprogressionsthrough

thesestages.

PTSDtreatmentsshouldalsobeinvestigatedinsuicidalindividuals.Suicideratesfor

theU.S.Armysurpassednationalratesforthefirsttimein2008,duetoOEF/OIFveterans

returningwithPTSD(Bakalaretal.,2016).Nearly40%ofstudiesthathavebeendoneon

exposuretherapieshavenotmentionedinclusioncriteriaregardingsuiciderisk,whatlevel

ofriskmightbeacceptabletoparticipateinthestudy,andhowsuicidalparticipantswere

monitoredforsafetythroughouttheprocess(Bakalaretal.,2016).Certaincomponentsof

exposuretherapymightbetoostressfulforsuicidalindividualswhocannothandlereliving

theirtrauma,andofferingthemmoresupportmightcompromisethecontrolofthestudy,

sovarioustherapymethodsshouldbetriedtoaddresstheuniqueneedsofthispopulation.

Itwouldbebeneficialfortherapystudiestobeconductedinpsychiatricinpatientsettings

andalsolong-termcaresettings.

Long-TermCareImplications

Nursinghomesarerequiredbylawtodivulgetheprevalenceofbehavioral

symptomsforalloftheirresidentseachquarterusingtheMinimumDataSet(MDS),but

thesereportsonlyneedtoincludebehaviorsshownwithintheweekbeforesubmission

(Powers,Gwirtsman&Erwin,2014).Perhapsfuturestudiescoulddeterminewhetherthis

timeframeencompassesenoughdatatoprovideanaccurateportrayalofresidentswith

PTSDanddementias.Thiscouldhelpstaffbettertrackthefrequencyandemergenceof

behavioralissuesthatmightneedaddressingmoreoften.

Onespecificbehaviorofconcerniswandering.Inoneinitialstudy,one-fifthofolder

adultsadmittedtoanursinghomewithcognitiveimpairmentdiagnoseswandered,and

27halfoftheresidentswhodidnothaveadementiabutdidhaveapsychiatricdiagnosis

alsowandered(Molinari,King-Kallimanis,Volicer,Brown&Schonfeld,2008).Wandering

withapsychosis,suchasPTSD,couldsuggestincreasedmotoractivityassociatedwith

ineffectivelytreateddeliriumoralarmsymptomatology(Molinarietal.,2008).Veterans

withPTSDhavenotbeendefinitivelydeterminedtoexhibitmoreaggressiontoother

residents,buttheymaybemoreparanoid,particularlyformerprisonersofwar(Balletal.,

2009).CombinedwiththeprevalentsleepdisturbancesthatplagueveteranswithPTSD,

theremaybemorefrequentnighttimewanderingifthereisaninabilitytosleepand

disorientationwithtime.

Itisimperativethatstaffmembersbeabletomanagethiswanderingbehaviorto

ensuresafety.InonesmallnursinghomeinAustralia,therearefourunitsaroundacentral

room,andresidentswhowanderintothecentralroomarepermittedtostayandrelax

whereanighttimestaffmembercansupervise(Cohen-Mansfield&Bester,2006).Thisidea

ofallowingnon-harmfulbehaviorratherthanforcingresidentstoconformtoacertain

schedulecouldhelpresidentsfeelmorecalmandathome.Thiscreatesadementia-friendly

environment,inwhichtheentiredesignofafacilityincorporatesopennessandlightforfall

preventionandoverallsafety(Davis,Byers,Nay&Koch,2009).Perhapslargerstudies

couldbedonetoseeifthislayoutwouldbebeneficialifwidelyreplicated,especially

alongsideothertherapiesandmeansofsupport.

IncreasingSupportandTherapyAdherence

OnestudyshowedthatmanyVietnamveteranswhoattendedveteransupport

groupmeetingsthoughtthattheywerehelpfulinbothprocessingmemoriesandalso

maintainingfellowship;however,manyWWIIveteransdidnotplacethesamevalueon

28suchsupportgroups,perhapsbecausetheyhadthesupportoftheirowncountrywhen

theywenttowar(Barnes&Harvey,2000;Brown,Knapp,Grubaugh,&Acierno,2016).

OEF/OIFveteranshavereportedhigherPTSDseveritythanveteransofotherwars,

particularlyintheavoidanceandhyperarousalsymptomcategories,butitisimportantto

considerthatOEF/OIFveteransmightbeoverrepresentedinstudysamplesasveteransof

previouswarsaremorelikelydeceased(Brownetal.,2016).Morein-depthanalysis

consideringsocialvariablescouldpossiblyuncovertrendstoseewhichgroupsofveterans

mightbenefitfromdifferentsupportstyles.

Itisnecessarytoanalyzenotonlywhatpopulationsmightutilizeoneformof

treatment,butalsohowandwhythosetreatmentswork,andhowtoincreaseadherenceto

treatmentprograms.Onestudyestimatedthatonly58%ofOEF/OIFveteranswithPTSD

haveusedVAPTSDservices,andonly38-45%expressedinterestintherapy,with67%

refusingorfeelingambivalentabouttherapyreferrals(Steenkamp&Litz,2013).Ofthose

veteranswhoacceptedreferrals,onequarterdidnotattendtheinitialtherapysession,and

anotherquarterdidnotattendasecondsession(Steenkamp&Litz,2013).Adequate

treatmentforPTSDisgenerallyconsideredatleasteightorninesessionsinayear,andone

CPTstudyhadonly8.5%ofpatientscompleteit(Luetal.,2016).Anotherstudyfoundthat

OEF/OIFveteranshadthehighestdropoutrateofallveterancohorts,despitethe

treatmentbeingequallyeffectiveacrossthecohorts(Brownetal.,2016).

Anotheraspectofthisissueismakingsurethattheservicesareaccessible,interms

ofbothlocationandcost.Onewaytoencourageveteranstoutilizeservicesistoensure

thattheycangettothemandnotspendalltheirincomeonthem;currently,PTSD

treatmentsandtherapiesaredifficulttoaccessformany(Duttonetal.,2013).Most

29availablePTSDtreatmentprogramsprovideservicesonceperweek,whichprolongs

treatmentovermultiplemonths,anditisdifficultforactivedutypersonneltoberelieved

fromdutyforsolong(Beideletal.,2017).Overcominggeographicalandfinancialbarriers

tocareshouldbeagrowingresearchareaintheupcomingyears.

BiologyandTraumaticBrainInjury

MoreresearchonbiologicalnetworksbetweenPTSD,dementias,andtheir

underlyingissuesshouldbeconductedaswell.TheAlzheimer’sDiseaseNeuroimaging

Initiative(ADNI)isalargepublic-privatepartnershipthataimstovalidateimagingand

biomarkersforAlzheimer’sclinicaltrials(Weineretal.,2014).Moreresearchcouldbe

doneonhowtheapolipoproteinE4allelemayworsentheseverityofAlzheimer’s,and

moreepidemiologicstudiescouldbedonetomoreclearlylinkAlzheimer’swithtraumatic

braininjury(TBI)(Weineretal.,2014).IthasbeenfoundthatTBImaybeassociatedwith

earlieronsetofAlzheimer’s,andAlzheimer’scharacteristicplaquesandintra-axonalbeta

amyloiddepositshavebeenfoundinone-thirdofagroupofpeoplewithTBI(Weineretal.,

2014).Nonblast-relatedTBIhasbeenassociatedsignificantlywithconcentrationand

memoryproblems,andblast-relatedTBIhasbeenfoundtohavemorePTSDsymptoms

overallcomparedtononblast-relatedTBI(Chapman&Diaz-Arrastia,2014).Whileonly

11.8%ofveteransarediagnosedwithTBIalone,themajority(70%)arediagnosedwith

bothTBIandPTSD(Sealetal.,2016).Themostfrequentsymptomsreportedfromveterans

withTBIareforgetfulness(77%)andpoorconcentration(71%),bothofwhichare

associatedwithPTSDanddementias(Sealetal.,2016).Moreconcreteconnectionsare

neededinordertomakesenseofthecomplexitieswithintheseassociations.

30 Inadditiontoallofthefutureresearchavenuesneededtocontinueinvestigating

thebiologicalandtreatmentareasofdementiaandPTSD,moreresearchneedstobedone

abouthowhealthcarecostswillbeaffected(Sibeneretal.,2014).Onestudyfoundthatthe

medianannualhealthcarecostsforveteranswithTBIarefourtimeshigherthancostsfor

veteranswithoutTBI,andcostsareevenhigherforveteranswithbothTBIandPTSD,

whichcouldincreaseprobabilityforneedingdementiacareaswell(Sibeneretal.,2014).

Traumaticbraininjurycanpredisposepeopletodevelopatauopathy-relateddementiaat

anearlyage,similartoAlzheimer’sdiseasebutwithadifferentpatternofphosphorylated

taudepositionthathasnotyetbeenexploredin-depth(Sibeneretal.,2014).

Inconclusion,knowledgegapsmustbeaddressedatalllevelsandinallfields,from

neurosciencetoeconomics,inordertocreateawell-roundedsystemofcareforaging

veterans.Manyveteransarefacingdiagnosiswithneurodegenerativediseasesatearly

stagesoflife,perhapsonaverageintheirforties,andtheseveteranscanbeexpectedtolive

anotherfortyyearsbeyondthat,whichwillgreatlyincreaselong-termcare,hospice,and

therapydemandsandexpenses(Sibeneretal.,2014).

31ReferenceSheet:AQuickLookatPTSDandDementia

Post-TraumaticStressDisorder(PTSD):amentalhealthconditionthatmaydevelop

whenadistressingeventoccursandinducessymptomssuchasintrusivethoughts,

hypervigilance,panicattacks,orflashbacks.

Symptomsinclude:

• flashbacksandmemoryproblems

• negativemood–disinterest,recklessness,aggression

• sleepdifficulty

• hypervigilance

• avoidance

Dementia:partofacontinuumofneurocognitivedisorders(NCDs);amajorNCD

characterizedbyseverecognitivedeclineinoneormorefunctionalareas.

Symptomsinclude:

• difficultywithmemory,cognition,andlanguage

• rapidlyfluctuatingorintenseemotions–anxiety,depression

• diminishedattentionspanandabstractthinking

• morespecificsymptomsbasedontypeofdementia

RecentResearchHighlights:

• PTSDpotentiallydoublestheriskfordementia

• biologicalsimilaritiesinPTSDanddementia–brainchangesinHPA,hippocampus,

andcortex

32FutureResearchNeeds:

• whichtherapeuticapproachesworkbestforwhichpopulations

• howtoincreaseadherencetotherapyprograms,andreducefinancialand

geographicalbarrierstoaccess

• howPTSDanddementiaincidenceswillaffecthealthcarecosts

• howtoimproveearlydiagnosisandtreatment,andimprovelong-termcarefacility

environments

KeyResources:

! Alzheimer’sAssociation–https://www.alz.org

! Dementiaresourcesbystate-https://www.alzheimers.net/resources/

! NationalCenterforPTSD-https://www.ptsd.va.gov

! PTSDAlliance-http://www.ptsdalliance.org/resources/

33References

Agaibi,C.,&Wilson,J.(2005).Trauma,PTSD,andresilience:Areviewoftheliterature.

Trauma,Violence,&Abuse,6(3),195-216.

Alzheimer’sAssociation.(2007).BehavioralandpsychiatricsymptomsofAlzheimer’s

disease.Retrievedfromwww.alz.org.

Alzheimer’sAssociation.(2012).Mildcognitiveimpairment(MCI).Retrievedfrom

www.alz.org.

Alzheimer’sAssociation.(2016).Alzheimer’sdiseasefactsandfigures.Retrievedfrom

www.alz.org.

AmericanPsychiatricAssociation.(2013).Diagnosticandsatisticalmanualofmental

disorders(5thed.).Arlington,VA:AmericanPsychiatricAssociation.

AustralianNursingandMidwiferyFederation.(2015).Post-traumaticstressdisorder.

Retrievedfromwww.anmf.org.au.

Averill,P.,&Beck,J.(2000).Posttraumaticstressdisorderinolderadults:Aconceptual

review.JournalofAnxietyDisorders,14(2),133-156.

Bakalar,J.L.,Blevins,C.L.,Carlin,E.A.,&Ghahramanlou-Holloway,M.(2016).

Generalizabilityofevidence-basedPTSDpsychotherapiestosuicidalindividuals:A

reviewoftheVeteransAdministrationandDepartmentofDefenseclinicalpractice

guidelines.MilitaryPsychology,28(5),331-343.

Ball,V.,Hudson,S.,Davila,J.,Morgan,R.,Walder,A.,Graham,D.,...Kunik,M.(2009).

Post-traumaticstressdisorderandpredictionofaggressioninpersonswith

dementia.InternationalJournalofGeriatricPsychiatry,24,1285-1290.

34Barnes,C.&Harvey,J.H.(2000).ComparisonofnarrativesoflossexperiencesofWorld

WarIIandVietnamcombatveterans.JournalofPersonalandInterpersonalLoss,5,

167-181.

Bartzak,P.(2016).Repetitivetranscranialmagneticstimulationaspotentialnew

treatmentforPTSD.MedSurgNursing,S11.

Beidel,D.C.,Stout,J.W.,Neer,S.M.,Frueh,B.C.,&Lejuez,C.(2017).Anintensiveoutpatient

treatmentprogramforcombat-relatedPTSD:Traumamanagementtherapy.

BulletinoftheMenningerClinic,81(2),107-122.

Brown,W.,Knapp,R.G.,Grubaugh,A.L.,&Acierno,R.E.(2016).Interplaybetweenservice

era,PTSDsymptomexpression,andtreatmentcompletionamongveterans.

MilitaryPsychology,28(6),418-428.

Buchanan,J.,Ebel,D.,Garcia,S.,VandeNest,F.,&Omlie,C.(2016).Agedifferencesin

perceptionsofgerotranscendence:Anexaminationofcosmicdimensionbehaviors.

JournalofReligion,Spirituality&Aging,28(3),239-254.

Chapman,J.C.,&Diaz-Arrastia,R.(2014).Militarytraumaticbraininjury:Areview.

JournalofAlzheimer’sandDementia,10,S97-S104.

Chodosh,J.,Sultzer,D.,Lee,M.,Hahn,T.,Reuben,D.,Yano,E.,...Rubenstein,L.(2007).

Memoryimpairmentamongprimarycareveterans.Aging&MentalHealth,11(4),

444-450.

Cloitre,M.,Jackson,C.,Schmidt,J.A.(2016).Casereports:STAIRforstrengtheningsocial

supportandrelationshipsamongveteranswithmilitarysexualtraumaandPTSD.

MilitaryMedicine,181(2),e183-e187.

35Cohen-Mansfield,J.,&Bester,A.(2006).Flexibilityasamanagementprinciplein

dementiacare:TheAdardsexample.TheGerontologist,46(4),540-544.

Cooley,S.,&Asthana,S.(2010).Dementiacareforveterans:Enhancingcomprehensive,

coordinatedservices.JournaloftheAmericanSocietyonAging,34(2),57-63.

Costanzo,M.,Jovanovic,T.,Norrholm,S.D.,Ndiongue,R.,Reinhardt,B.,&Roy,M.J.

(2016).Psychophysiologicalinvestigationofcombatveteranswithsubthreshold

Post-traumaticstressdisordersymptoms.MilitaryMedicine,181(8),793-802.

Dallam,D.,Mellman,T.,Bhatnagar,A.,Nguyen,S.,&Kurukumbi,M.(2011).Trauma

reenactmentsinagingveteranswithdementia.JournaloftheAmericanGeriatrics

Society,59(4),766-768.

Davis,S.,Byers,S.,Nay,R.,&Koch,S.(2009).Guidingdesignofdementiafriendly

environmentsinresidentialcaresettings:Consideringthelivingexperiences.

Dementia,8(2),185-203.

Davison,E.,Kaiser,A.,Spiro,III,A.,Moye,J.,King,L.,&King,D.(2016).Fromlate-onset

stresssymptomatologytolater-adulthoodtraumareengagementinagingcombat

veterans:Takingabroaderview.TheGerontologist,56(1),14-21.

Davison,E.,Pless,A.,Gugliucci,M.,King,L.,King,D.,Salgado,D.,...Bachrach,P.(2006).

Late-lifeemergenceofearly-lifetrauma:Thephenomenonoflate-onsetstress

symptomatologyamongagingcombatveterans.ResearchonAging,28(1),84-114.

Dewey,L.(2004).Warandredemption:Treatmentandrecoveryincombat-related

posttraumaticstressdisorder.Burlington,VT:AshgatePublishingCompany.

36Duax,J.M.,Waldron-Perrine,B.,Rauch,S.A.M.,&Adams,K.M.(2013).Prolonged

exposuretherapyforaVietnamveteranwithPTSDandearly-stagedementia.

JournalofCognitiveandBehavioralPractice,20,64-73.

Dutton,M.A.,Bermudez,D.,Matás,A.,Majid,H.,&Myers,N.(2013).Mindfulness-based

stressreductionforlow-income,predominantlyAfricanAmericanwomenwith

PTSDandahistoryofintimatepartnerviolence.JournalofCognitiveandBehavioral

Practice,20,23-32.

Finley,E.P.(2011).Fieldsofcombat:UnderstandingPTSDamongveteransofIraqand

Afghanistan.Ithaca,NY:CornellUniversityPress.

Glasser,R.J.(2011).Brokenbodies,shatteredminds:AmedicalodysseyfromVietnamto

Afghanistan.Palisades,NY:HistoryPublishingCompany.

Greenberg,M.S.,Tanev,K.,Marin,M.,&Pitman,R.K.(2014).Stress,PTSD,anddementia.

JournalofAlzheimer’sandDementia,10,S155-S165.

Grossman,A.,Levin,B.,Katzen,H.,&Lechner,S.(2004).PTSDsymptomsandonsetof

neurologicdiseaseinelderlytraumasurvivors.JournalofClinicalandExperimental

Neuropsychology,26(5),698-705.

Heisel,M.(2016).InvestigatingthepsychometricpropertiesoftheGeriatricSuicide

IdeationScale(GSIS)amongcommunity-residingolderadults.Aging&Mental

Health,20(2),208-221.

Holsinger,T.,Plassman,B.,Stechuchak,K.,Burke,J.,Coffman,C.,&Williams,Jr.,J.(2015).

Stabilityofdiagnosesofcognitiveimpairment,notdementiainaVeteransAffairs

primarycarepopulation.JournaloftheAmericanGeriatricsSociety,63,1105-1111.

37Jewell,A.(2014).Tornstam’snotionofgerotranscendence:Re-examiningand

questioningthetheory.JournalofAgingStudies,30,112-120.

Karel,M.,Teri,L.,McConnell,E.,Visnic,S.,&Karlin,B.(2016).Effectivenessofexpanded

implementationofSTAR-VAformanagingdementia-relatedbehaviorsamong

veterans.TheGerontologist,56(1),126-134.

Lemke,S.,&Schaefer,J.(2010).VAnursinghomeresidentswithsubstanceusedisorders:

Mentalhealthcomorbidities,functioning,andproblembehaviors.Aging&Mental

Health,14(5),593-602.

Lu,M.W.,Plagge,J.M.,Marsiglio,M.C.,&Dobscha,S.K.(2016).Cliniciandocumentationon

receiptoftrauma-focusedevidence-basedpsychotherapiesinaVAPTSDclinic.

JournalofBehavioralHealthServices&Research,43(1),71-87.

Menefee,D.S.,Leopoulos,W.S.,Tran,J.K.,Teng,E.,Wanner,J.,Wilde,E.,...Day,S.X.

(2016).Inpatienttrauma-focusedtreatmentforveterans:Implementationand

evaluationofpatientperceptionsandoutcomesofanintegratedevidence-based

treatmentapproach.MilitaryMedicine,181(11/12),e1590-e1599.

Meziab,O.,Kirby,K.A.,Williams,B.,Yaffe,K.,Byers,A.L.,&Barnes,D.E.(2014).

Prisonerofwarstatus,posttraumaticstressdisorder,anddementiainolder

veterans.JournalofAlzheimer’sandDementia,10,S236-S241.

Mohlenhoff,B.S.,Chao,L.L.,Buckley,S.T.,Weiner,M.W.,&Neylan,T.C.(2014).Are

hippocampalsizedifferencesinposttraumaticstressdisordermediatedbysleep

pathology?JournalofAlzheimer’sandDementia,10,S146-S154.

38Molinari,V.,King-Kallimanis,B.,Volicer,L.,Brown,L.,&Schonfeld,L.(2008).Wandering

behaviorinveteranswithpsychiatricdiagnosesresidinginnursinghomes.

InternationalJournalofGeriatricPsychiatry,23,748-753.

Naparstek,B.(2005)Invisibleheroes:Survivorsoftraumaandhowtheyheal.NewYork,

NY:BantamBooks.

Paulson,D.S.,&Krippner,S.(2007).Hauntedbycombat:UnderstandingPTSDinwar

veteransincludingwomen,reservists,andthosecomingbackfromIraq.Westport,

CT:PraegerSecurityInternational.

Powers,J.,Gwirtsman,H.,&Erwin,S.(2014).Psychiatricillnessandresidentassaults

amongveteransinlong-termcarefacilities.JournalofGerontologicalNursing,

40(4),25-30.

Préville,M.(2015).Associationbetweenperceivedsocialstigmaagainstmentaldisorders

anduseofhealthservicesforpsychologicaldistresssymptomsintheolderadult

population:validityoftheSTIGscale.Aging&MentalHealth,19(5),464-474.

Qureshi,S.,Kimbrell,T.,Pyne,J.,Magruder,K.,Hudson,T.,Petersen,N.,...Kunik,M.(2010).

Greaterprevalenceandincidenceofdementiainolderveteranswithposttraumatic

stressdisorder.JournaloftheAmericanGeriatricsSociety,58(9),1627-1633.

Read,S.,Braam,A.,Lyyra,T.,&Deeg,D.(2014).Donegativelifeeventspromote

gerotranscendenceinthesecondhalfoflife?Aging&MentalHealth,18(1),117-124.

Reisberg,B.(2006).Diagnosticcriteriaindementia:Acomparisonofcurrentcriteria,

researchchallenges,andimplicationsforDSM-V.JournalofGeriatricPsychiatryand

Neurology,19(3),137-146.

39Rybarczyk,B.,Garroway,A.,Auerbach,S.,Rodríguez,V.,Lord,B.,&Sadock,E.(2013).

Primarycarepsychology:Anopportunityforclosingthegapinmentalhealth

servicesforolderadults.ClinicalGerontologist,36,195-215.

Sachs-Ericsson,N.,Joiner,T.,Cougle,J.,Stanley,I.,Sheffler,J.(2016).Combatexposurein

earlyadulthoodinteractswithrecentstressorstopredictPTSDinagingmale

veterans.TheGerontologist,56(1),82-91.

Safir,M.,Wallach,H.,&Rizzo,A.(2015).Futuredirectionsinpost-traumaticstressdisorder:

Prevention,diagnosis,andtreatment.NewYork,NY:Springer.

Sani,G.,Serra,G.,Kotzalidis,G.D.,Romano,S.,Tamorri,S.M.,Manfredi,G.,...Girardi,P.

(2012).Theroleofmemantineinthetreatmentofpsychiatricdisordersother

thanthedementias.CNSDrugs,26(8),663-690.

Schmied,E.A.,Larson,G.E.,Highfill-Mcroy,R.M.,&Thomsen,C.J.(2016).Reciprocal

relationshipsbetweenstressorsandmentalhealthproblemsinmilitaryveterans.

JournalofSocialandClinicalPsychology,35(9),705-721.

Seal,K.H.,Bertenthal,D.,Samuelson,K.,Maguen,S.,Kumar,S.,&Vasterling,J.J.(2016).

Associationbetweenmildtraumaticbraininjuryandmentalhealthproblemsand

self-reportedcognitivedysfunctioninIraqandAfghanistanveterans.Journalof

RehabilitationResearchandDevelopment,53(2),185-198.

Searby,A.,Maude,P.,&McGrath,I.(2015).Maturingout,naturalrecovery,anddual

diagnosis:Whataretheimplicationsforolderadultmentalhealthservices?

InternationalJournalofMentalHealthNursing,24,478-484.

40Sibener,L.,Zaganjor,I.,Snyder,H.M.,Bain,L.J.,Egge,R.,&Carrillo,M.C.(2014).

Alzheimer’sdiseaseprevalence,costs,andpreventionformilitarypersonneland

veterans.JournalofAlzheimer’sandDementia,10,S105-S110.

Steenkamp,M.M.,&Litz,B.T.(2013).Psychotherapyformilitary-relatedposttraumatic

stressdisorder:Reviewoftheevidence.ClinicalPsychologyReview,33,45-53.

Tanielian,T.,&Jaycox,L.(2008).Invisiblewoundsofwar:Psychologicalandcognitive

injuries,theirconsequences,andservicestoassistrecovery.RANDCorporation.

VanderLinde,R.,Dening,T.,Matthews,F.,&Brayne,C.(2013).Groupingofbehavioraland

psychologicalsymptomsofdementia.InternationalJournalofGeriatricPsychology,

29,562-568.

VanderLinde,R.,Stephan,B.,Matthews,F.,Brayne,C.,&Savva,G.(2012).Thepresenceof

behavioralandpsychologicalsymptomsandprogressiontodementiainthe

cognitivelyimpairedolderpopulation.InternationalJournalofGeriatricPsychology,

28,700-709.

VanderMussele,S.,Mariën,P.,Saerens,J.,Somers,N.,Goeman,J.,DeDeyn,P.,&

Engelborghs,S.(2014).Aging&MentalHealth,19(9),818-828.

Verma,S.,Orengo,C.,Maxwell,R.,Kunik,M.,Molinari,V.,Vasterling,J.,&Hale,D.(2001).

ContributionofPTSD/POWhistorytobehavioraldisturbancesindementia.

InternationalJournalofGeriatricPsychiatry,16(4),356-360.

Wang,T.,Wei,H.,Liou,Y.,Su,T.,Bai,Y.,Tsai,S.,...Chen,M.(2016).Riskfordeveloping

dementiaamongpatientswithposttraumaticstressdisorder:Anationwide

longitudinalstudy.JournalofAffectiveDisorders,205,306-310.

41Weiner,M.W.,Veitch,D.P.,Hayes,J.,Neylan,T.,Grafman,J.,Aisen,P.S.,...Mohlenhoff,B.

(2014).Effectsoftraumaticbraininjuryandposttraumaticstressdisorderon

Alzheimer’sdiseaseinveterans,usingtheAlzheimer’sDiseaseNeuroimaging

Initiative.JournalofAlzheimer’sandDementia,10,S226-S235.

Wilson,J.,Harel,Z.,&Kahana,B.(1989).Thedayofinfamy:ThelegacyofPearlHarbor.InJ.

P.Wilson(Ed.),Trauma,transformationandhealing(pp.129-159).NewYork:

Brunner/Mazel.

Yaffe,K.,Hoang,T.,Byers,A.,Barnes,D.,&Friedl,K.(2014).Lifestyleandhealth-related

riskfactorsandriskofcognitiveagingamongolderveterans.Alzheimer’s&

Dementia,10,S111-S121.

Yaffe,K.,Vittinghoff,E.,Lindquist,K.,Barnes,D.,Covinsky,K.,Neylan,T.,...Marmar,C.

(2010).PosttraumaticstressdisorderandriskofdementiaamongUSveterans.

ArchivesofGeneralPsychiatry,67(6),608-608.

Yehuda,R.,Golier,J.,Tischler,L.,Stavitsky,K.,&Harvey,P.(2005).Learningandmemoryin

agingcombatveteranswithPTSD.JournalofClinicalandExperimental

Neuropsychology,27,504-515.

Zhou,X.,Chu,K.,&Luo,B.(2011).Functionalabnormalitiesandcerebralatrophyin

posttraumaticstressdisorderanddementia:Isthereacausallinkbetweenthe

twodiseases?JournaloftheAmericanGeriatricsSociety,59(2),378-379.